[Congressional Record Volume 140, Number 101 (Thursday, July 28, 1994)]
[House]
[Page H]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: July 28, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
                       DO NO HARM IN HEALTH CARE

  The SPEAKER pro tempore (Mr. Engel). Under the Speaker's announced 
policy of February 11, 1994, and June 10, 1994, the Chair recognizes 
the gentleman from Georgia [Mr. Gingrich] for 60 minutes as the 
designee of the minority leader.
  Mr. GINGRICH. I thank the Chair for recognizing me. The title of my 
talk tonight is ``Do no harm in health care.''
  You know, the first rule of the Hippocratic Oath for doctors for over 
2,000 years has been ``Do no harm.'' If you were not sure what you were 
doing, then a doctor had an obligation not to harm the patient. And I 
think as we go into this period of trying to write a health bill, that 
we should start with that premise, that Congress should learn from 
medicine, and Congress should do no harm. If we are not sure about 
something, let us go carefully, because in health care, we are dealing 
with the life and death of individuals, we are dealing with 
relationships that can change entire industries.
  Done improperly, it is conceivable, for example, the wrong health 
reform will bankrupt the teaching hospitals of America. Done improperly 
it is conceivable that the wrong health reform will destroy the 
hospital system of New York City. Done improperly, many bad things can 
happen, and they can ruin entire communities, they can ruin industries, 
and they can risk the lives of people.
  Now, I notice that last Saturday, in the Democrat and Chronicle of 
Rochester, NY, there was an article about Rochester's health system, 
which is a very famous health system, maybe the leading managed care 
system in the country. The entire community has community managed care.
  This is the title: ``Senator Vows to Exempt Rochester's Health 
System.'' This is the article from the Rochester Democrat and 
Chronicle.

       Senator Daniel Patrick Moynihan promised to exempt 
     Rochester's health system from any harm caused by a final 
     national reform plan. When you have a system that is working, 
     when you have a model plan, you keep it that way, Moynihan 
     said in an interview. They go on to say later in the article, 
     it has been proposed, legislation has been proposed allowing 
     Rochester's regional system to operate out of any mandatory 
     or voluntary purchasing alliances.

  Now, I just want to raise this point: I am glad that the 
Representative from Rochester and the Senator from New York want to 
exempt Rochester from the national health plan. But there are 3,000 
counties in America. Should the other 2,999 counties be told, I think 
there are actually about 3,300 counties, should the other counties be 
told you do not get to be exempted, but Rochester does?
  I picked this up, because I just saw this outrageous effort to exempt 
a single county, and I was fascinated because I noticed in the 
Education and Labor version of the health bill that the State of Hawaii 
was exempted. That is the entire State.
  Let me make a clear point here. While there has been a great deal of 
publicity about Hawaii, and people talk about Hawaii supposedly having 
universal coverage, the fact is that Hawaii does not have universal 
coverage. It has about 89 percent coverage. In fact, the State of 
Connecticut has a far higher percentage of its population covered with 
insurance than does Hawaii. But apparently one of the Members from 
Hawaii, a very powerful Representative on the Committee on Education 
and Labor, was able to get an amendment adopted to that particular 
health version, which exempted the State of Hawaii. Should the other 49 
States have the same right of exemption?
  Congressman Pete Hoekstra of Michigan sponsored a bill that says 
there ought to be a referendum in each State. If the people of the 
State do not vote to be part of the national health plan, they should 
not be forced into it.
  I must say, when you see Hawaii being exempted in one bill, when you 
see a promise by a very powerful Senator to exempt Rochester in another 
place, you begin to ask yourself, maybe everybody should be exempted 
and only the White House should have to serve under the bill. Or maybe 
only Members who vote yes should have to serve under the bill.
  But it raises again a question which I have been raising for several 
days, which is, with only 2 week to go before the August recess, how 
can the Democratic leadership plan to bring a bill in, which nobody has 
read, which has had no hearings, which does not really exist yet?
  I am told they will be releasing not the bill, but principles 
tomorrow morning. Apparently, they will then be negotiating to rewrite 
the principles. And maybe by next Friday they will have begun to write 
a bill. And the following Monday or Tuesday we will start voting. But 
Members will be voting in ignorance.
  Now, this has already started. There is an article in the Washington 
Post of July 13 by David Broder entitled ``Health Care Disarray.'' It 
says the following.

