[Congressional Record Volume 140, Number 89 (Tuesday, July 12, 1994)]
[House]
[Page H]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: July 12, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
                NEBRASKANS' VIEWS ON HEALTH CARE REFORM

  The SPEAKER pro tempore (Mr. Johnson of Georgia). Under the Speaker's 
announced policy of February 11, 1994, and June 10, 1994, the gentleman 
from Nebraska [Mr. Bereuter] is recognized for 60 minutes as the 
designee of the minority leader.
  (Mr. BEREUTER asked and was given permission to revise and extend his 
remarks and include extraneous material.)
  Mr. BEREUTER. Mr. Speaker, it is quite coincidental that I am 
speaking after the gentlewoman from Ohio [Ms. Kaptur], but then indeed 
the subject is the same. I have great admiration for the gentlewoman's 
approach to gathering the information from her constituents which she 
referred to as part of the heartland of America. The part of the 
heartland I represent is a little farther west. But I have no doubt 
whatsoever that the gentlewoman's approach to bipartisanship and a 
greater focus on what our constituents are telling us is the proper way 
to proceed, and while my constituents would probably come up with a 
somewhat different plan than the gentlewoman's constituents happen to 
come up with, I think that many elements are the same.
  Mr. Speaker, this evening this Member will attempt to summarize 
Nebraskans' views on health care reform or health insurance reform as 
they have expressed their views to this Member.
  Mr. Speaker, for the past several years, health care reform or health 
insurance reform has been the dominant issue at most of this Member's 
town hall meetings. This year, this Member has received more mail and 
more citizen contact on this issue of health care reform or health 
insurance reform than on any other issue ever faced in this Member's 
time serving in Congress.
  Until the last 3 months or so most of that mail was self-generated, 
not a result of a mail-in campaign of postcards or other 
communications, and almost one-third of that mail began with the 
phrase, ``I have never written to another public official before, 
Congressman, but I want you to know that * * *'', and they then pour 
out in detail their heartfelt concerns, fears, and desires. In many 
cases they would supplement their remarks with illustrations about 
expensive or unmet health care or health care insurance problems they 
or their family has faced in the past.

  Here is what the Nebraskans from around the whole State who have 
written to this Member or told me at 40 town hall meetings I have held 
thus far which were focused primarily on health care, to the extent 
that one can gather a consensus. They are first of all concerned that 
government really does not do anything well. They are worried about 
turning over one-seventh of our economy--the health care industry--to 
still greater governmental control; worried about the size of 
bureaucracy; and worried about a bureaucrat coming between them and 
their physician, other health care providers, and their health care. 
Also, based upon the Medicare and Medicaid precedents, for example, 
they say, ``given that history with Medicare and Medicaid costs, How 
can you really expect that the projected costs of health care reform 
proposals are going to be realistic?''
  Second they are concerned about health care rationing. When 
government is given a larger role in health care, it is clear from 
experiences in other countries that soon there inevitably will be some 
kind of constraint or limit imposed upon health care costs, and with 
constraint, along with it comes health care rationing. People are 
concerned that they will be told ``you are simply too old or you have 
medical conditions that do not warrant this kind of procedure or 
operation.'' They are also concerned they may be told ``you may have to 
wait 3 or 4 months to see if in fact we have any funds left for this 
kind of elective surgery.'' In addition, many people are aware of the 
reports that hospitals in Toronto shut down for about 4 weeks, except 
for emergency care, because of budget restraints in Canada.

