[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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