       Two things make the work even more arduous than it sounds. 
     As one of those in volunteered told me last week, ``This is 
     not legislation where you can take a piece from this bill and 
     a piece from that in order to satisfy different political 
     factions or needs. It has to work as a system or you will do 
     terrible damage.''

  Broder goes on to write,

       The second problem is that some of the bills approved 
     before the July 4 break are not really bills, but notions or 
     plans approved as concepts. Many of the critical details were 
     left undefined. That is particularly true of the Senate 
     Finance Committee version, which was passed after several 
     confusing, chaotic sessions, as committee members tried to 
     get out of town. The version that the House Committee on Ways 
     and Means finished a few days earlier was also written in 
     short bursts of debate, interrupted frequently by rollcalls 
     on the House floor. Now staff Members are trying to translate 
     those ad hoc decisions into coherent legal language.

  Now, notice the contradiction in the two points that Mr. Broder 
makes. First he says, quoting a Democratic staffer, or Democratic 
Member he describes as one of those involved, he quotes them as saying 
this is not legislation where you can take a piece from that in order 
to satisfy different political factions or needs. It has to work as a 
system, or you will do terrible damage.
  Having said the first need is to have a systematic approach, let us 
go back to how he describes the Committee on Ways and Means bill. He 
said it was ``written in short bursts of debate, interrupted frequently 
by rollcalls,'' and then describing both the Senate Finance Committee 
and the Committee on Ways and Means bills, he says, ``Now staff Members 
are trying to translate those ad hoc decisions.'' Let me repeat, ``ad 
hoc decisions into coherent legal language.''

                              {time}  2010

  Notice the juxtaposition in two short paragraphs in his column 
entitled ``Health Care Disarray.'' Mr. Broder talks about it has to 
work as a system and in the following paragraph describes ad hoc 
decisions, which are, by definition, of course, not a system.
  Now, I reported the other day to the House that we had called to 
check on the Senate Finance Committee bill and it still has not been 
written. It was passed, and people could see it being passed on C-SPAN 
on July 2. So they have now had 26 days to write it, almost 4 weeks. 
But it is not written yet, because they apparently cannot finalize the 
language.
  Now we are being told that a new set of principles will be announced 
tomorrow to be voted on within 2 weeks and yet there is no language. 
Principles are not the same as legislation. Human beings can live or 
die depending on the legislation. Hospitals, industries, medical care 
can live or die depending on the legislative language.
  The deficit can be dramatically higher or dramatically smaller, 
depending on the legislative language. I remember several years ago a 
mistake was made on a Medicaid provision about 3 in the morning and the 
staff wrote the bill wrong and instead of costing $300 million, it has 
so far cost, I believe, $49 billion because it was written wrong.
  So this idea that we should legislate from a series of outlines 
without having seen the bill is, I think, utterly destructive.
  Robet J. Samuelson, a very sophisticated analyst, one of the leading 
economic analysts in the country, had the following to say in the 
Washington Post on July 13.

