[Congressional Record Volume 140, Number 13 (Thursday, February 10, 1994)]
[House]
[Page H]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: February 10, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]


                              {time}  1830
 
                MORE PROBLEMS IN THE CLINTON HEALTH PLAN

  The SPEAKER pro tempore (Mr. Chapman). Under a previous order of the 
House, the gentleman from Florida [Mr. Goss] is recognized for 60 
minutes.
  Mr. GOSS. Mr. Speaker, I know the hour is late and people are 
concerned about the weather, and I will try and accommodate those 
concerns. There are some things that have happened though that I think 
are worthy of attention.
  I think a very important part of the debate on health care reform, a 
new round has been fired, as it were, new information is in. I think it 
will be the grist for the mill for days to come, and I wanted to sort 
of introduce the subject, because I think it is one of great import. 
And those interested in this subject I am sure will be interested. I 
want to refer them directly to an article in the New Republic by 
Elizabeth McCaughey that speaks as a return to the criticism she has 
received from the White House with regard to her earlier comments on 
the Clinton health plan. It gets very specific.
  The article is entitled ``Clinton's Plan on the Ropes.''
  It is further entitled ``She's Baaack,'' and it is from the New 
Republic edition of February 20.
  The war of words has escalated regarding the chasm between what the 
spin doctors at the White House about Clinton health and what the bill 
that's been submitted actually. In a recent article for the New 
Republic a respected health care expert, Elizabeth McCaughey, spelled 
out a number of serious inconsistencies between the rhetoric of Clinton 
health and the actual requirements of the legislation the President has 
proposed. As the walls came tumbling down around the President's plan, 
with a series of negative reviews including a damning budgetary 
assessment by the Congressional Budget Office, the White House panicked 
and began an exercise of shooting the messenger. Elizabeth McCaughey's 
analysis was ridiculed and lambasted. Undaunted, Ms. McCaughey has 
responded again, this time citing chapter and verse--actual page 
numbers and verbatim references to the Clinton health bill to back up 
her assertions. I would like to share with my colleagues some of the 
highpoints of Ms. McCaughey's most recent critique, in the February 20 
edition of the New Republic.
  I would not want in any way to discourage anybody from reading the 
whole article because it is very complicated to try to interpose a 
three-way debate that is going on between her first article, the White 
House, and then her retort.
  Mr. Speaker, I include that article for the Record.

                 [From the New Republic, Feb. 28, 1994]

               Clinton's Plan on the Ropes: She's Baaack!

                        (By Elizabeth McCaughey)

