[Congressional Record Volume 140, Number 114 (Monday, August 15, 1994)]
[House]
[Page H]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: August 15, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
                           HEALTH CARE REFORM

  Mr. DURENBERGER. Mr. President, I really appreciate the indulgence of 
the Senator from Hawaii, who is currently occupying the chair. The hour 
is late and the majority leader has already announced that we may be 
here all night and morning tomorrow. So I wish to express, as I begin 
my comments, my appreciation to him and maybe more particularly, since 
he is elected to do that, to all of the staff here at the same time who 
are not able to leave until I finish this statement.
  The comment by my colleague from South Dakota about health care 
reform, about an understanding of Government's role, reminds me that we 
are going to be here for quite a while. If we cannot understand the 
difference between the Federal Employee Health Benefit Plan and 
Government-run programs like Medicare and Medicaid, I, for one, am 
going to spend a lot of time here educating my colleagues, and I do not 
want anybody to call it a filibuster.
  The Federal Employee Health Benefit Plan, or plans, if you will, are 
a series of health plans which all of us have an opportunity to buy. 
But they are all private plans everybody in this community can buy if 
they have an employer who provides it to them or they can buy it in the 
open market.
  There are Blue Cross/Blue Shield plans in that, and I think there is 
a Kaiser plan in this community, but they are private plans. What they 
do is ensure all of our access to the doctors, hospitals, and so forth, 
that we need in this area--Washington, DC, northern Virginia, Maryland, 
and so forth--but it is basically a private plan.
  It is an American system. The doctors and hospitals set the fees. 
They charge the insurance companies. The insurance companies pay the 
bills. You pay your deductible or your cost share, something like that. 
That is an American system. This one happens to be very costly.
  I can get the same health plan in Minnesota for half of what I pay 
for it here, for example, and you are all paying 72 percent of that 
bill. But it shows you that health care costs in one community can 
differ substantially from another.
  My son and his wife just had a child by cesarean section in St. Paul, 
MI. It was about $6,000 for the doctor and hospital bill. Here in this 
community it is like $14,000, $15,000. That is why your health care 
expenses are so high in this community. But it is still basically your 
American system.
  But inside that American system we run a Canadian system. We run it 
right here. For the poor, it is called Medicaid because they are 
welfare eligible. For the elderly, it is called Medicare. For people 
with disabilities, it is Medicare. But it is run by the Government. All 
the prices are set right here by the Government, just like in Canada. 
There are 7,000 procedures that doctors can use and each one has a 
dollar value, and we set that value, or it is set over here, just like 
Canada. There are 468 procedures in hospitals. Every one of them has a 
price put on it by a Government agency and that is what is paid. Every 
year we decide how much money we are going to spend on Medicaid--we, 
the Government--and Medicare. And to the extent that the cost to the 
doctors and hospitals goes up faster than what we pay, what do you 
suppose happens to the difference? The difference is shifted onto the 
private system here in the District of Columbia or back home.
  So make no mistake about it, we are running a Canadian system right 
inside America, in every community in this country. It is called 
Medicare and Medicaid.
  It is about time we stopped it. It is about time we stopped it. If we 
did not have an American system around onto which we could shift the 
bills, we would be in trouble because you cannot keep working for 59-
cent dollars if you are a doctor. You cannot keep working for 71-cent 
dollars if you are a hospital. It does not work. So only the cost shift 
makes it possible to keep doctors and hospitals serving Medicare and 
Medicaid patients.
  But suppose everybody were in a Government system and all doctors got 
paid 59 cents on the dollar and all hospitals got a buck on the dollar. 
You would not have doctors and hospitals. That is what is happening in 
Calgary, and that is what is happening in Canada. If the Canadians did 
not have a United States, there would not be any medicine in Canada, 
and it would cost a lot more.