       Congress should simply start over. The best thing Congress 
     could do now on health care would be to start over next year. 
     The most important social legislation in a quarter century 
     should not be approved as a last minute, poorly-understood 
     patchwork.
       From the start the debate has suffered from the Clintons 
     wild promises that they could achieve universal coverage at 
     little extra cost. This has produced five inconsistent 
     congressional bills that all in one way or another fanatasize 
     a health care future that will never happen. Health politics 
     has become bumper sticker politics. Everything is being done 
     for image and immediate bragging rights.
       Vast promises are made of new benefits with little 
     effective control on cost. Health spending already 
     constitutes 21 percent of Federal spending and one-seventh of 
     all spending in the economy. The danger of a poorly-crafted 
     program is that although it might be popular in the short 
     run, it could encumber our economy with long-term commitments 
     that we simply cannot afford, warns the Bipartisan Committee 
     for a Responsible Federal Budget.
       What really is at stake is the integrity of government. 
     Popular cynicism is no secret. In surveys, Americans express 
     discontent with government, yet surveys also show that 
     Americans want more from government in the way of health 
     care, education, environmental protection and economic 
     security. Politicians pander to the inconsistencies by posing 
     government as a solution to a multitude of problems. The 
     Clintons are practitioners of this style of politics. The 
     trouble is that when the solutions do not match the promises, 
     public disillusion deepens.
       Universal coverage is a swell slogan but a meaningless 
     concept. Almost no one today has complete insurance coverage 
     against all health risks. For example, only about 45 percent 
     of the elderly have insurance for long-term care. And the 
     idea that complete coverage can be constructed is a mirage 
     because health care is an infinitely elastic concept. It 
     expands with every new technology, drug or discovered 
     ailment.
       Consider between 1982 and 1991 the number of cornea 
     transplants doubled from 18,500 to 41,500. We will never be 
     able to afford everything. Some rationing by income or 
     availability will always exist.
       What the debate skirted is the morally awkward issue of 
     whether health care is a right and, if so, what care is a 
     right. The Clintons evaded this question by promising to 
     control costs and expand benefits. The claim was always 
     dubious.
       Five outside groups reestimated the Clintons basic package 
     of insurance benefits. All found higher costs than the White 
     House did. For individual coverage, the costs were put from 9 
     to 26 percent higher. For two-parent families, the costs were 
     13 to 59 percent higher. No matter. The Clintons set 
     Congress's agenda.
       How bad are the resulting bills? Examine the Senate Finance 
     Committee bill described as moderate. Its goal is to raise 
     the share of Americans with insurance to 95 percent by the 
     year 2002. Small firms with fewer than 100 workers could buy 
     health insurance from big purchasing cooperatives. Insurers 
     would have to accept almost anyone who applied. There would 
     be insurance subsidies for everyone with an income of up to 
     twice the poverty line. In 1993, the poverty line for a 
     family of four was $14,335.
       What are the bills defects. Here with the top three: One, 
     it creates a huge off-budget entitlement. True, the bill 
     doesn't compel companies to buy insurance. But it does decree 
     what all insurance must cover and the coverage is lavish. 
     Aside from most doctor and hospital bills, it also includes 
     mental health, rehabilitation services, drug and alcohol 
     abuse services, hospice care and family planning services.
       Although a national health board would set the details, 
     Congress would have the final say. And it has little reason 
     to resist inevitable demands for new benefits because 
     mandates could be expanded without imposing new taxes.
       Two, there is no effective cost control. Indeed, because 
     the bill mandates comprehensive insurance, it would probably 
     accelerate spending. The new spending pressures would 
     overwhelm the tiny measures intended to curb costs, putting 
     small companies in buying pools and instituting a complex, 
     probably unworkable tax on high priced insurance plans.
       Three, subsidies for the poor are not financed. No one yet 
     knows how much the subsidies would cost but the tax increases 
     in the bill, the cigarette tax goes from 24 cents a pact of 
     $1.24 a pack, might cover only half the amount. In short, the 
     finance bill would probably speed up health spending, skimp 
     on subsidies and miss its 95 percent coverage target. Other 
     bills are as bad or worse.
       The House Ways and Means Committee wants bigger mandates 
     and subsidies. It pays for its subsidies mainly from savings 
     generated by price and spending controls. But no one knows 
     whether the controls would work or be acceptable. A single 
     payer bill has the honesty of avoiding mandates and pays for 
     government insurance with taxes. However, benefits are so 
     generous that by one estimate they would raise health 
     spending by an extra $300 billion by the year 2000. The 
     increase is assumed away with cost controls.
       All these bills indulge in make believe. Although they 
     sound good, they would break down in practice. A sensible 
     bill might be put together with some modest insurance 
     reforms, but this seems unlikely, precisely because it would 
     be so politically unexciting. What should not be forgotten in 
     the inevitable clamor to do something is that a bad bill 
     would be worse than no bill at all. Opposing such a bill is 
     prudence, not obstructionism. The country deserves a more 
     candid debate than Congress can provide this year.
       It is between those who consider health care a right and 
     those like me who think the first focus should be on cost 
     control.
       If it is a right, then put the spending in the budget and 
     pay for it with taxes. If the focus is cost, then curb tax 
     subsidies for insurance or impose strict spending controls. 
     Neither approach would be easy. Any sweeping reform requires 
     public understanding. This is now missing.
       ``Great innovations,'' Thomas Jefferson once said, ``should 
     not be forced on slender majorities.''

