[Congressional Record Volume 140, Number 99 (Tuesday, July 26, 1994)]
[Senate]
[Page S]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: July 26, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
                           HEALTH CARE REFORM

  Mr. KERREY. Mr. President, my colleagues and I this morning have come 
to the floor to talk about health care reform. We are the group, or at 
least part of the group, that has been described as the mainstream 
coalition.
  We come today with great respect for the work that is being done this 
week by Majority Leader Mitchell who is writing and intends to 
introduce shortly a health care reform bill which he hopes to enact 
this year. To be clear, we do not come to the floor to oppose Senator 
Mitchell. Rather, we come constructively hoping that our work will help 
him achieve the majority he seeks.
  From the beginning of this debate, we have held to the belief that 
health care reform must transcend party politics. Thus, the mainstream 
coalition is a combination of two bipartisan bills. The first, Senators 
Breaux, Durenberger, and Lieberman introduced a bill called the Managed 
Competition Act of 1993. The second, Senators Chafee, Danforth, Bond, 
and later, Kerrey and Boren, among others, sponsored a bill called the 
HEART bill.
  The mainstream coalition bill is a combination of these two pieces of 
legislation, with additional input and suggestions and changes made by 
Senator Bradley of New Jersey and Senator Conrad of North Dakota. While 
there are differences, the Senate Finance Committee bill derives most 
of its operative mechanisms from this mainstream effort.
  Mr. President, the coming together of this group of Republicans and 
Democrats is not accidental. We did not unite because of a desire to 
position ourselves in the center or to appear more moderate. Instead, 
we are united by the following set of common assumptions:
  First, Americans spend too much on health care. Sheltered by a third 
party reimbursement system which now socializes the cost of 80 percent 
of all health care bills, Americans have been on a spending binge. The 
problem is not--and I repeat is ``not''--that we do not spend enough; 
the problem is that we spend too much.
  Second, the market can control costs, reduce inefficiencies, 
eliminate waste, and minimize fraud. Just 3 years ago, there was 
considerable doubt about this fact. Today, after unprecedented change 
in the market, the good news is that we can count on the market to be 
our best ally for controlling costs.
  Third, the Government will be needed to help tens of millions of our 
citizens who will not be able to pay the bills without our collective 
effort. At some point, the market breaks down and our conscience will 
not allow any American to be denied access or coverage. One way or the 
other, we are going to pay. Our moral character will not permit us to 
turn anyone away. Either we pay with direct, clear, and fully disclosed 
subsidies, or we pay indirectly with cost shifts. The mainstream 
coalition prefers to go direct.
  Fourth, we politicians--representatives of the people--cannot be 
trusted to say ``no'' to increased demands for public spending. The 
definition of health is constantly broadening, technology is coming on 
line at break-neck speed, our life spans and expectations continue to 
grow and, given the chance, we would rather have someone else pay the 
bills. Thus, the mainstream coalition believes we need a failsafe 
mechanism to guarantee and enforce a balanced Federal health care 
budget.
  Fifth, if we politicians suffer the malady of not being able to say 
``no,'' in the private sector the comparable problem is greed. Across 
the board, the current system is ripe for gaming at considerable cost 
in public and private dollars. Not only do we spend a lot of money, we 
waste a lot of money. What we need is a system where accountability and 
consumer access to information is our No. 1 virtue. The market will not 
work unless we get engaged in the job of evaluating price and quality. 
To do the work of making these evaluations, we need to know whether a 
procedure is worth the price. We need to know if a less expensive 
alternative exists and whether the outcomes would be comparable.
  Sixth, most Americans will need to change their behavior to make this 
work. If we expect something for nothing, we will not make it work. If 
we expect to live forever, we cannot make it work. And if we continue 
to finance sickness instead of health, we will wonder why it does not 
seem to work. Doctors are going to have to change; hospitals will have 
to change; pharmaceutical companies and equipment manufacturers are 
going to have to change; and most important of all, Americans--as 
patients, payers, and citizens--are going to have to change to make 
this work better.
  Seventh, we need health care reform which rises above party politics. 
The only way the American people will support reform is if it has the 
support of the majority of both parties in this Congress. A 51-vote 
strategy just will not work. High costs and lack of coverage in our 
health care system are neither a Republican problem; nor a Democratic 
problem; they are an American problem.