       On January 31 the White House press office released a 
     statement questioning the accuracy of my recent article in 
     TNR (``No Exit,'' February 7, 1993). I welcome this 
     opportunity to engage in a dialogue with the White House 
     about the content of its health bill. As I did in my original 
     article, I will be documenting my description of the bill--
     and my point-by-point rebuttal of their arguments--with page 
     numbers from the November 20, 1993, version. If White House 
     representatives challenge the accuracy of my description 
     again, I hope they will provide page numbers, too, so that 
     TNR readers can compare the evidence and decide for 
     themselves.
       Most of the White House challenge focused on this paragraph 
     from my article:
       If the bill passes, you will have to settle for one of the 
     low-budget health plans selected by the government. The law 
     will prevent you from going outside the system to buy basic 
     health coverage you think is better, even after you pay the 
     mandatory premium (see the bill, page 244). The bill 
     guarantees you a package of medical services, but you can't 
     have them unless they are deemed ``necessary'' and 
     ``appropriate'' (pages 90-91). That decision will be made by 
     the government, not by you and your doctor. Escaping the 
     system and paying out-of-pocket to see a specialist for the 
     tests and treatment you think you need will be almost 
     impossible. If you walk into a doctor's office and ask for 
     treatment for an illness, you must show proof that you are 
     enrolled in one of the health plans offered by the government 
     (pages 139, 143). The doctor can be paid only by the plan, 
     not by you (page 236). To keep controls tight, the bill 
     requires the doctor to report your visit to a national data 
     bank containing the medical histories of all Americans (page 
     236).
       The White House responded:
       ``There is nothing in this Act to prohibit any individual 
     from going to any doctor and paying, with their own funds, 
     for any service.'' ``Under the Act, you can pay `out-of-
     pocket[sic]' for anything you want at any time, to any 
     physician or hospital willing to treat you.'' Price controls 
     on doctors' fees? ``That is wrong,'' according to the White 
     House. ``There are no price controls. * * *''
       How accurate are these statements from the White House? The 
     text of the bill proves they are untrue.
       Can you pay any doctor any price for any service you want? 
     Although it is possible to buy cosmetic surgery, 
     psychotherapy or other uncovered services out-of-pocket, the 
     bill prohibits doctors from accepting payments directly from 
     you for the basic kinds of medical care listed in the 
     Clinton benefit package. Below are the regulations barring 
     doctors from taking your money. If you go to a doctor for 
     treatment, the doctor will be paid by your health plan. 
     That is true no matter what kind of health plan you are 
     enrolled in. The doctor is prohibited from accepting 
     payment from you (except fixed co-payments) for any basic 
     medical services listed in the Clinton benefit package. 
     That applies to doctors treating patients in HMOs and 
     doctors outside HMO networks. Doctors outside HMOs must 
     submit charges for your care to your health plan, accept 
     reimbursement based on the government's schedule of price-
     controlled fees and report your visit according to the 
     requirement of title V of the bill, which establishes the 
     national electronic data bank:
       Sec. 1046(d)(2) Direct Filing.--A provider may not charge 
     or collect from an enrollee amounts that are payable by the 
     health plan * * * and shall submit charges to such plan in 
     accordance with any applicable requirements of part 1 of 
     subtitle B of title V (relating to health information 
     systems).
       Are you allowed to pay a surgeon more, in hopes of getting 
     the most expert, experienced care? No:
       Sec. 1406(d)(1) Prohibition on Balance Billing.--A provider 
     may not charge or collect from an enrollee a fee in excess of 
     the applicable payment amount under the applicable fee 
     schedule [page 236]. * * *
       (3) Agreement With Plans.--The agreements * * * between a 
     health plan and the health care providers providing the 
     comprehensive benefit package to individuals enrolled with 
     the plan shall prohibit a provider from engaging in balance 
     billing described in paragraph (1) [page 237].
       The White House attacks the use of the phrase ``price 
     controls on doctors' fees'' in my article. ``Wrong,'' says 
     the White House. ``There are no price controls in the 
     president's plan. Price controls--calling for government 
     micromanagement of every health care service, doctor's fee, 
     drug technology and product--were considered and specifically 
     rejected.''
       But the text of the bill proves there are price controls on 
     health plan premiums, new drugs and doctors' fees. Here are 
     the price controls on doctors' fees:
       Sec. 1322(c) Establishments of Fee-For-Service Schedule (1) 
     In GENERAL.--Each regional alliance shall establish a fee 
     schedule setting forth the payment rates applicable to 
     services furnished during a year to individuals enrolled in 
     fee-for-service plans (or services furnished under the fee-
     for-service component of any regional alliance health plan) 
     [page 134]. * * *
       (4) Annual Revision.--A regional alliance * * * shall 
     annually update the payment rates provided under the fee 
     schedule [page 135].
       The White House says ``it is not clearly why a patient 
     would want to pay a doctor ``directly, for services that 
     their [sic] insurance company is obligated to buy.'' One 
     reason is privacy. Evading government regulations and paying 
     the doctor directly would allow you to keep your personal 
     medical problems out of the national data bank.
       Will your personal medical history be stored in a national 
     data bank? The White House says ``not true'' and ``patently 
     untrue'' to my statement that ``the bill requires the doctor 
     to report your visit to a national data bank containing the 
     medical histories of all Americans. The administration argues 
     that although ``physicians may be required to submit data * * 
     * for the purpose of improving quality and assessing 
     treatments and outcomes,'' the bill ``prevents against tying 
     this data to specific individuals.''
       The text of the bill proves that the administration is 