  Third, Nebraskans tell this Member that they are concerned about 
losing their choice--the choice of their own physician, other health 
care providers, or choice of hospital. They want to maintain that 
choice and they are very concerned that a larger Government involvement 
in health care may cause them to lose their choices or current options.
  Fourth, they are interested in securing what might be called 
portability, the opportunity to take health care coverage from one 
employer to another without a gap in coverage, without being concerned 
that a pre-existing condition will prevent them from maintaining health 
care coverage with the second employer, or that they will be paying a 
substantially larger amount because of a discovered medical condition 
when they change employment or retire.
  Fifth, they are concerned about the escalating cost of health care, 
and especially hospitalization. The same is also true of long-term care 
or nursing home care. They are not quite sure, frankly, how to address 
this problem. Many have graphic examples of what certainly seem to be 
excessive costs, and a few have cost-containment ideas, but for the 
most part there is simply recognition that health care costs have been 
escalating far more rapidly than the overall inflation rate. They also 
have that same concern about health care insurance premiums. In fact, 
when this Member conducted his biennial agriculture advisory committee 
meetings this year, at three of the four meetings the very high and 
increasing cost of health care premiums for the farm families was the 
most frequent issue raised.

  This leads this Member to comment on a concern expressed and shared 
not just by farmers but by many Americans, especially the self-
employed. Our country has currently great inequities between what 
people directly pay for their health care insurance, and it has great 
inequities in the way our tax system treats individuals with respect to 
the deductibility of health care insurance premiums. For example, many 
Americans employed by large corporations, and certainly many of the 
largest unions' employees and some local and State employees have 100 
percent of their health care premiums paid for by their employer as a 
negotiated employee benefit. If the employer is a corporation, of 
course, those costs become a corporate cost of doing business which is 
deducted like any other business expense before corporate taxes are 
calculated. Now, on the other end of the spectrum are the self-
employed, be it farm families, or any self-employed persons working in 
a city or elsewhere. For the self-employed, who pay 100 percent of 
their health care premiums, the most they can deduct on their income 
taxes is 25 percent of the cost of their health care insurance 
premiums. This also represents a very large inequity in this respect.
  Sixth, citizens are concerned about the cost of prescription drugs. 
Many Americans have had direct experience, or contact with friends and 
neighbors, allegedly being able to go to Mexico, and apparently, buying 
the same drug produced by the same company, even manufactured in the 
same factory, for one-half to one-third the cost that they can buy that 
drug in the United States. Therefore, they are convinced that there is 
cost shifting going on, which suggests to them that in this country the 
charges for prescription drugs are based less on cost plus a reasonable 
profit and more upon what the market will bear. Relatedly, many other 
Americans bring us the concern about cost shifting which is 
precipitated by the fact that the cost constraints imposed on Medicare 
and Medicaid for providers, hospitals, and at nursing homes simply 
causes those reduced payments from Medicare and Medicaid patients to be 
balanced by shifting more costs to the private-pay or insurance-pay 
patients.

  Seventh and finally, among the strong consensus views of Nebraskans, 
especially in this case from small businesses and some of their 
employers: they are quite concerned that the employer mandates, the 
requirement that the employer pay for 80 percent of more of their 
employees' health care premiums. They fear such a mandate will make 
that business noncompetitive, or force it out of business. They are 
very concerned about that prospect, and that is an overwhelmingly 
strong concern among small business families.
  Mr. Speaker, it has been said that somewhere around 15 percent, or 
perhaps slightly more of the American public, is not covered by 
Medicaid and does not have health care insurance. That amounts to about 
37 million Americans. Much of the debate and concern has been focused 
upon whether or how to provide health care insurance or coverage for 
those 37 million Americans or that 15 percent of our population. If you 
break those numbers down it is said by some that perhaps one-half the 
people in the 15 percent could afford health insurance but choose not 
to buy it. Most of those people apparently are young individuals and 
young couples who make the decisions that they can avoid major illness 
and thus avoid paying for health insurance at that stage of their life; 
they simply choose to use their money for other purposes. But certainly 
there must be, it is suggested, about 5 to 8 percent of the American 
public that would like to have health care insurance but who simply 
cannot afford it, and they are not eligible for the Government's 
welfare-related medical program, Medicaid. A very substantial 
percentage of this Member's constituents by letter and at town hall 
meetings suggested, ``perhaps we need to focus on that 5 to 8 percent, 
because after all it was President Clinton that stood up at the State 
of the Union message and said, waving his pen, `I will veto any plan 
that does not provide for universal coverage.' So if that's the 
problem, my constituents go on to suggest, ``why don't we simply focus 
on that 5 to 8 percent of Americans who want health care insurance but 
who cannot afford it, instead of radically changing, or 
dramatically altering, the health care system that we have today, and 
the health care insurance system that is a part of it.''