  Eighth, we must pass a health care reform bill this year. We are 
dedicated to working toward this end. If we do not, costs will continue 
to rise and fewer and fewer people will be able to afford health care 
coverage. The President and the First Lady have done this country a 
great service. Even though we will not be passing their legislation, we 
will be passing a bill thanks to their leadership and effort.
  As I said earlier, Mr. President, the foundation of the mainstream 
coalition is the Senate Finance Committee bill. This is not a perfect 
product and needs some change. However, it is a good beginning, and we 
believe it has the best chance of passing Congress this year.
  The mainstream bill is similar to other approaches on the left and on 
the right. It contains insurance market reform; subsidies for low-
income families; extended tax deductibility for self-employed and 
individual taxpayers; cost containment; expanded choice; administrative 
simplification; malpractice reform; antifraud and abuse provisions; and 
a set of mechanisms which move us rapidly toward universal coverage.
  The mainstream coalition bill is a national market-based solution to 
health care reform. It sets up a framework of national rules that allow 
local markets to operate more efficiently to deliver high-quality 
health care at affordable prices to all Americans.
  The highlights of market based reform are:
  First, establishing national standard benefits packages and national 
standards so that consumers can choose among health plans based on 
quality and cost effectiveness.
  Second, market-based cost containment, including incentives to 
encourage cost-conscious consumer purchasing.
  Third, small market reforms, such as eliminating preexisting 
conditions as a reason to deny coverage, adjusted community rating, and 
voluntary purchasing cooperatives.
  Fourth, allowing large employers to continue to play a central role 
in keeping health care costs down through active negotiation with 
health plans.
  Fifth, administration simplification.
  Sixth, provisions to combat fraud and abuse.
  Seventh, malpractice reform.
  Eighth, a failsafe mechanism which does not allow deficit financing 
of Federal health care spending.
  Mr. President, we do not believe we can or should reform everything 
in this first year. In essence, we are not only fixing those things we 
are certain are broken, we are preserving those things which are 
working well. Future reform will be made easier by mechanisms which 
require full disclosure of how much is being spent at the Federal 
level, which taxes are being used to make those expenditures, and who 
is paying and who is being subsidized.
  Mr. President, I would like to issue this warning for those who are 
uninitiated in the ways of health care reform: Sometimes it seems like 
God has put this issue on Earth to torment us and amuse Him. It is an 
issue guaranteed to make you humble. Humility comes when you discover 
that many actions designed to help create as many problems as they 
solve.
  Fifty years ago, Americans were given special tax breaks designed to 
make it easier to buy health care.
  While it has become a sacred fringe benefit, tax deductibility has 
also encouraged us to buy, buy, buy with little regard for price.
  Thirty years ago, Americans passed national health insurance for our 
citizens over 65 and a Federal-State payment system for citizens who 
could prove they were poor or disabled. While these programs have 
reduced the suffering and fear of old and young alike, they have also 
driven tremendous new demand into a market that responded with more 
expensive technology and solutions driving costs higher for everyone.
  Today, our efforts to hold down costs by focusing on prevention and 
the financing of health instead of sickness can save money in the short 
run but cost us money in the long run. Death, the symptom we all seek 
to avoid at all costs, is not only low cost but it is in the end 
unavoidable. If we expect our hospitals and doctors to give us eternal 
and pain-free life, we are knocking on the wrong door.
  Mr. President, the majority leader says that he is days away from 
laying down a bill before this Senate which will set the stage for as 
good a debate and discussion of the economics and morality of health 
care as Americans have ever seen. I believe that the Senators in this 
body are ready to do the work. The mainstream coalition hopes that most 
of the Senate Finance Committee bill is include in this proposal. If it 
is, we will begin with bipartisan agreement and proceed to honest and 
easier to understand nonpartisan differences of opinion. With this as 
our beginning, I do not doubt we will end by enacting reform which 
satisfies the American people.
  Mr. President, I close by thanking the distinguished Senator from 
Rhode Island, who has been working a long time on health care reform. 
It does seem to an awful lot of people who are outside of this process 
that all we are doing with the mainstream coalition is trying to cobble 
together a bill but, as I have tried to indicate, there are significant 
unifying agreements that have held this group together and that give, I 
believe, the American people a clear sense of how it is that we want to 
reform health care to not only give the American people a sense, but 
the majority leader a sense as well of what it is that needs to be done 
if we expect to enact health care reform in 1994.