     mistaken. Information about your physical and mental health 
     and any treatments or tests you have will be entered in a 
     national data network and linked to you through your health 
     security number. Here is what the bill says: the National 
     Health Board will establish an ``electronic data network'' 
     with regional centers to collect, compile and transmit 
     information. The information expressly includes ``clinical 
     encounters,'' that is, when a physician treats a patient 
     (page 861). A doctor who treats you (except for an uncovered 
     service such as dental work or cosmetic surgery) and does not 
     record your ``clinical encounter'' on the standardized form 
     and submit it to your health plan will be fined up to 
     ``$10,000 for each such violation'' (pages 236, 885-886). As 
     the data about you travel from your doctor's office to the 
     health plan, and then to the national electronic data 
     network, this information continues to be tagged with your 
     ``unique identifier number.''
       The bill leaves no doubt that the network contains 
     ``individually identifiable health information,'' which is 
     defined in the bill to include your ``past, present or future 
     physical or mental health'' and health care provided to you 
     (page 877). To protect your privacy, the bill offers this 
     vagueness:
       All disclosures of individually identifiable health 
     information shall be restricted to the minimum amount 
     necessary to accomplish the purpose for which the information 
     is being disclosed [page 873].
     and this:
       [You] have the right to receive a written statement 
     concerning * * * the purposes for which individually 
     identifiable information provided to a health care provider, 
     a health plan, a regional alliance, a corporate alliance or 
     the National Health Board may be used or disclosed by, or 
     disclosed to, any individual or entity [page 874].
       It would be unfair to suggest that the bill's authors are 
     unconcerned about privacy. The bill mandates that the 
     National Health Board will ``promulgate standards respecting 
     the privacy of individually identifiable health information 
     that is in the health information system'' within two years 
     and propose privacy legislation within three years (pages 
     871, 876). But contrary to the White House statement, doctors 
     must report their patients' personal medical information to a 
     national data bank or risk harsh penalties, and the 
     information in the bank remains individually identifiable.
       Price controls on premiums will mean too little money to 
     care for the sick. Limiting how much money people can choose 
     to pay for basic health coverage limits how much money is in 
     the pot to take care of them when they are sick. That was the 
     point of the ad on television that the First Lady criticized. 
     A couple are discussing what price controls on premiums will 
     mean, and the woman asks, ``But what if there's not enough 
     money.''
       The bill's authors anticipate that restricting dollars 
     available for health care will produce shortages: when 
     medical needs outspace the budget and premium money runs low, 
     state governments and insurers must make ``automatic, 
     mandatory, nondiscretionary reductions in payments'' to 
     doctors, nurse and hospitals to ``assure that expenditures 
     will not exceed budget'' (pages 113, 137).
       In a charge echoed by Michael Weinstein of The New York 
     Times, the White House accused me of misleading readers by 
     ``implying that such a mechanism exists in the main 
     proposal.'' The White House stated emphatically that ``it 
     does not.'' The White House and Weinsein argue that only 
     under a single-payer system would payments to doctors and 
     others be cut off if needs outpace the budget and premium 
     money runs low. They expressly charge me with quoting the 
     single-payer regulations and misrepresenting them to be rules 
     for the ``main'' Clinton health proposal.
       The text of the bill proves that the White House and 
     Weinstein are wrong. Cutting or delaying payments to doctors, 
     other health care workers and hospitals to stay in budget is 
     an integral mechanism in the administration's bill, and one 
     of the two passages I quoted (page 137) is from the ``main 
     proposal.'' It provides that if needs exceed budget and 
     premium money runs low:
       Sec. 1322 (c)(2) PROSPECTIVE BUDGETING DESCRIBED * * * the 
     plan shall reduce the amount of payments otherwise made to 
     providers (through a withhold or delay in payments or 
     adjustments) in such a manner and by such amounts as 
     neccessary to assure that expenditures will not exceed 
     budget.
       The government will decide what is ``necessary'' and 
     ``appropriate'' care. The White House attacks as ``wrong'' 
     and ``very misleading'' my statement that ``the bill 
     guarantees you a package of medical services, but you can't 
     have them unless they are deemed `necessary' and 
     `appropriate.' '' The administration also says it is 
     ``untrue'' that that decision will be made by the government 
     not by you and your doctor.
       Let's look a the actual bill:
       Sec. 1141. Exclusions
       (a) Medical necessity--The comprehensive benefit package 
     does not include
       (1) an item or service that is not medically necessary or 
     appropriate: or,
       (2) an item or service that the National Health Board may 
     determine is not medically necessary or appropriate in a 
     regulation promulgated under section 1134 [pages 90-91].
       Sec. 1154. Establishment of standards regarding medical 
     necessity
       The National Health Board may promulgate such regulations 
     as may be necessary to carry out section 1141(a)(2) (relating 
     to the exclusion of certain services that are not medically 
     necessary or appropriate).
       The bill uses the word ``regulations,'' not 
     ``recommendations,'' to describe the National Health Board's 
     decisions. The bill also grants the National Health Board 
     power to change the preventive treatments guaranteed in the 
     benefit package and decide at what age and how often you are 
     entitled to tests and screenings, immunizations and check-ups 
     (page 94). Regarding practice guidelines, the bill makes it 
     clear that the National Quality Management Council will 
     develop measures of ``appropriateness of health care 
     services'' (page 839) and ``shall establish standards and 
     procedures for evaluating the clinical appropriateness of 