  Mr. Speaker, that seems to this Member, and it seems to them, to be a 
commonsense approach. They are worried that in the process of making 
these dramatic changes in American health care, we may lose what is 
best about American health care. After all, they point out quite 
appropriately, ``the best quality health care delivered in the world is 
delivered in this country.'' The problems are affordability, and in 
some cases, especially in rural and sparsely settled parts of the 
Nation, in accessibility.
  Mr. Speaker, the following supplementary information to the foregoing 
remarks is a synopsis of health care letters received through May 1994. 
It constitutes a brief summary of the most common or consensus views 
and beliefs on health care issues which were expressed to this Member 
by letter from Nebraskans up through and including the month of May 
1994.

                           I. Main Responses


                           A. GENERAL REFORM

       The overall expression in the health care reform letters 
     was that a massive and comprehensive reform of our nation's 
     health care system was not needed. Many stated that there is 
     no crisis. In fact the majority of the people are very happy 
     with their current system of health insurance and care. It 
     was often pointed out that the American health care system is 
     the best in the world, so why would we want to change it? 
     Most did concede that some small reforms and changes are 
     needed to lower the cost of health care and to give universal 
     care and insurance to all citizens, but they feel that there 
     is no need for a drastic and substantial reform. Two well-
     known phrases were often used to express the feelings on 
     reform, ``If it's not broke, don't fix it,'' and ``Don't 
     throw the baby out with the bath water.'' The letters convey 
     the message that the average consumer does not want an 
     overhaul of the current health care system.


                           B. ADMINISTRATION

       An overwhelming majority of the constituent letters voiced 
     opposition to government control of the health care system 
     because it would eliminate freedom of choice and take away 
     the principles of democracy. Many people said that the 
     government was already too involved in public life and 
     that a government-run health care system would be a 
     disaster. They pointed out that the government is much too 
     inefficient to run such a large and important business. A 
     number of people believed that rather than administering 
     the health care system, the Federal Government should 
     regulate it, and a new and large bureaucracy is not 
     needed.
       The largest reason given for this opinion is that it would 
     eliminate the people's right to choose. They are afraid that 
     a government system will take away their right to choose 
     their own provider and insurer. A great number of people were 
     vehemently opposed to this. They do not want the government 
     telling them which doctor they will see or limit the number 
     of specialists that are available to them. They also do not 
     like the concept of a Mandatory Alliance because it will not 
     allow them to choose their own insurer.
       Many persons were also afraid that the cost of building a 
     new system would be massive and greatly add to the Federal 
     deficit. They were also very opposed to a tax increase to 
     fund this new system. Most people feel that they are already 
     paying too much in taxes and any significant tax increase 
     would create an insurmountable burden on them.


                              c. insurance

       The main objections of insurers are the suggested mandatory 
     alliances. Concern was also expressed regarding employer 
     mandates. The insurers feel that a mandatory alliance would 
     kill their industry, especially an alliance that disallows 
     the purchase of any supplementary insurance. Many owners and 
     employees of independent insurance companies are extremely 
     concerned that these alliances would eliminate a great number 
     of jobs. Many of them suggest that a voluntary alliance would 
     be a much better alternative. They feel that this would 
     ``promote a free-market, competitive environment in which 
     both corporate and independent insurers can survive.''


                           d. small business

       Many small business owners, all with less than 150 
     employees and most of them with less than 15 employees, feel 
     that a government mandate for purchasing health insurance for 
     their employees would cause them to shut down. They feel that 
     their business cannot afford to pay either a certain 
     percentage of their employees health insurance or an 
     alternative payroll tax. They argue that this would cause a 
     rise in unemployment and a subsequent rise in people without 
     health care, which would defeat the purpose of reform. 
     Several of the business owners specifically mentioned that 
     they are currently providing health insurance for their 
     employees in a manner which satisfies the employees. They do 
     not want to be forced to change this because of a government 
     mandated health alliance or through employer mandates or 
     payroll taxes.


                              e. abortion

       There were a great number of responses on this subject--
     more than any other--with the overwhelming majority opposed 
     to the funding of abortion in any public health care plan. 
     Many of these letters and cards also expressed their 
     opposition to the ``hidden rationing'' of health care under 
     President Clinton's plan. They feel that it would be horrible 
     to deny a person, especially the disabled or elderly, life 
     saving care because of their ``quality of life.'' They felt 
     that this is discrimination. However, number of letters 
     supporting the coverage of all reproductive services, 
     including the full funding of abortions, were received.

             II. Other Issues With Smaller Response Levels

       There were a large number of other issues that were given 
     either significant support or opposition to inclusion in a 
     new health care package. They are as follows:


                           a. long term care

       About half of the letters specifically mentioned the 
     inclusion of community-based long-term care or home-based 
     long-term care because they have loved ones that are 
     dependent upon these services.


                       b. pre-existing conditions

       A large number of people were very supportive of the 
     elimination of pre-existing condition limits in a new health 
     insurance plan. Most of them were personal letters that 
     described family situations or stories of people being denied 
     insurance because of a pre-existing condition.


                         C. MALPRACTICE REFORM

       Many letters were in favor of setting a cap on malpractice 
     compensation so as to relieve doctors of excessive 
     malpractice insurance costs. They feel that if the provider 
     pays less for malpractice insurance, that will translate to 
     lower fees.


                             D. PORTABILITY

       Many people are in support of the portability of insurance 
     between jobs.


               E. UNIVERSAL COVERAGE AND UNIVERSAL ACCESS

       A greater number of people mentioned they were in favor of 
     universal coverage than the number of people mentioning 
     support universal access. Many people seemed to use the terms 
     interchangeably not realizing the difference between them.


                              F. RATIONING

       A great number of people, other than those in opposition to 
     abortion, opposed the rationing of health care.


              G. REDUCE PAPERWORK AND INCREASE EFFICIENCY

       This category received support because people felt that 
     reducing paperwork and increasing efficiency would decrease 
     needless claim forms and bureaucracy. Some specifically 
     mentioned the use of a standard claim form for doctors' 
     offices, hospitals, and insurance companies.


                           H. PRICE CONTROLS

       Substantial opposition was noted for a control over the 
     cost of physician care. There were also some people that 
     opposed the use of a cap to control premium costs.


                     I. MEDICARE OR MEDICAID REFORM

       There were an appreciable amount of people who supported 
     reform in this area, especially physicians because it would 
     reduce the costs-shifting to paying customers that occurs 
     when doctors must compensate for income lost on Medicare or 
     Medicaid reimbursements. A greater number of people opposed 
     the reform of Medicare or Medicaid because it is currently 
     meeting their needs. They state that there is no need to cut 
     a program that is working fine.


                            J. QUALITY CARE

       Individuals expressed the desire to ensure that health care 
     reform does not effect the quality of health care available 
     to the consumer.


               K. HEALTH MAINTENANCE ORGANIZATIONS (HMO)

       A number of people specifically objected to being placed in 
     HMO-type of care.


                   L. CIGARETTE, ALCOHOL, AND GUN TAX

       A number of people objected to increases in these taxes.

         III. Issues Desired to be Included in Health Care Plan

       Following are list of services/occupations that a 
     significant number of people (predominantly health 
     professionals and some consumers) wish to be included in 
     health care reform. The more prevalent ones are listed first.


             a. mental health and substance abuse treatment

       Many constituents want mental health and substance abuse 
     services to be included in the standard benefits package. 
     They want this category of care to be treated the same as are 
     other medical fields and procedures. The professionals were 
     in particular support of a benefits package that reduces 
     costly inpatient care and emphasizes outpatient care.


                           b. preventive care

       A substantial number of people believe that there should be 
     an emphasis on preventive care services.


                         c. prescription drugs

       Numerous letters expressed the desire to have prescription 
     drugs covered as part of any standard benefits package 
     (including Medicare coverage.)


                            d. chiropractic

       These constituents desire to have chiropractic care 
     included in any basic benefits package. The letters were 
     evenly split between Chiropractors and patients.

               IV. Different Plans for Health Care Reform


                            a. clinton plan

       The vast majority of letters were in opposition to the 
     Clinton plan for numerous and varying reasons. These reasons 
     generally ranged from opposition of government run mandatory 
     alliances to the opposition of ``hidden rationing.'' Those in 
     support of the Clinton plan generally gave no reasoning or 
     explanation as to why they chose to do so. Some did indicate 
     that they liked the President's plan simply because it was a 
     means of providing all persons with some form of health care 
     insurance.


             b. mcdermott/wellstone ``single-payer'' system

       Numerous people voiced their opposition to a Canadian-style 
     system because they feel it would be socialistic which has no 
     place in our government. They mention that Canadians and 
     Europeans are coming to America to receive health care. 
     ``People look to us as the model system for health care, so 
     why are we going to change it?'' The opposition also did not 
     like the possibility of waiting in line for health care that 
     seems to be prevalent in that type of system. Proponents of a 
     single-payer system disagreed saying that the Canadians are 
     very happy with their system. They also liked the fact that a 
     single-payer system provides universal coverage and noted the 
     low cost of the plan.


                      c. ``fee-for-service'' plan

       The majority of the letters supported a ``fee-for-service'' 
     approach to health care reform.


                       d. medical savings account

       Many people wrote to specifically support such an account 
     or what some referred to as a ``Medical IRA.''
       Twelve Key principles of health care reform favored by this 
     member include the following:
       (1) Tort reform airmed at excessive malpractice costs.
       (2) Portability of insurance as employees change jobs.
       (3) A simplified standard claim form.
       (4) More emphasis on preventive health care.
       (5) Greater standardization of minimum insurance coverage 
     programs among the states.
       (6) Maximizing the ability of Americans to choose their 
     health care providers and supplemental insurance policy.
       (7) Additional emphasis for a national health service corps 
     to provide health care services to rural and other undeserved 
     areas.
       (8) Marketing reforms, such as voluntary purchase pools--
     for small businesses and individuals.
       (9) Tax fairness so self-employed and individuals get the 
     same tax treatment as corporations and their employees.
       (10) Anti-trust reform, so hospitals, providers, etc., can 
     jointly purchase or share equipment and technology at reduced 
     costs.
       (11) Vouchers and tax credits to help low-income, Medicaid-
     ineligible individuals afford coverage.
       (12) Flexibility for states so that they can better manage 
     Medicaid and reduce costs, and continue innovation reforms at 
     that level.
       In general, I favor an approach that would combine the best 
     of public and private elements, maintain quality, cut 
     bureaucracy, emphasize affordability, and preserve the best 
     features of our private health insurance system. In addition, 
     as a Nebraska I want to ensure that any changes are adaptable 
     for the conditions in rural areas.

  Mr. Speaker, my Nebraska constituents have given we a clear and 
strong consensus of their views on health care reform or health 
insurance reform. This member will be working and voting to implement 
their views for their common sense views, and concerns from the 
heartland of America also represent the American mainstream.

                          ____________________