  Mr. President, I thank the Chair, and I yield the floor.
  The ACTING PRESIDENT pro tempore. The Chair will advise the Senator 
from Nebraska, under the previous order, controls the hour until 9 a.m.
  Does the Senator yield time?
  Mr. KERREY. I yield such time as is necessary for the Senator from 
Rhode Island.
  The ACTING PRESIDENT pro tempore. The Senator from Rhode Island is 
recognized.
  Mr. CHAFEE. Mr. President, I thank the Chair and the distinguished 
Senator from Nebraska for his comments. He has been a really key player 
in the coalition that he described, which goes under the name of the 
mainstream coalition. He has been working on this since certainly last 
November and really prior to that. I thank him not only for his work 
there but for his remarks this morning.


                         Privilege of the Floor

  Mr. CHAFEE. Mr. President, I ask unanimous consent that privileges of 
floor be granted to Doug Guerdat of my staff.
  The ACTING PRESIDENT pro tempore. Without objection, it is so 
ordered.
  Mr. CHAFEE. Mr. President, following up on what the distinguished 
Senator from Nebraska said, in November of last year a bipartisan group 
of Senators, and I think it is very, very important to note the term 
``bipartisan'' because we have Democrats and Republicans involved in 
this group, began to work on a compromise for health care reform. We 
were drawn together by a common goal of believing that this issue was 
important enough that it should not be destroyed by party politics. We 
really had two objectives.
  The first objective was to assure that every American had access to 
affordable health care coverage. That was the first thing. Every 
American.
  Second, we wanted to do something to slow the rate of growth of the 
cost of health care.
  In this group of Senators were Senator Kerrey from Nebraska, Senator 
Durenberger, who just spoke so well here, Senator Breaux, Senator 
Danforth, Senator Boren, Senator Bond, Senator Lieberman, Senator 
Bradley, Senator Gorton, Senator Conrad, and myself. And we became 
known as the mainstream coalition.
  Earlier this month, as has been pointed out, the Senate Finance 
Committee reported a health care reform bill, and that Senate Finance 
Committee bill embodied the principles of the mainstream coalition.
  What were some of those principles? They have been ticked off here 
both by the Senator from Minnesota and the Senator from Nebraska.
  We wanted to eliminate, and we did, job lock so that insurers would 
not be able to refuse coverage to anyone, either he or she, who came in 
and who were sick. In other words, you could not be kept from getting 
insured because of a preexisting condition.
  We provided subsidies to the low- and middle-income families to help 
them in the purchase of insurance. The way we did this, Mr. President, 
was we started covering those who were 90 percent of the poverty level 
or below.
  Who are we talking about? These are the working poor. As the Chair 
knows, if someone is on an assistance program, that individual will 
receive Medicaid. It is when the people go to work, leave the assisted 
program, AFDC, or whatever it might be, take a job where the job does 
not provide health care coverage, that individual is really giving up a 
lot. He or she is giving up the insurance that comes with Medicaid if 
one is on an assistance program.
  So what we do is we start providing a voucher to purchase health 
insurance to those at 90 percent of the poverty level or less. Then we 
move upward and extend that to those who are 100 percent of the poverty 
level, and indeed we go up as high as 200 percent of the poverty level. 
At 200 percent of the poverty level, we do not pay the entire premium. 
It is on a declining scale, as you move up from 100 percent of the 
poverty level to 200 percent. These are the subsidies I am referring 
to.
  Next we eliminate the onerous paperwork that doctors and hospitals 
have to fill out in order to have a bill paid. We reduce the cost of 
medical malpractice insurance both for doctors and hospitals by 
reforming the medical liability laws.
  This is a very, very important part of our plan, that we go into 
considerable detail. We do not just say reform medical liability. We 
have a whole series of specifics. We put a cap on pain and suffering of 
$250,000. We have limitations. First, we require that if someone wants 
to sue a doctor or sue a hospital, he or she must start off with an 
alternative dispute resolution approach. In other words, go through an 
arbitrator. You cannot just go directly to the courts. One has a right 
to appeal from the decision of the arbitrator to the courts, but first 
one must start through the alternative dispute resolution route.
  We provide workers with the choice of health insurance plans. If you 
work for a large company, you must have a choice of at least three 
plans. And we give them comparative information so that these 
individuals can choose the plans based on quality and based on price. 
This is all involving the uniform benefit package, as the Senator from 
Nebraska previously outlined.
  We increase the number of doctors and nurses in rural and urban areas 
where there are shortages of health care providers. We allow those who 
are self-employed or individuals to deduct 100 percent of the health 
insurance cost. It is clearly an anachronism existing in our health 
insurance deductibility privileges now. As the Presiding Officer knows, 
if you work for a large company you can receive the most grandiose of 
health care programs, and that is not taxable to you as an individual. 
That is what is known in the trade as a tax-free fringe benefit. If you 
leave that company and you go out on your own, as an entrepreneur, as a 
farmer, as any individual, individual practitioner of the law, for 
example, first, if you so seek to buy health insurance, clearly it is 
more expensive than if you are part of a big company. The plan you get 
will cost you much more than it cost General Motors for that same plan. 
But when you pay for that plan, you can only deduct 25 percent of the 
cost. It is an outrage.
  Why should you get it all free when you work for a company, but when 
you go out and do what we think is right in America, go out and have 
your own business, when you start out it costs you more to get the 
program to start with, and then you can only deduct 25 percent of it?
  We provide under our plan you can deduct 100 percent of that. We 
increase the availability of primary care and preventive services.
  We believe that at a minimum these reforms, and they are reforms, 
will provide comprehensive health insurance coverage to more than half 
of the uninsured population that is out there now.
  As the Chair knows, the statistic that is commonly used is 37 million 
Americans at any one time are without health insurance coverage, for a 
variety of reasons. First, they cannot deduct it or can only deduct 25 
percent of it. Second, it is very, very expensive. Third, they cannot 
afford it. So for a variety of reasons, they are not covered. Fourth, 
they have a preexisting condition.
  We believe that these reforms that I have delineated here will cover 
more than half of those 37 million Americans. In other words, 20 
million Americans who are out there now uninsured, a very substantial 
percentage of them children, will be able to get health insurance 
coverage with these reforms that I have mentioned.
  This objective can be met without imposing any mandates on small 
business. This does not rely upon the so-called employer mandate or an 
individual mandate.
  Why are we objecting to the employer mandate? We believe that many 
small businesses would be forced to lay off their employees or shut 
their doors if they were required to provide insurance under the so-
called employer mandate which currently provides, under the plans that 
have been presented, that the employer pay 80 percent of the health 
insurance premium of every single one of his or her employees.
  In addition, we believe that this can be done without adding to the 
Federal deficit. We are hopeful that, with additional financing, we 
will be well within striking distance of universal coverage by the year 
2002.
  Now, you will note that I used the term ``universal coverage.'' It is 
a little fuzzy what universal coverage means. Does universal coverage 
mean 100 percent, everybody in the United States of America covered, 
every citizen or every legal alien? I do not know. I suspect that 
universal coverage does not mean 100 percent. I suspect that universal 
coverage means probably something in the neighborhood of perhaps 97, 98 
percent.
  But we believe that under our program we can reach 95 percent of 
everybody in the United States and with some additional financing we 
think we can get up close to the 97, 98 percent by the year 2002.
  Many have criticized our approach by saying that, ``OK, you reached 
95 percent, but what about the other 5 percent of the population?''
  That is a misrepresentation of our program. We say that at least 95 
percent of Americans must be insured by the year 2002. That is what we 
say in the mainstream approach, and, indeed, that is what is in the 
Finance Committee bill. If that goal is not met, if we do not reach 95 
percent coverage, then Congress must act on a series of recommendations 
to increase insurance coverage.
  Opponents of our approach paint a picture of 12.5 million Americans 
uninsured who are either too poor to buy insurance or so sick that 
insurance companies will not sell policies to them. In reality, we 
provide subsidies to help low-income and middle-income Americans 
purchase coverage, and we prohibit insurers from denying coverage to 
those who are sick.
  On the other side of the political spectrum are those who try to 
paint our proposal as Government intervention at its worst. They label 
our subsidies as a great big new entitlement program and accuse us of 
eliminating consumer choice.