     protocols used to manage health service utilization'' (page 
     848).
       Racial quotas in medical training. The White House calls 
     such a suggestion ``ridiculous,'' but the bill shows it is 
     true. Government will allocate graduate training positions at 
     the nation's teaching hospitals based on race and ethnicity. 
     In determining how many training positions teaching hospitals 
     will have, the National Council on Graduate Medical Training 
     will calculate the percentage of trainees at each teaching 
     hospital ``who are members of racial or ethnic minority 
     groups'' and which minority trainees are from groups ``under-
     represented in the field of medicine generally and in the 
     various medical specialities'' (page 515).
       Protecting consumers or HMOs? The White House calls it 
     ``deliberately inaccurate'' to say that the bill pre-empts 
     important state laws protecting the ability of patients to 
     choose the hospital they think is best and make other choices 
     about their health care. Here is what the bill provides:
       Sec. 1407. pre-emption of certain state laws relating to 
     health plans
       (a) * * * no state law shall apply * * * if such law has 
     the effect of prohibiting or otherwise restricting plans 
     from--
       (1) * * *  limiting the number and type of health care 
     providers who participate in the plan;
       (2) requiring enrollees to obtain health services (other 
     than emergency services) from participating providers or from 
     providers authorized by the plan;
       (3) requiring enrollees to obtain a referral for treatment 
     by a specialized physician or health institution. * * *
       (6) requiring the use of single-source suppliers for 
     pharmacy, medical equipment and other health products and 
     services.
       Fee-for-service will be almost impossible to buy. The White 
     House labels it wrong to predict that fee-for-service 
     insurance will be extremely hard to buy. They point to the 
     provision that ``in general, each regional alliance shall 
     include among its health plan offerings at least one fee-for-
     service plan.'' But many doctors, hospital administrators and 
     health insurance experts say confidently that in practice, 
     because of the broader provisions of the bill, fee-for-
     service will seldom be available. I cited these experts in my 
     article. Here are their reasons:
       (1) Regional alliances cannot permit the average premium 
     paid in the region to exceed the ceiling imposed by the 
     National Health Board (pages 1,000-1,005). Fee-for-service 
     insurance, which allows patients to get a second opinion when 
     they have doubts and see a specialist when they feel they 
     need one, generally costs more than prepaid health plans that 
     control patient access to medical care.
       (2) Regional alliance officials are empowered to exclude 
     any plan that costs 20 percent more than the average plan 
     (page 132). They will have to apply the 20 percent rule 
     virtually all the time in order to keep total spending on 
     health plans below the ceiling imposed by the National Health 
     Board. In order to offer a plan that costs more than 20 
     percent above the average plan and still stay under the 
     ceiling, there would have to be other plans offered at well 
     below the average-priced plan. That is unlikely. The bill 
     limits the annual increase in premium prices to the Consumer 
     Price Index, which is significantly below current annual 
     increases in medical spending. Insurers will have a difficult 
     time staying under the premium ceiling, and certainly will 
     not offer plans well below it.
       (3) Regional alliance officials are empowered to set the 
     fees for doctors treating patients on a fee-for-service 
     basis, and it is illegal for doctors to take more. In 
     addition, prospective budgeting limits what fee-for-service 
     doctors can earn yearly, even if they see more patients and 
     work longer hours to make up for reduced fees. As Cara 
     Walinsky of the Health Care Advisory Board and Governance 
     Committee, which advises 800 hospitals, explains, the Clinton 
     bill contains ``very strong incentives'' against doctors 
     practicing on a fee-for-service basis. For all these reasons, 
     Dr. John Ludden, medical director of the Harvard Community 
     Health Plan, predicts that fee-for-service will ``vanish 
     quickly.''
       Does supplemental insurance provide an ``exit''? The bill 
     requires you to buy one of the low-budget health plans 
     offered by your regional alliance. You can't go outside the 
     system to buy basic coverage you prefer, even after you pay 
     the mandatory premium. Is supplemental insurance the way out? 
     The White House states ``there are no restrictions on the 
     purchase of supplemental insurance.'' The fact is the bill 
     contains two important restrictions that will effectively 
     close the door to better basic medical care: supplemental 
     insurance cannot duplicate any of the coverage in the 
     comprehensive benefit package, and it must be offered to 
     ``every individual who seeks'' to buy it, regardless of 
     health history or disability (page 244). Those two 
     restrictions mean that the seriously ill will line up to buy 
     it; insurers will not line up to sell it.
       Finally, it is important to note one of the points the 
     White House did not challenge: the Clinton bill is designed 
     to push people into HMOs, which aim to limit patient access 
     to specialized medicine and high-tech care. The premium price 
     controls will pressure HMOs to use even more stringent 
     methods of restricting care, yet the bill omits any 
     safeguards to protect patients from abusive cost-cutting 
     practices such as the withhold.
       These facts, straight from the text of the bill, 
     demonstrate the accuracy of my article ``No Exit,'' and the 
     appropriateness of its title. The White House would have you 
     believe that its bill can stop rising health care spending 
     and extend coverage to millions of uninsured Americans, 
     without changing the quality and choice of the medical care 
     you have now. Common sense suggests otherwise. A close 
     reading of the bill proves it is untrue. Several alternatives 
     by other Democrats and Republicans offer promising health 
     insurance reform without limiting what you can buy and how 
     much you can pay for it. It's time to give those bills a 
     close look.
  I will begin by quoting from the February 20 New Republic. Ms. 
McCaughey has said this:

       I will be documenting my description of the bill--and my 
     point-by-point rebuttal of their arguments--with page numbers 
     from the November 20, 1993, version. If White House 
     representatives challenge the accuracy of my description 
     again, I hope they will provide page numbers, too, so that 
     TNR readers can compare the evidence and decide for 
     themselves.
       Most of the White House challenge focused on this paragraph 
     from my article:
       ``If the bill passes, you will have to settle for one of 
     the low-budget health plans selected by the government. The 
     law will prevent you from going outside the system to buy 
     basic health coverage you think is better, even after you pay 
     the mandatory premium (see the bill, page 244). The bill 
     guarantees you a package of medical services, but you can't 
     have them unless they are deemed `necessary' and 
     `appropriate' (pages 90-911).''

                              {time}  1840

  Again, continuing:

       That decision will be made by the government, not by you 
     and your doctor. Escaping the system and paying out-of-pocket 
     to see a specialist for the tests and treatment you think you 
     need will be almost impossible. If you walk into a doctor's 
     office and ask for treatment for an illness, you must show 
     proof that you are enrolled in one of the health plans 
     offered by the government (pages 139,143). The doctor can be 
     paid only by the plain, not be you (page 236). To keep 
     controls tight, the bill requires the doctor to report your 
     visit to a national data bank containing the medical 
     histories of all Americans (page 236).

  That was essentially the passage that stirred the White House's 
attention and retort.
  Now, I am going to go to the current day and this article and speak 
what Ms. McCaughey has said in response to the White House's retort, 
and I will try and give fair justice to both what the White House has 
said and what Ms. McCaughey has said, because these are the issues that 
are out there on people's minds:

       The White House responded:
       ``There is nothing in this Act to prohibit any individual 
     from going to any doctor and paying, with their own funds, 
     for any service.'' ``Under the Act, you can pay `out-of-
     pocket [sic]' for anything you want at any time, to any 
     physician or hospital willing to treat you.'' Price controls 
     on doctors' fees? ``That is wrong,'' according to the White 
     House. ``There are no price controls * * *.''
       How accurate are these statements from the White House? The 
     text of the bill proves they are untrue.
       Can you pay any doctor any price for any service you want? 
     Although it is possible to buy cosmetic surgery, 
     psychotherapy or other uncovered services out-of-pocket, the 
     bill prohibits doctors from accepting payments directly from 
     you for the basic kinds of medical care listed in the Clinton 
     benefit package.