  Mr. Speaker, I think Mr. Samuelson's column is so important that it 
is worth focusing on two or three parts. First of all, he says 
``universal coverage is a swell slogan but a meaningless concept.''
  I thought the President, for a brief moment Monday, a week ago, 
admitted that Mr. Samuelson was right when the President went to Boston 
to the National Governors Association and said ``You know, maybe 
universal coverage cannot mean more than 95-percent coverage. Maybe 
that is the best we can do.'' By the end of that day, he was forced by 
the White House staff to retract what he said, and they put out a 
number of people who began to say he never said it, or he did not mean 
it, or it was all a mistake.
  I thought for a brief moment that President Clinton was beginning to 
get the message that Mr. Samuelson meant when he wrote ``Universal 
coverage is a swell slogan, but a meaningless concept.''
  Note that he described accurately the bills, and as I said earlier, 
some of the bills do not even technically exist. He is describing the 
concepts of the Senate finance bill, because the fact is the bill 
itself has not been written yet.
  He says ``All these bills indulge in make believe. Although they 
sound good, they would break down in practice.'' Mr. Speaker, I think 
that where we are is, we have 3 futures. One is the effort which, 
sadly, the President and the Democratic leadership is still committed 
to, a future in which we try to somehow write an impossible bill in an 
impossible length of time, and we do grave damage, both to public trust 
in the Congress and to the public deficit, and to the health care 
system.

  I oppose trying to write a massive, comprehensive bill in a 2-week 
period with no public hearings, with no public examination, with no 
public understanding.
  Second, we could do nothing. As Mr. Samuelson's headline of his 
column entitled ``Congress Should Simply Start Over,'' in his opening 
sentence, ``The best thing Congress could do now on health care would 
be to start over next year.''
  Mr. Speaker, I think there is a third thing we could do. It would be 
better than trying to ram through a bad bill by political manipulation, 
and it would be better than doing nothing. Mr. Samuelson alludes to it 
when he says ``A sensible bill might be put together with some modest 
insurance reforms.'' I like that term, ``a sensible bill,'' because I 
believe we could write a sensible bill.
  I believe it is possible for us to take the essence of the Rowland-
Bilirakis bill, to take the best ideas of the Michel-Lott bill, to take 
the best ideas of Senator Dole's bill, and to write an honest bill 
which does good things with almost no damage to the system. I think 
that kind of bill is the best path.
  Mr. Speaker, I urge the Democratic leadership, and I urge President 
Clinton, let us work together to write a bill that is positive, that 
could get overwhelming support on both sides, that would do good things 
without doing harm.
  We could start with malpractice reform, which one recent study said 
would save $76 billion over 5 years. Then we could go and add 
guaranteed insurance for everyone who is in the system, so that you 
cannot get a precondition. Once you buy insurance and once you are 
being insured, you could change jobs and you would not lose your 
coverage.
  We could eliminate preconditions for the insured, and that would, for 
the 85 percent of Americans who already have insurance, that would be a 
tremendous step.
  Mr. Speaker, then we could agree to allow the States to manage 
Medicaid. This is something governors, both Democrat and Republican, 
have asked for. It would clearly allow us to lower the cost of Medicaid 
and to serve poor people at less expense with greater controls by 
simply having managed care.
  Then we could allow the 35 States that currently are not allowed to 
have senior citizens buy into a managed care plan, 15 States allow it, 
but for the 35 the Health Care Financing Administration has not 
approved, simply allow senior citizens to have the choice, because in 
fact, there are managed care plans today offering senior citizens 
better coverage with prescription drugs at lower cost. That would be a 
good step.
  We could also provide for group insurance for small business. That 
would be a good step, because it would lower the cost of insurance for 
small business. Then, Mr. Speaker, we could extend the same tax 
deductibility to the self-employed, the unemployed, and the family 
farmers that we get if we are in a big corporation. That would be a 
good step.
  Also, we could provide tax neutrality, so you could either take the 
tax deduction yourself, if you wanted to buy the insurance, or your 
employer could take it, but you would not be trapped in only buying the 
insurance your employer wants you to have. That would be a good step.
  Finally, for those Americans who still would not be covered, we could 
double the number of community health center patients who are dealt 
with, and that would take care of another 4 million people who could go 
to a community health center, instead of going to the emergency room, 
and that would both save money and increase health care for the working 
poor.
  Every one of the things I just mentioned, I believe, could get 
overwhelming support from Republicans, and I believe could get 
overwhelming support from Democrats. I believe it would be possible to 
have 290 votes for the bill I just described. It would fit what Mr. 
Samuelson described when he said ``A sensible bill might be put 
together with some modest insurance reforms.''
  It would be an honest bill. It could be scored by the Congressional 
Budget Office. We would know exactly what we were doing. We would not 
harm a single teaching hospital. We would not weaken the New York City 
hospital system, which is an enormous and complex and very expensive 
system.

  We would not block anybody from leaving their home State to go to the 
Mayo Clinic, or to go to any other great center. We would not limit 
choice for individuals, in terms of choice of their doctor and choice 
of their hospital.
  We would not weaken the quality of the best health care system in the 
world. We would have established no new Government bureaucracies in 
Washington. We would establish no new Government controls in 
Washington.
  However, we would have improved for every individual who is self-
employed, every individual who is unemployed, every family farm, every 
small business, we would have improved dramatically their access to 
health care, and we would have guaranteed for the 85 percent of 
Americans who already have health care that they could change jobs 
without any fear of precondition, and that they could never lose their 
insurance coverage if they got a disease or an illness.
  Mr. Speaker, every one of those items could be passed by an 
overwhelming majority. I like the quote that Mr. Samuelson had from 
Thomas Jefferson: ``Great innovations should not be forced on slender 
majorities.''
  It seems to me we want to pass a health bill that the American people 
are convinced does no harm, and the best way to do that is to have a 
bipartisan effort with the Democratic leadership and the Clinton White 
House sitting down with the Republican leaders and writing a bill at 
the leadership level. It will be far better to have a Gephardt-Michel 
bill in the House, to have a Mitchell-Dole bill in the Senate, to have 
the President in a position to be for a positive bill. The President 
would have lowered his sights and would have accepted less than he 
might like, but he would be accepting things that everyone could agree 
are good, without imposing things that are destructive. Then we would 
not have to have Democrats trying to exempt the county that Rochester 
is in. Then we would not have to have Democrats trying to exempt the 
entire State of Hawaii.
  My challenge is this, Mr. Speaker: If any place is going to be 
exempted, every place ought to have the right to be exempted. This 
should not be a matter of power politics, and somebody on the right 
committee, or somebody with the right friends getting a special deal.

  If we are going to start exempting, then every county in the United 
States should have the same opportunity that some Democrats want to 
give to Rochester. If we are going to start exempting, then every State 
should have the same opportunity that some Democrats want to give to 
Hawaii.
  However, Mr. Speaker, if something is so bad that we have to talk 
about exempting, if something is so destructive, so harmful, so 
dangerous that we have to start talking about making sure that our 
particular county is not in it, or our particular State is not in it, 
maybe we should not do it to anybody. Maybe something so bad, that it 
requires exemptions, should not be passed in the first place.
  Mr. Speaker, let me just say in closing, I think it will be a 
terrible mistake for the President and the Democratic leadership, I 
think it will be a terrible mistake for the Congress and a terrible 
mistake for the country if there is an effort made to ram through a 
comprehensive health bill without public hearings, without adequate 
understanding, without a chance for the news media to take it apart, to 
look at it, without an opportunity for experts to analyze it.

                              {time}  2030

  Mr. Speaker, I want to close by going back to the way in which Mr. 
Samuelson closed his column.
  He said, ``Any sweeping reform requires public understanding. This is 
now missing.''
  If there is an understanding and if it is a comprehensive bill, what 
did Mr. Samuelson suggest?

       What should not be forgotten in the inevitable clamor to 
     ``do something'' is that a bad bill would be worse than no 
     bill at all. Opposing such a bill is prudence, not 
     obstructionism.

  So I would say, if we have to, we are prepared to try to stop a bad 
bill. But that would be a sad thing. Far better to work together to 
produce a good bill; far better to produce a bill that the American 
people can have faith in; and far better to write a modest but positive 
bill that does no harm, that we can publish and let people look at.
  I go back to what I suggested a few days ago, because it is the acid 
test. If we could introduce a bill in writing the last day we are in 
session, if we could then go home for the 3 weeks of the August recess 
and allow the country to see the bill, if we could then, having had 
people look at it in public, having had them take it apart, if we could 
come back and in the opening 2 or 3 days in September clean up any 
mistakes we learn about during the recess, improve it a little bit, and 
then pass it by overwhelming Republican and Democratic majorities, then 
I think we would have done something worthy of the Congress. Then we 
could be proud that we had followed the right procedures. And then we 
could go home and say, yes, this is a start. And next year we will do 
something that builds on this. But at least what we did was right and 
harmed no one.

                          ____________________