  Mr. President, within the next few weeks, the Senate will begin 
consideration of health care reform. We do not yet know the details of 
the proposal that will be brought to the floor by the majority leader, 
Senator Mitchell. But I am absolutely convinced that no health care 
reform bill will pass this year without strong bipartisan support. I 
believe just as strongly, as does the Senator from Nebraska, who has 
been such an important member of our group, that it is essential that 
any health care reform measure pass by a very, very strong majority in 
this body. It will be unfortunate if some kind of a program sneaks 
through 52-48 or 51-49 or 53-47. That does not lay the stage for a good 
future for health care reform.
  I seek a program that is going to pass here 80-20 or 70-30, a 
healthy, strong, bipartisan support for that measure on the floor of 
the Senate.
  I believe Congress has the unique opportunity to enact legislation 
this year. We, as members of the mainstream coalition, have been forced 
to make certain compromises. In this bill that we are supporting, not 
every one of us are for every feature of it, but we submerged our own 
beliefs in order to get strong bipartisan support for the whole.
  Some support employer mandates; others individual mandates. Some 
support limiting the tax deductibility of health insurance plans. That 
is the so-called tax cap. If you poll the members of the mainstream 
coalition, nearly half of them are for the tax cap; the other half are 
against it. So those who are for it said, ``All right, we will back 
off, because it is something that is disapproved by half of our 
group,'' and, also, the belief that many on the Democratic side feel 
very strongly against the so-called tax cap.
  Some advocate a single benefit, standard package, while others wanted 
no standards. So we had to make some compromises. Each of us had to 
give up something in order to reach an agreement.
  Despite our willingness to find a workable middle ground on this 
issue, certainly passage of a health reform bill this year is not 
assured.
  Last week, the President stated at the National Governors' 
Association meeting in Boston that the general approach we had was 
something he could support. Immediately, he was attacked by some 
members of his own party as selling out on the proposition of universal 
coverage.
  If we do not succeed in enacting health care reform this year, 
certainly the blame will not lie with members of the mainstream 
coalition who are so anxious to get something done.
  I might say we are under attack from both ends of the political 
spectrum and sometimes we are accused of being traitors to our 
respective parties. We are also being attacked by special interests who 
feel threatened by the approach that we have taken.
  If we do not succeed--this mainstream coalition and others who are 
dedicated to getting a bill that will pass--it will be because, Mr. 
President, extremists on both sides of the aisle refused to compromise. 
There are those who seek perfection and there are those who do not want 
to do anything. And if they can get together and defeat what the others 
want to achieve, it seems to me it would be very, very unfortunate.
  As the Chair well knows, in political life there is a saying that the 
perfect is sometimes the enemy of the good. What does that mean? That 
means that those who seek everything, those who want the employer 
mandate and everything that goes with it, who are not going to budge an 
inch, may well end up with nothing. And so it is best to settle for 
something that can be passed.
  This is not the last time we are going to be dealing with this 
subject. This subject is not to be heard of never in the future once it 
is passed in 1994. We will have a chance to revisit it in 1995, 1996 
and in future years.
  So, Mr. President, it is my fervent hope that we do not let this 
great opportunity that we have here to do something significant in 
connection with those points that I ticked off and the Senator from 
Nebraska previously ticked off--doing something about persons in 
cooperatives, doing something about preexisting conditions, reform of 
the insurance market, doing something about medical liability reform, 
and making certain that those who are individually self-employed have 
full deductibility of their health insurance premiums.
  These and a whole series of other reforms should be enacted this 
year. I certainly hope we do not let this opportunity slip between our 
fingers.
  I thank the Chair.
  I yield the floor.
  Mr. KERREY addressed the Chair.
  The ACTING PRESIDENT pro tempore. The Chair recognizes the Senator 
from Nebraska [Mr. Kerrey].
  Mr. KERREY. Mr. President, am I correct we have until 9:05? Is that 
the order?
  The ACTING PRESIDENT pro tempore. The Senator from Nebraska controls 
the time until 9 a.m.
  Mr. KERREY. Mr. President, in the 10 minutes left, unless some other 
Members come, I would like to talk about a couple of things that I 
think are going to be very actively debated after the majority leader 
lays down his bill.