  The doctor is prohibited from accepting payment from you.
  Now, Ms. McCaughey goes on, and I will skip some of the words here 
and come to the section she has quoted:

       ``Sec. 1406(d)(2) direct filling--A provider may not charge 
     or collect from an enrollee amounts that are payable by the 
     health plan . . . and shall submit charges to such plan in 
     accordance with any applicable requirements of part 1 of 
     subtitle B of title V (relating to health information 
     systems).''
       Are you allowed to pay a surgeon more, in hopes of getting 
     the most expert experienced care? No:
       ``Sec. 1406(d)(1) prohibition on balance billing--A 
     provider may not charge or collect from an enrollee a free in 
     excess of the applicable payment amount under the applicable 
     fee schedule [page 236]. . . .''

  What we have got here is the White House spin doctors saying, ``Oh, 
no problem,'' but the bill says, ``Yes, a problem.'' Stop and read the 
fine print.
  Going along to another section, another issue that Miss McCaughey 
particularly selects, and again I am quoting here:

       The White House attacks the use of the phrase ``price 
     controls on doctors' fees'' in my article. ``Wrong,'' says 
     the White House. ``There are no price controls in the 
     president's plan.''
       But the text of the bill proves there are price controls on 
     health plan premiums, new drugs and doctors' fees. Here are 
     the price controls on doctors' fees:
       ``Sec. 1322(c) establishment of fee-for-service schedule 
       (1) In general--each regional alliance shall establish a 
     fee schedule setting forth the payment rates applicable to 
     services furnished during a year to individuals enrolled in 
     fee-for-service plans.''
       The White House says ``it is not clear why a patient would 
     want to pay a doctor `directly' for services that their [sic] 
     insurance company is obligated to buy.'' One reason is 
     privacy. Evading government regulations and paying the doctor 
     directly would allow you to keep your personal medical 
     problems out of the national data bank.

  Now, we will talk a little bit more about privacy and the 
confidentiality of your own medical records as we go along. But again, 
the point here about the price control, what is true and what is in the 
bill needs to be studied, and I think Miss McCaughey has pointed this 
out.
  Going on to a third point:

       Will your personal medical history be stored in a national 
     data bank? The White House says ``not true'' and ``patently 
     untrue'' to my statement that ``the bill requires the doctor 
     to report your visit to a national data bank containing the 
     medical histories of all Americans. The administration argues 
     that although ``physicians may be required to submit data . . 
     . for the purpose of improving quality and assessing 
     treatments and outcomes,'' the bill ``prevents against tying 
     this data to specific individuals.''
       The text of the bill proves that the administration is 
     mistaken. Information about your physical and mental health 
     and any treatment or tests you have will be entered in a 
     national data network and linked to you through your health 
     security number. Here is what the bill says: the National 
     Health Board will establish an ``electronic data network'' 
     with regional centers to collect, compile and transmit 
     information. The information expressly includes ``clinical 
     encounters,'' that is, when a physician treats a patient 
     (page 861). A doctor who treats you (except for an uncovered 
     service such as dental work or cosmetic surgery) and does not 
     record your ``clinical encounter'' on the standardization 
     form and submit it to your health plan will be fined up to 
     ``$10,000 for each such violation'' (pages 236, 885-886).
       The bill leaves no doubt that the network contains 
     ``individually identifiable health information,'' which is 
     defined in the bill to include your ``past, present or future 
     physical or mental health'' and health care provided to you 
     (page 877). To protect your privacy, the bill offers this 
     vagueness:
       ``All disclosures of individually identifiable health 
     information shall be restricted to the minimum amount 
     necessary to accomplish the purpose for which the information 
     is being disclosed [page 873].''
     and this:

  I do not know what the minimum-amount-necessary test really means, 
but if I were making a job application and that information were made 
available, I am not sure it would be relevant, and I am not sure whose 
decision it would be to make that determination about whether or not 
the minimum amount necessary revealed would include medical information 
on my job application.
  Going back to the article and quoting further:

       It would be unfair to suggest that the bill's authors are 
     unconcerned about privacy. But contrary to the White House 
     statement, doctors must report their patients' personal 
     medical information to a national data bank or risk harsh 
     penalties, and the information in the bank remains 
     individually identifiable.

  So there is yet another point we have got, the question of price 
controls we have discussed, we have discussed the question of whether 
or not you can pay extra fees for surgeons for things that you want or 
other doctors for things that you want, we have got the privacy issue, 
and now, going back to another issue that is often referred to as the 
rationing issue, Mr. McCaughey says this in her article:
  ``Price controls on premiums will mean too little money to care for 
the sick.''
  Continuing to read:

       The bill's authors anticipate that restricting dollars 
     available for health care will produce shortages: when 
     medical needs outpace the budget and premium money runs low, 
     state governments and insurers must make ``automatic, 
     mandatory, nondiscretionary reductions in payments'' to 
     doctors, nurses and hospitals to ``assure that expenditures 
     will not exceed budget'' (pages 113, 137).
       The White House argues that only under a single-payer 
     system would payments to doctors and others be cut off if 
     needs outpace the budget and premium money runs low.
       The text of the bill proves that the White House is wrong. 
     It provides that if needs exceed budget and premium money 
     runs low:
       ``Sec. 1322(c)(2) Prospective Budgeting Described.--The 
     plan shall reduce the amount of payments otherwise made to 
     providers (through a withhold or delay in payments or 
     adjustments) in such a manner and by such amounts as 
     necessary to assure that expenditures will not exceed 
     budget.''

  So it appears that we have two sides of the mouth speaking 
simultaneously, the bill saying that we cannot exceed the budget, the 
White House saying, ``Wait a minute, that is not so.''
  Going on to the next point, and this point has to do with who 
determines what health care is appropriate for you. Again, quoting the 
article:

       The government will decide what is ``necessary'' and 
     ``appropriate'' care. The White House attacks as ``wrong'' 
     and ``very misleading'' my statement that ``the bill 
     guarantees you a package of medica services, but you can't 
     have them unless they are deemed `necessary' and 
     `appropriate.''' The administration also says it is 
     ``untrue'' that that decision will be made by the government, 
     not by you and your doctor.
       Let's look at the actual bill:

     ``SEC. 1141. EXCLUSIONS

       (a) Medical Necessity.--The comprehensive benefit package 
     does not include--
       (1) an item or service that is not medically necessary or 
     appropriate; or,
       (2) an item or service that the National Health Board may 
     determine is not medically necessary or appropriate in a 
     regulation promulgated under section 1134 [page 90-91].''
       ``Sec. 1154. establishment of standards regarding medical 
     necessity
       The National Health Board may promulgate such regulations 
     as may be necessary to carry out section 1141(a)(2) (relating 
     to the exclusion of certain services that are not medically 
     necessary or appropriate).''
       The bill uses the word ``regulations,'' not 
     ``recommendations,'' to describe the National Health Board's 
     decisions. The bill also grants the National Health Board 
     power to change the preventive treatments guaranteed in the 
     benefit package and decide at what age and how often you are 
     entitled to tests and screenings, immunizations and check-ups 
     page 94).

                              {time}  1850

  Mr. Speaker, I would unquote at that point and say we have already 
had a debate about how often we should have testing for certain 
procedures, preventative procedures, cancer particularly, women's 
cancer clinics. That has already been in debate, so I do not think 
there is any question that America is missing the point here that there 
is a debate on this subject and there is a very great difference 
between what the White House has been saying in its advertising, and 
what this legislation points to, and where the cuts will come, if there 
have to be cuts, and who will be making those decisions.
  Getting into somewhat more subliminal points about this bill that 
are, I think, important, but perhaps not as compelling as some of the 
issues we have talked about, choice and rationing so far, I am going to 
quote now from a couple of other areas from the article specifically. 
Quoting:

       Racial quotas on medical training. The White House calls 
     such a suggestion ``ridiculous,'' but the bill shows it is 
     true. Government will allocate graduate training positions at 
     the nation's teaching hospitals based on race and ethnicity. 
     In determining how many training positions teaching hospitals 
     will have, the National Council on Graduate Medical Training 
     will calculate the percentage of trainees at each teaching 
     hospital ``who are members of racial or ethnic minority 
     groups'' and which minority trainees are from groups ``under-
     represented in the field of medicine generally and in the 
     various medical specialities'' (page 515).