  So when people make these comparisons about how cheaply it is done up 
there, and so forth, versus what is done down here, remember, the same 
thing is happening right here in your own community.
  Health care reform used to be, and maybe still is, possible. But Bill 
Clinton says we cannot find an immediate solution to the health care 
reform problem because Bob Dole ``never stops moving to his right.'' 
How many times have we heard that statement? Bob Dole keeps moving to 
his right so we cannot get him to stop and get health care reform.
  Well, Bob Dole about 5, 6 weeks ago decided he was not moving 
anymore, if that is what they were accusing him of. He introduced a 
bill with 40 Republicans on it, and he stopped moving. There it is.
  There it is. So we are waiting for President Clinton to decide how 
close to Bob Dole he is going to come. That is what this whole issue is 
all about. The other fear in all of this, and let us say that is Bill 
Clinton's problem right now, he cannot figure out if he is fearful of 
what Bob Dole might do. I doubt that he might fear Bob Dole might move 
any further. Bob Dole's concern is there are four Republican Senators 
who might sign on to a modified version of Senator Mitchell's bill thus 
depriving him the power of the filibuster. That is the other side of 
this problem. If the Mitchell bill is as bad as we all say it is, and I 
believe it is--I will not take your time tonight to debate that, you 
can understand why the minority leader, the Republican leader, with the 
responsibility riding on his shoulder--83 percent of my phone calls 
from Minnesota, and over 2,000 we have gotten, are all negative on this 
health reform bill. Look at the responsibility he has. He has four 
Republican Senators that might switch, leaving him with only 40 votes. 
What does he do? So unfortunately, a lot of this debate is driven by 
leadership concerns.
  Tomorrow those of us in the so-called mainstream rump group on our 
right will present our package of bills. It is very similar to the bill 
that Senator Chafee and others put together called S. 1770, as modified 
by the work we did on the Finance Committee, the learning curve that we 
have all been on; very bipartisan arrangement. We had 17 Members at the 
last meeting, Democrats and Republicans. It is no longer just a handful 
of us. It certainly is not just three Republicans who started out on 
it.
  Tomorrow, I understand Sam Nunn and Pete Domenici and David Boren and 
Bob Bennett will also put in a bipartisan bill. So you will have two 
major bipartisan pieces of legislation, and Senator Dole's bill with 39 
other Republicans on it. Then the question is going to be for the 
people on this side of the aisle, when are you going to move it? They 
are going to suggest to us that we ought to go through an amendment 
process in order to bring us to the middle. I am here to tell you that 
is not possible.
  As I said earlier, I am on both of these committees. I have been 
through this several times already--the drafting process, and putting 
bills together. I am a cosponsor with John Breaux on a bipartisan bill 
which has now moved to its right, passing Chafee on its way, if you 
will. You cannot amend that bill. We would be here until the first of 
the year, if we were going to try to amend that Mitchell bill, not just 
because it is in its third iteration, because it was too complicated to 
begin with.
  Our staffs for a dozen committees spent literally 4 straight days 
last Friday, Saturday, Sunday, and Monday--not this past week, but the 
weekend before that--going through the first iteration of the Mitchell 
bill. They came to us frustrated at the end of the day on Monday saying 
that you cannot amend it. You will not believe this language.
  So it is not hardhearted filibustering over here. It is people for 
the most part with a genuine concern for doing health policy right who 
have looked at that bill, and said as a practical matter we cannot 
stand here, even if we got off of our opening speeches, finally, and 
got to the heart of this debate--we cannot stand here and make this 
bill what the American people deserve.
  There is clearly a concern also articulated by an article today which 
I will ask unanimous consent be printed in the Record in full at the 
conclusion of my remarks, by Bill Safire in the New York Times called, 
``Why the Rush?'' in which he talks among other things about, ``The 
health care push, on the contrary, is now seen by voters for what it 
is: a return to Great Societyism.'' That is a characterization of 
Clinton-Mitchell.
  After calling the Dole-Packwood insurance reform bill sensible, he 
says:

       Mitchell's first fallback position was launched as a bill 
     to set up a compromise with a group headed by Republican 
     Senator John Chafee of Rhode Island.
       Chafee had been placed at the head of the bipartisan group 
     that has labeled itself ``mainstream,'' not so subtly 
     suggesting that conservative opposition to Government-
     dominated medicine is extremist.
       Obviously, Chafee is using Mitchell's liberal bill as his 
     lodestar.

  To that, I say bull. We have invested on this side of the aisle 4 
years in reform breakfasts, every Thursday morning starting in August 
1990, just down the hall; for an hour every Thursday morning with lots 
of Republican Senators. Last fall, 20 Republican Senators signed up on 
a John Chafee bill.
  So this notion that somehow or other a rump group with Chafee put in 
charge of it is--what does he call it?--``using Mitchell's liberal bill 
as his lodestar,'' that somehow or other we are here sneaking a 
Democratic bill through a Republican caucus just does not hold up.
  So for those of you who think that everyone seems around this place 
as William Safire obviously does, maybe as some people hope, I am here 
to tell you there is no truth to it.
  Partisan rhetoric, Mr. President, is what this debate has been 
characterized as. I would characterize it more as a lack of problem 
definition, and a substantial difference on solution as we have gone at 
the health care reform debate so far.
  One issue in particular needs clarification. That involves what is 
called the standard benefit package. I have been reading since I 
discovered the material from the Progressive Policy Institute. Let me 
tell you what the Progressive Policy Institute is, although the current 
Chair may know what I am talking about. It is a project of the 
Democratic Leadership Council. It is a center for policy innovations, 
to develop alternatives, a conventional left-right debate. Thank God 
somebody is doing it.
  Anyway, from the publication they put out in June of this year, let 
me read:

       The key issue in health care reform is this: Where should 
     responsibility for restraining costs be lodged, in the 
     Government or in market? PPI supports a decentralized 
     approach, seeks to harness the power of choice, competition 
     and market incentives to control cost, to enhance quality, to 
     reward efficiency, to encourage innovation, and to empower 
     consumers. It promotes individual responsibilities instead of 
     bureaucratic micromanagement as the remedy for our current 
     cost-unconscious health care plan.

  It is a terrific presentation. They point out some of the problems in 
the current system. The main problem they say is what is called risk 
skimming in the insurance business. This is a process by which health 
insurance companies compete with each other by avoiding risks rather 
than managing them--risk skimming, in which health insurance companies 
compete by avoiding risks rather than managing them.
  What is the answer to that? It says here on page 8: ``Create a 
standard benefits package.''
  If you do not like risk skimming or risk avoidance, because it leads 
to cost unconscious health care financing, then the answer is to create 
a standard benefits package. This gives consumers a basis for comparing 
competing plans, like we do in the Federal employee health benefit 
plan, one of the few places in America where you can actually open up 
the book, and you can actually compare the plan. But you have to have a 
standard benefit package in order to compare these plans. It is not 
some Government scheme. It is simply a way to make a comparison, like 
opening up the catalog, whichever catalog you get in the mail, and see 
the statistics for your golf hobby, compare golf clubs, compare golf 
bags, and compare golf balls. That is basically what we are talking 
about here; competing, comparing, plans. It prevents insurers from 
segmenting the market by offering customized packages of benefits.
  Alain Enthoven illustrates the problem of segmenting in this way: 
Imagine two health plans, one that offers vision care but no podiatry, 
and another that offers podiatry but no vision care. People with bad 
eyes and good feet sign up for the first plan; those with good eyes and 
bad feet sign up for the second. Differences in price will be 
irrelevant to people who choose a plan because it meets their 
particular needs.
  Some Republicans have equated the standard package with the loss of 
freedom, loss of choice, loss of all of this sort of stuff we are going 
to lose.
  Some Democrats have equated the standard benefit package with a giant 
entitlement program which describes every kind of a service you could 
possibly imagine jammed into this program. So no wonder it is confusing 
to people watching it.
  So tonight I want to step back to the first principle and try to put 
a context on the discussion, and then I will suggest to my colleagues 
why the Dodd amendment, which is the pending business, is not good for 
the health of moms and babies, why a benefit package is part of 
insurance reform. I have already laid the ground work for this.
  There seems one element of health care reform everybody wants 
included, and that is insurance reform. The idea of a standard benefit 
package is essential to insurance market reform. We all seem to agree 
on many of the elements--guaranteed issue, renewability, limits on 
preexisting conditions--but we cannot have informed consumers 
purchasing health plans on the basis of price, value, satisfaction with 
the services and quality, unless there is a similarity or a 
comparability about the product that is being sold.
  There are 27,000--get this--in the State of North Carolina, there are 
27,000 Blue Cross-Blue Shield plans. Every one of them is different. I 
do not mean 27,000 people with Blue Cross-Blue Shield plans; I mean 
27,000 different Blue Cross-Blue Shield plans. They are going after the 
people with the good feet and this sort of thing. That is what is going 
on out there today. There are 1,400 insurance companies who are all 
looking for healthy people to sell insurance to.
  Contracts present a confusing array of options, exclusions, and fine 
print. People are frustrated even if they have a choice when they 
discover what they bought is not what they thought it was. