[Congressional Record Volume 140, Number 71 (Thursday, June 9, 1994)]
[Senate]
[Page S]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: June 9, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
                     HEALTH CARE REFORM LEGISLATION

  Mrs. KASSEBAUM. Mr. President, earlier today, the Senate Committee on 
Labor and Human Resources concluded its consideration of health care 
reform legislation. The vote on final passage was 11 to 6, split 
largely along party lines.
  Our action today was the culmination of 3 weeks of lengthy committee 
deliberations.
  I want to praise all of the committee members, and all of the staff 
members, who spent an enormous amount of time on an exceptionally 
complex piece of legislation. The Presiding Officer, the Senator from 
West Virginia, certainly knows how complex, comprehensive, and 
important this legislation is.
  Although I acknowledge the commitment and serious attention which 
went into the effort--and it was indeed that, on the part of everyone--
I am also deeply disappointed with the product of our work. Committee 
debate and discussions were thoughtful, and I hope that they served to 
clarify some of the fundamental issues involved in health care reform. 
Even those of us on the committee learned a great deal about the health 
care issue.
  The quality of the debate, however, did not translate into a quality 
piece of legislation. I am speaking as one who recognizes a need for 
change in our health care system. I have believed for several years it 
was important for us to address this subject.
  Clearly, the status quo cannot be sustained--which is why the health 
care system is changing itself, even in the absence of legislation. It 
is changing itself significantly, and it will continue to do so. This 
may or may not be, in the end, the best for the delivery of quality 
health care. Nevertheless, it is occurring, and it will continue to 
occur whether legislation is passed or not.
  The public does seek a sense of security that health care will be 
available and affordable, and these concerns are real. The real 
question is whether we are addressing these concerns or whether we are 
adding to those concerns.
  I think my biggest disappointment is the fact that we seem to have 
lost our sense of what the debate is really all about. What drew me 
into the health care debate several years ago was deep public concern 
about the cost of care. Today, the debate has lost its roots in concern 
about costs and, in fact, it has seemed to take a direction where cost 
is no object. And I am afraid that many of our proposals are simply 
adding more and more costs to the public.
  This debate has lost its focus. We must recognize that general public 
concern about health care is a fragile foundation indeed. What I fear 
we are doing is building a luxury skyscraper on the shifting sands of a 
very uncertain public consensus. We have done so without knowing the 
cost of the building, or whether anyone wants to or can afford to move 
in. And, Mr. President, unless we can develop a consensus of support 
from the public for this health care issue, we will not be able to pull 
together a constructive piece of legislation.

  We have to have the public's confidence in what we are doing. We have 
to be able to make the public feel more secure that we are indeed 
addressing their concerns. This must occur before we can address a 
comprehensive, complex, major piece of legislation in a way that is 
going to be constructive.
  A variety of agendas, many of them contradictory, have come into play 
in the name of addressing these public concerns. The failure in 
leadership has been the failure to establish the ground upon which true 
consensus lies, as well as a failure to define the task in terms of 
what realistically can be accomplished.
  We kid ourselves if we think Congress and the Federal Government, in 
one fell swoop, are going to be able to design and regulate every 
aspect of the health care system, from specifying the exact number and 
types of vaccinations to be covered for 3-year-olds, to the prices that 
a plan will charge for insurance premiums.
  The public expected government to fix health care, not to run it. And 
that, I think, is a crucial difference.
  This is where the President, I believe, went off track. President 
Clinton cared a great deal about this. He and the first lady raised 
this issue in debate. It is an important debate. It is one in which we 
all need to understand the terms and the root causes of the problems we 
are addressing. But the President, I suggest, interpreted public 
concern about health care as a mandate for government takeover of the 
system. This is a clear misreading of the situation. A sure applause 
line when I speak at home is to say that the Clinton bill, as such, is 
not going to pass. Of course, that is putting it very simplistically. 
It does a disservice to all of the aspects of the issue involved. But 
it also is a reading of where public sentiment lies on this issue.
  The legislation reported by the Labor and Human Resources Committee 
about an hour ago is sitting at the same railway siding. After sorting 
through some differences in semantics, one finds the basic core of the 
Clinton bill has emerged unscathed.
  In my opening statement when we began the debate in committee, I 
noted that the American public is extremely confused and skeptical 
about President Clinton's proposal, due to its size, complexity, and 
bureaucracy. The bill we reported out of the committee is just as big, 
just as complex, and just as reliant on government regulation as the 
Clinton bill.
  The most troubling elements of this bill 3 weeks ago and remain in 
the bill today. These include: Massive government regulation, heavy 
employer mandates; an extensive and overly specific benefit package; 
rigid premium caps; countless new opportunities for lawsuits; and 
costly new initiatives, including four new entitlement programs.
  Maintaining these features of the bill will have major consequences, 
intended and unintended. Let me mention just a few:
  First, government regulation: Relying upon governmental regulatory 
structures rather than market forces as the framework for delivery of 
health services will bog us down in mounds of paperwork and a dizzying 
array of lines and boxes on organizational charts.

  This is not what we mean by quality health care that is affordable, 
is accessible.
  There is a difference between setting up a structure which allows a 
system to heal itself and one which takes over the control of that 
system. There is a difference between offering businesses the 
opportunity to pool themselves together in voluntary purchasing groups 
and demanding that they do so under an alliance structure.
  Second, employer mandates: Employer mandates are extremely costly to 
our society as a whole. They mean lost jobs and lower wages for 
American workers. The precise numbers of jobs lost is certainly not 
particularly relevant, but the fact is that there will be jobs lost, 
and that there will be economic dislocations is a given. Whether you 
use one figure or another, we have, I think, put forward the bottom 
line--that jobs will be lost. Moreover, the estimated wage loss per 
worker could well be $1,200. Even small businesses, which might 
arguably be helped with subsidies and other protections, worry that 
what is mandated will be so rich that any short-term advantages will 
quickly disappear. With modifications made in committee, we have also 
created a cliff effect, I suggest, where the addition of even one 
employee to the company payroll holds major financial consequences.
  I think you can tell from my remarks I do not support an employer 
mandate. I do not believe they are necessary to get universal coverage. 
And I support universal coverage. I believe it is necessary for us, in 
the long run, as we can pay for it, to be able to reach this goal. Of 
course, we must address other challenges, such as ending discriminatory 
prior health conditions, developing voluntary pools and cooperative 
arrangements, and assuring that we have portability of benefits.
  Third, the benefit package: The legislation that we just passed out 
of the Labor and Human Resources Committee all but writes the entire 
plan into statute. Not only is this level of detail excessive for 
legislative language, but it also invites the addition of any items not 
already specified. It lays the groundwork for assuring that we will 
ultimately be unable to say no to anyone or anything.
  Fourth, premium caps: I believe that cost containment is important 
and, in fact, I included premium increase limits in my own 
comprehensive legislation 2 years ago as a backstop in the event that 
market-based reforms alone fail. My purpose was not to wring 
unsustainably large sums from the system in a short period of time--
which is the effect of the very stringent caps included in the 
committee bill. I am also increasingly troubled that these premium caps 
will become means to make projected subsidy and other costs appear to 
be much more than they are. It is alarming to consider the budget 
implications if we discover later that cost projections related to the 
premium cap turn out to be wrong. One recent analysis conducted by Peat 
Marwick concludes that the caps would be 50 percent effective, at best. 
If Peat Marwick is right, the result will be a $101 billion shortfall 
in financing of the President's bill in the year 2003.
  Fifth, opportunities for lawsuits: Any gains we might have hoped to 
achieve through the modest malpractice reform in the bill have been 
completely overshadowed by the endless new opportunities for litigation 
provided by this bill. New legal remedies are available to deal with 
alleged violations of the numerous requirements of the bill, with 
additional remedies on issues of fraud and abuse. On top of that, even 
more remedies are provided to deal with charges of discrimination by a 
vastly expanded list of protected groups.
  I believe we have opened Pandora's box in this area, with 
consequences we can only begin to imagine at this point.
  Costly new initiatives: We will have to await a full Congressional 
Budget Office report before we get a handle on what all of this might 
cost. The consequences of our actions, however, will go beyond dollars 
and cents. As just one example, the new early retiree entitlement 
program is estimated to result in forcing the early retirement of 
600,000 American workers.
  These items reflect the biggest points of contention. Every serious 
attempt in committee to reshape these core elements was thwarted. 
Moreover, even with 3 weeks of consideration, it was difficult to do 
more than scratch the surface of other less visible issues, such as the 
creation of duplicate new programs and the treatment of graduate 
medical education, among others.
  I had hoped that in the course of our deliberations, we would have 
been able to pull this bill into the mainstream. I and others put 
forward amendment after amendment designed to reduce regulation, 
streamline bureaucracy, establish a more manageable and a less specific 
benefits package, eliminate the employer mandate, and reduce 
opportunities for litigation.
  Unfortunately, movement in any of these directions was minimal at 
best. The slight streamlining and a nod toward cost containment in the 
benefits package are positives, but they fall far short of the mark we 
need to reach.
  Clearly, the Labor Committee is not the only player in the health 
reform debate, and the bill reported is but one step in the process. 
For all practical purposes, this particular proposal has reached the 
end of its trail because it fails to offer a middle ground upon which 
the public or the majority of the Senate can comfortably stand.
  Mr. President, on the floor at this time is a colleague who has 
played a major role in the Labor and Human Resources Committee 
deliberations on this legislation. He is also a member of the Finance 
Committee, as is the Senator from West Virginia, the Presiding Officer, 
and the action clearly shifts there.
  However, I think the Senator from Minnesota would agree with me that 
the work we did in the Labor Committee was not without merit, if only 
for educational purposes, and that we did do some extensive analysis of 
these various provisions. The ones I mentioned, I believe are 
cornerstones that are absolutely fundamental to what most of us worry 
about and to what will need to be addressed if we are to accomplish 
health reform in this Congress.
  Mr. President, I yield the floor.
  Mr. DURENBERGER addressed the Chair.
  The PRESIDING OFFICER. The Senator from Minnesota.
  Mr. DURENBERGER. Mr. President, I appreciate very much the comments 
of our colleague from Kansas. I came to the floor, as I saw her rise, 
to speak so that I might share with my colleagues the pleasure of 
someone who has been engaged since before I got here in health care 
reform--and I have been here for 16 years--at how well my colleague, 
who is the ranking member of the Labor and Human Resources Committee, 
represented all of us--not just the Republicans, but all of us--in the 
health care reform debate that took place in conjunction with the 
markup and reporting out of the committee the health care bill which 
she has talked about.
  It reminds me, and I think reminds everyone, that health care reform 
did not begin with Hillary Clinton, as our colleague from West Virginia 
well knows, because he and I, and others, have engaged in health care 
reform, and members of the health subcommittee, for quite a long time.
  The Senator from Kansas is the author of a major piece of health care 
reform legislation which she authored several years ago. A number of 
our colleagues, principally on this side of the aisle, have authored 
major reform legislation. Some of it goes back into the early eighties, 
which we all cooperated on, in the Finance Committee. Some of it is of 
more recent origins, since the Pepper Commission, which our colleague 
from West Virginia chaired, pointed out the need in this country to do 
major reform and to get off the sort of piecemeal reform we were trying 
to do through Medicare, and actually deal with the fact that a system 
that costs $1 trillion a year may deliver quality health services, but 
it is sick and it needs to be changed.
  We all owe a debt of gratitude to the Senator from West Virginia for 
stepping in and chairing that Commission, highlighting--those six of us 
from the Senate and six from the House and, at that time, presumed 
leaders in health care reform--highlighting the need for this body and 
the American people and the President of the United States to engage on 
this issue.
  I was very proud of my colleague from Kansas, and I told her that at 
the end of the meeting. The Labor Committee is not usually engaged in 
health care reform. It is usually engaged in authorizing new Federal 
programs to meet a variety of new needs. Even the chairman expressed 
this at the end of the meeting. For him, in 30 years of trying to deal 
with the issue of health care, this was a new experience for Senator 
Kennedy as well. For me, it was a new and delightful experience to work 
with my colleague from Kansas, and it also was a wonderful experience 
to work with our colleague from Massachusetts, for whom we all have 
much respect, who took the lead in at least getting something going.
  We all have been proposing health reform bills, saying it ought to 
get done, and as a committee chair, he took the responsibility of 
holding the very first markup, presented his own mark, took a lot of 
heat from those of us who disagreed with a lot of the things that were 
in it, and yet, at the end, I think there was a consensus that, as we 
finished the process this evening, we were at the end of the beginning 
of a process which has an end in sight, and it is not very distant.
  I am in the unusual position, as the occupant of the chair knows, 
because we had the Labor markup in Dirksen 212, or Hart, whatever it 
is, on the second floor. I could walk from one of my committees to the 
other, and did that this afternoon at 4 o'clock. I walked up from the 
markup in Labor and walked over to Chairman Moynihan's sort of exposing 
the Democrat and Republican members of the Finance Committee to his 
outline of his mark, and his encouragement that next week we begin the 
process in the Finance Committee of working our way toward a mark and a 
markup process.
  So we are now into the second phase of reform.
  I have no doubt at all in my mind that we will reach a consensus on 
this. We will probably reach an outline consensus on this before we 
come to the floor of the U.S. Senate. I suggest if anyone in authority 
is listening to me, that that might not be a bad idea. The Clean Air 
Act precedent might be a good one this time.
  We learned a lot, not only about health care reform and its elements, 
but we learned a lot about each other during the course of the markup 
in the Labor Committee. I think in the Finance Committee, we will have 
a similar experience.
  I think the Democratic leader would be well advised to suggest that 
at some point in time, after those two bills are out of committee, 
which I hope is done by the Fourth of July recess, that there be some 
period of time set aside in his outer office--where we did this for the 
clean air bill in February 1990--for the leadership of both of those 
committees and the main authors of some of these bills to get together 
with some of the people from the administration who need to understand, 
as my colleague from Kansas has said, that the Clinton bill, as 
proposed, is not going to pass; that there will be a bill with the 
President's name on it, perhaps the same title of the President's bill, 
the Health Security Act of whatever year it is, 1994; but that the 
reality is that what passes is a bill that hopefully will be sort of 
redesigned or put together at a session such as I have suggested.
  Having said that, Mr. President, let me also say that my optimism 
comes only with some experience with health care itself, health care 
delivery and health care reform. I am sure for most people around this 
place, because of the obstacles before us--three major committees on 
the House side, none of which has reported yet, the Finance Committee 
here just starting with an outline of the chairman's mark, 30-some 
working days until the August recess begins--it probably looks 
impossible. I disagree. I think it is possible.
  One thing I observe: We are not going to get a lot of help from the 
American people on this issue. I remember very well back in May of last 
year, when it became obvious the President was not going to meet his 
one self-imposed 100-day deadline for health care reform, he invited a 
group of Republicans down to have lunch. At that lunch, when it came my 
turn to make some comments, I complimented the President and Mrs. 
Clinton on taking on the responsibility for major reform. I said: It is 
a wonderful thing; you have these 500 people working up all these 
proposals, and you are going to have a terrific plan when you get 
through.
  But one thing you have neglected. You have not spent any time trying 
to explain the problem or engage in a dialog on the problem with the 
American people. And what is going to happen here, at some point in 
time your plan is going to land along with this plan and that plan and 
that plan and the other plan and the House plan and the Senate plan and 
the Republican plan and the single-payer plan and the managed 
competition plan, and to the public out there it is going to look like 
the battle of the plan, which would not be so bad if they were not all 
invented in Washington, DC, a place the public has learned to hate, or 
at least distrust. And that is the environment in which we are working 
today.
  People who do not want health care reform--and there probably are a 
few Members of this body who do not want health care reform--are in the 
ascendance, at least with the people out there because the public's 
interest in the subject is waning. Its disapproval of a lot of the 
specifics is rising, which means the challenge before us is becoming 
incredibly difficult because you are not going to be able to go home 
and find a whole bunch of people, wherever you go, saying ``right on,'' 
cheering, cheering, and cheering and hollering and supporting what you 
are doing.
  So this is not an easy task. I would say, Mr. President, that it is 
going to have to lend itself very quickly to some common set of 
principles or some common guidelines on which everyone can agree, and I 
am just going to suggest a couple to the people here. One is that you 
cannot get the universal coverage, if that is the Democratic goal, 
unless you do cost containment. The second is you cannot do cost 
containment if the Government tries to do it. It is not going to get 
done. It is impossible.
  Every effort at Government competition or Government regulation or 
Government anything in this country has been a failure. You cannot 
control prices with premium control. You cannot do it with any other 
device that has been incorporated into any of these bills. So you are 
going to have to make the decision that markets can be made to work in 
health care and the only way that is going to happen is if you set some 
national rule so that all these local markets in Colorado and Rhode 
Island and Minnesota and Kansas can work. You are going to have to take 
down all of the rules that have been put into law in Colorado, 
Minnesota, Rhode Island, and Kansas that prevent competition, that 
prevent consumer choice, that prevent an assessment of what is good 
quality, and set rules that permit you to do that, because it is only 
through the functioning of free markets in this country that we are 
going to get those costs under control.
  The bottom line on the President's approach or the Labor, Human 
Resources Committee bill approach is simply this: If we do nothing 
about health care costs in this country, 10 years from now in the year 
2003 we Americans will be spending $2.2 trillion on health care in just 
1 year. That is 20 percent of our GDP compared to 14 percent today, if 
we do nothing. If we did the Clinton bill, or tried to do the Labor, 
Human Resources Committee bill that got reported out tonight, where do 
you think we will be in the year 2003? We will be at $2.07 trillion, 
which is 19 percent of the GDP.
  We do not have it. We do not have that kind of money. Right now we 
are taking it away from community services and other kinds of health. 
The deterioration in a lot of our communities and a lot of our public 
health and health prevention is directly attributable to the fact we 
are spending all our money on medical cures and miracles. You cannot go 
to 19 percent even in a nation as rich as ours. So you have to find a 
way to turn that thing around. And the answer to it is in--if anyone is 
willing, and I think more people are willing today than perhaps a week 
or a month or 2 months ago--the answer to it is here, and it is in 
bipartisan, agreed upon sets of principles expressed in a variety of 
bills that are in committee. There are bipartisan agreements on what we 
need to do to change this system. And one need only take a look at 
them, try to understand them, and I hope we will do that in the Finance 
Committee during the course of the next 2 weeks so that we can bring to 
the floor of the Senate a bill which when combined with the best in 
what the Labor Committee was able to produce will be a challenge to 
American medicine.
  I am always reminded to remind others of something that I have 
learned from 20-plus years now of dealing with this subject, and that 
is American medicine is remarkably inventive, and I do not mean just 
the drug companies and so forth. I mean the doctors, I mean the nurses, 
I mean anyone who is in this field, because it is a human service, 
human problem kind of a field, are by nature incredibly creative. And 
all we need to do is turn that creative genius, which is in tens of 
thousands of health caregivers in this country, loose on doing it 
better for less. That is how we get down, instead of going to the 20 
percent GDP, get it down to below 14--13, 12, 11 or even 10 percent--
through creative genius.
  That is how we do it with every other field of endeavor in America. 
Why not do it in health care? And the way to do it has been presented 
to us if we will look not at the Democratic plan, not at the 
President's plan, not the Labor Committee plan, not at the far right of 
the Republican Party plan, which is either there is no crises or all we 
have to do is give everybody $2,000 walk-around money and they will 
turn the system around, but look in the middle. Look where most of the 
people are who have a record for reform in this place, Democrats and 
Republicans, and I think that is where we will find our solution.
  Finally and most difficult for everyone--and I say this as a person 
who has been engaged in reform for a long time--is really a political 
challenge. Most of the Democrats, the President himself, the Kennedy 
bill and a lot of others believe we can get to universal coverage in 
this country without reforming the current $400 billion plus of Federal 
programs. And I want to stand on the floor tonight and say you are not 
going to get away with it. You are not going to get the universal 
coverage, and I wish to get there, but you are not going to get there 
with an employer mandate. You are not going to get there by pretending 
that somehow or other all of the workers in America can carry the load 
for going to universal coverage and that we who have responsibility for 
tax subsidies, Medicaid, Medicare, and all that sort of thing do not 
have to do anything, because we are afraid of the elderly, we cannot 
touch Medicare; because we are afraid of the unions, we cannot touch 
the tax subsidy that enriches the rich and povertizes the poor; because 
we are afraid of the politics of it, we cannot take on Medicaid reform.