  Still quoting:

       Protecting consumers or HMOs? The White House calls it 
     ``deliberately inaccurate'' to say that the bill pre-empts 
     important state laws protecting the ability of patients to 
     choose the hospital they think is best and make other choices 
     about their health care. Here is what the bill provides:
       ``Sec. 1407. pre-emption of certain state laws relating to 
     health plans
       (a) * * * no state law shall apply * * * if such law has 
     the effect of prohibiting or otherwise restricting plans 
     from--
       (1) * * * limiting the number and type of health care 
     providers who participate in the plan:
       (2) requiring enrollees to obtain health services (other 
     than emergency services) from participating providers or from 
     providers authorized by the plan;
       (3) requiring enrollees to obtain a referral for treatment 
     by a specialized physician or health institution. * * *
       (6) requiring the use of single-source suppliers for 
     pharmacy, medical equipment and other health products and 
     services.''

  Unquoting for a moment, Mr. Speaker, what that basically says is 
there is an awful lot of regulations being imposed by the Federal 
Government on the ability to choose and on the regulatory programs that 
States already have in place.
  Going back to the article and continuing to quote:

       Fee-for-service will be almost impossible to buy.

  Many doctors, hospital administrators and health insurance experts 
said confidently that in practice, because of the broader provisions of 
the bill, fee-for-service will seldom be available. I cited these 
experts in my article. Here are there reasons:

       (1) Regional alliances cannot permit the average premium 
     paid in the region to exceed the ceiling imposed by the 
     National Health Board.

  Skipping some words, Mr. Speaker, I will continue with the quotation:

       (2) Regional alliance officials are empowered to exclude 
     any plan that costs 20 percent more than the average plan.

  Again skipping a section:

       (3) Regional alliance officials are empowered to set the 
     fees for doctors treating patients on a fee-for-service 
     basis, and it is illegal for doctors to take more.
       For all these reasons Dr. John Ludden, Medical Director of 
     the Harvard Community Health Plan, predicts that fee-for-
     service will vanish quickly.

  There we have a lot of discussion going on. I have skipped some of 
the parts of the argument in this passage in order to save some time, 
but I recommended to everybody to read because it gets to that bottom 
line point that fee-for-service is going to be an endangered specie 
under this plan because the incentives clearly move it out of the way.
  The final area I will quote from is:

       Does supplemental insurance provide an ``exit''? The bill 
     requires you to buy one of the low-budget health plans 
     offered by your regional alliance. You can't go outside the 
     system to buy basic coverage you prefer, even after you pay 
     the mandatory premium. Is supplemental insurance the way out? 
     The White House states ``there are no restrictions on the-
     purchase of supplemental insurance.'' The fact is the bill 
     contains two important restrictions that will effectively 
     close the door to better basic medical care: supplemental 
     insurance cannot duplicate any of the coverage in the 
     comprehensive benefit package, and it must be offered to 
     ``every individual who seeks'' to buy it, regardless of 
     health history or disability (page 244). Those two 
     restrictions mean that the seriously ill will line up to buy 
     it; insurers will not line up to sell it.

  Mr. Speaker, insurers will not line up to sell it.
  What we have got here, I think, is a very interesting response on a 
number of extremely important points of the health care debate. I do 
not know who is actually totally right or who is actually totally wrong 
on all of these points. I do not think anybody does yet. But I do 
think, as this debate goes forward, the people who are trying to 
champion one cause or another are going to be particularly well served 
if they speak with a unified voice rather than having one message 
coming from spin doctors, one message coming from the White House, and 
one message coming from heaven knows where. We are all anxious to get 
to the bottom of this, and what the truth is and what is going to work 
best for the American people.
  I very much suggest, Mr. Speaker, that we are going to be hearing 
lots of quotations and lots of references to Elizabeth McCoy in the 
days ahead. She has really taken up this issue of health care reform 
and what is real and what is not in it. I think she is going to be in a 
position where she is going to be on the stump in public, and frankly I 
would welcome a debate between Ms. McCoy and the First Lady, or anybody 
in the Clinton plan, spokespersons who would like to have that debate. 
I think the American public would profit. I know I would like to hear 
the debate.
  There are many questions. I do not have the answer on this matter 
yet. These are the things that will happen in the days to come.
  I thank my colleagues for bearing with me as I have tried to do 
something that is very difficult to do which is carry on a debate in 
surrogate, but I think that it is important to know that this debate 
has got to go on and we have to get to the bottom line.

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