  The first is the idea of cost control. One of the arguments that is 
gaining a lot of favor is you cannot get cost control until you get 
universal coverage, and you cannot get universal coverage until you get 
cost control. It is a very nice little phrase. It seems to be 
persuasive just because it has a certain balance to it. And, though I 
believe we need mechanisms to get us as quickly as possible to 
universal coverage both for moral and for economic reasons, I believe 
the evidence is rather startling that we are getting cost controls now.
  Indeed, one of the most important things for us to do as we begin 
this debate is to open up our windows and look out and see what is 
going on in the market. To ask people to bring us information about 
what the market has been doing for the last 3 years will produce, I 
believe, some rather startling and good news for colleagues who are 
trying to figure out how it is that we should control costs of health 
care. The market is working. We hear some objections to it. That is 
where the ``any willing provider'' issue comes from. It comes from 
people who are saying, ``Gee, the market is working too well.'' We hear 
complaints from people who are saying, ``Gee, all of a sudden people 
are actually competing for my services and they are not guaranteeing me 
the job and income I had before.''
  The market does that, as we all know. It is working. It creates some 
insecurities. It creates some difficulties. It creates some 
uncertainty. But the stunning change, the unprecedented change that is 
going on right now in the market I believe should give us a 
considerable amount of confidence and provide us with a clue about how 
to reform the other programs that we operate--particularly Medicare and 
Medicaid--how to get the Government programs under control, and how to 
produce the revenue that we need, the money that we need to extend 
coverage to every single American.
  The second thing I would say that is sort of connected, is why I, for 
one individual, one Senator, do not like the proposal to mandate that 
businesses purchase insurance. To be clear, not only do I not object to 
asking people to pay who are free riding the system; not only do I not 
object to that, indeed I am an advocate of making sure that every 
single American pays something--has some contribution. That 
contribution ought to be based upon their capacity to pay. My objection 
to the mandate has to do with a number of considerations.
  First, it is a regulatory device. It is indirect and thus it is far 
less efficient than going direct. If we see an individual or a business 
whom we believe ought to be paying, we ought to go direct. We have a 
tax system in place and we ought to have the courage to go direct, if 
we see somebody free riding the system, and get the money from them. 
That would be, in my judgment, a far simpler, a far more efficient way 
to approach it.
  The second problem I have with the mandate of insurance is that it 
embeds additional costs in employment. We already have businesses that 
are making decisions about technology, making decisions about hiring, 
that are adverse to employment as a consequence of saying, ``I have 
$10,000, $12,000, $15,000, sometimes $20,000 a year in cost of hiring 
before I ever get to a salary, before I ever decide what the wage is 
going to be.'' Thus, we are saying here is another $3 or $4 an hour, in 
some cases, we are going to impose as an embedded cost of employment 
that employers will factor in before they make hiring decisions.
  There are far more progressive ways for us to generate the revenue--
particularly if we go direct, it seems to me. I think the mandate--in 
my judgment--must be seen as a way for us to generate revenue to pay 
for the bills. But I think it is a very inefficient way to do it and is 
also something which will embed cost in employees and I believe create 
a disincentive, the very kinds of disincentives we do not want to have.
  The distinguished occupant of the chair has spoken eloquently on the 
floor about crime and has alerted an awful lot of people who had sort 
of fallen asleep at the switch about the problem of crime. All of us, 
when we go home and wrestle with the problem of crime, typically come 
to the conclusion, at least I do, that one of the unifying things that 
solves this problem is a job. If somebody has a job and is working, 
particularly a job that produces some sense of dignity, some sense of 
self-worth and value, it is far less likely that individual is going to 
turn to crime.
  Thus, if we pass legislation that discourages people from hiring at 
the very time we are saying we want them to hire more, I think we will 
create the kind of environment that will make it difficult for us to 
solve other problems.
  The next thing I would talk about--as much as I believe the market 
can work, I will make it clear that there are times when I am prepared 
to say let us pay the bills. There are many Americans out there who are 
simply not going to be able to pay the bills. They are disabled, they 
have lost the capacity to earn--for whatever the reason, they simply 
cannot pay the bills. I am prepared to pass the collective hat.
  I have had the opportunity, as a consequence of my own disability, to 
visit many, many people in hospitals. When I meet the person about whom 
I have said, ``My gosh, I do not think they are going to be able to pay 
for the prosthesis; I am not sure they are going to be able to pay for 
the rehabilitation,'' I have yet to find myself in a situation where I 
did not think I could persuade 99 percent of the citizens of Nebraska 
to pass the collective hat to help those individuals pay the bills.
  There will be times when it is necessary for us to pass the hat. And 
we are not going to be able to do it with premiums. We are going to 
pass the collective hat through our tax system and we are going to make 
expenditures through our tax system. In other words, Government is 
going to finance this thing. Either directly or indirectly, Government 
is going to be involved in financing it.
  The question for us must be, first, in what circumstances do we 
finance it? And, second, once we have decided to finance it, what is 
our source of revenue? One of the things I will argue that we need in 
this legislation is a much more honest budget and much more strict 
accountability on our part required when we finance. Let me give an 
example.
  It would surprise most Americans to hear the numbers of what the 
Federal Government currently spends. I go home and I hear people say, 
get the Federal Government out of health care, who, very often, are 
getting Federal money. At a townhall meeting I heard a woman get the 
entire audience to give her a standing ovation when she said, 
``Whatever you do, get the Federal Government out of health care.''
  I am always interested in standing ovations and so I was kind of 
curious about her own circumstance, and discovered that she is on 
Medicare. Furthermore, she is on the Frail Elderly Program, which means 
that Medicaid is paying her part B. In her mind, Medicare is not a 
Government program. She is a good person, an intelligent person, but in 
her mind Medicare is not a government program.
  I have heard so-called private sector business people who are 
involved in hospitals that are 501(c)(3) tax exempt operations, that 
think of themselves as private sector businesses, that are getting at 
least 40 percent of their revenue from the Federal Government. Many 
rural governments get over 70 percent of their tax dollars from the 
Federal Government.
  We need to disclose this, otherwise it is going to be very difficult 
for us to decide where do we want to help pay bills; and, once we have 
made that decision, how do we want to pay for them?
  This year, in 1994 fiscal year starting October 1: $318 billion of 
direct spending and $70 billion of tax spending. That is the decision 
we have all made. Very few people have stood on the floor and objected 
to those expenditures; a $38 billion increase in spending at the 
Federal level from last year to this year. But the only dedicated 
source of revenue that we have is a payroll tax and a premium.
  The payroll tax generates about $90 billion; the premium generates 
about $15 billion. Mr. President, we are about a couple of hundred 
billion dollars short. I say to my colleagues and the citizens who 
wonder where we get the money, we get the money from other taxes. A 
full 28 percent, by my accounting, of income tax dollars, and 28 
percent of corporate income tax dollars, are collected and used to pay 
for Federal health care spending today. Without people knowing about 
it, without our having informed them that that is what we are doing, it 
is impossible, in my judgment, for us to have an informed and rational 
and constructive debate--not only, as I said, about where are we going 
to pass the collective hat.
  I want to make it clear to you, Mr. President, I have seen far too 
much tragedy and far too much suffering out there to say otherwise. I 
am willing to pass the collective hat. I prefer to subsidize other 
people. I do not want to be subsidized. To be clear, if I am being 
subsidized a couple of hundred thousand dollars a year, that means I am 
sick, and I would rather not be sick.
  Much more important, we need a rational debate. Once we have decided 
that we are going to provide assistance, whether it is Medicare or 
Medicaid or the VA or the Army or Air Force or Navy or Marine Corps or 
CHAMPUS or Federal Employee Health Benefit Program or an NIH or the tax 
deductibility and the FICA offset--once we have made the decision to 
provide the subsidy, then we need to have a debate about which taxes 
are we going to use to pay the bills.
  I hope that my colleagues understand that we have come to the floor--
and there is a large group, a mainstream group--we have come to the 
floor to engage in a constructive debate. We want to help Senator 
Mitchell pass a bill this year. He has committed to getting that done 
in 1994, and I can think of no greater piece of good news than to have 
Senator Mitchell, as the majority leader, now in the homestretch, 
working to get that done.
  I see Senator Bond on the floor. Mr. President, does the Senator from 
Missouri wish to speak? I yield the floor to the Senator from Missouri.
  The PRESIDING OFFICER (Mr. Campbell). The Senator from Missouri is 
recognized.

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