  We are going to continue to have elderly people spend down in nursing 
homes because we have not got the guts to take on that program. We are 
going to continue to encourage young women to have children in order to 
get health care because we have not figured out how to take them on. 
And I daresay the Republican challenge to the Democrats in health care 
reform will be we will meet you on universal coverage; we ought to 
guarantee every American the right to have a private health plan that 
nobody can take away from you, but in return for that you are going to 
have to face up to the entitlement problem in this country.
  Entitlements created in the 1950's and 1960's do not work in the 
1990's because our children and our grandchildren cannot afford to run 
them the way they were contemplated to be run in the 1950's and 1960's. 
There is $400 + billion this year being spent in public subsidies to 
put the elderly and the disabled in this country into Government-run 
health care programs. Take them out of creative, changing, private 
health plans and stick them into single-payer, Government-run systems. 
What kind of a nation is this? If you are elderly, at 65, we take you 
out of a market that gives you a choice of health plans, choice of 
providers, all that sort of thing and we put you in the single-payer, 
Government-run system like you were going to Canada. And we do the same 
thing in Government disability, and we do the same thing if you are 
poor--say, sorry, you cannot be in the market with everybody else 
getting the benefit of creative new plans or HMO's or whatever it is.
  We are going to put you in our United States version of the Canadian 
system, a single-payer system. That is what it is. Think about it. 
Medicare is a single-payer system, like they have in Canada. The 
Government pays the doctors. The Government pays the hospital and pays 
the doctors 9,000 different fees for 9,000 different procedures and 
pays the hospital 468 different fees.
  It is a Government-run system. It is run by Government people--535 
Members of Congress, and the President of the United States. I thought 
the President said, ``I want a system that guarantees every single 
American the right to a private health plan that cannot be taken away 
from them.''
  Well, if that is his promise, then let us take on Medicare. Let us 
guarantee every person in America 65 years and older the right to own 
the same kind of health plan they had when they were under 65, when 
they were working but with improved benefits and a different way to pay 
for it so they can get the same benefit of this creative new market we 
are talking about that everybody else gets.
  Why can we not do the same thing for low-income people? It is not 
hard, Mr. President, to do this. But it does take political courage. 
People stand around and say we cannot do Medicare because we had a 
problem on the floor with catastrophic. Then you will not get universal 
coverage. People say we cannot take on the unfairness of this employer 
tax subsidy because somebody is going to call it a tax and fringe 
benefit. You will not get universal coverage. You will have to decide 
what you want, what is most important, and what you are willing to pay.
  I think the Finance Committee is an exciting place to be. I will 
regret that at the end of this year not having the opportunity to serve 
with the people who have been on the forefront of health care reform as 
long as I have been here. That has been the case, and it includes 
Republicans and Democrats. In fact, the Democratic leader succeeded me 
as chairman of the Subcommittee on Health Care. Together we did the 
catastrophic, and together we stood here on the floor of the Senate, 
got the vote count up to about 46 against a repeal but we could not get 
it up to 51. So it backed down to 35. There is no partisanship in 
health care reform. It takes a lot of courage to do it.
  Right now, that courage is particularly needed because the public is 
not going to be of any help to us. The naysayers are going to cut us 
down every chance they get. Then the idealists of one stripe or another 
will want to have it their way. There is a way. There is an American 
way, and everything that the President and Mrs. Clinton have said about 
health care that it is an American system, it takes American reform, 
American genius, whatever it is, that is all possible.
  Yes, today, we took the first step in that process. Six of us 
disagreed with the conclusion that 11 of our colleagues came to about 
how to do it. But I think there was a consensus there that this was the 
first step, and the next couple of steps need to come fairly quickly.
  I am grateful to have had the opportunity this evening to say what I 
have said, and particularly to express my appreciation to Chairman 
Kennedy with 30 years of leadership on his part; the staff; members of 
the committee with which I serve; and particularly to compliment, as I 
already have, my colleague from Kansas for the leadership she has 
displayed for all of us, particularly for those of us on the Republican 
side of the aisle.
  Mr. President, I yield the floor.
  Mr. PELL addressed the Chair.
  The PRESIDING OFFICER. The Senator from Rhode Island [Mr. Pell] is 
recognized.

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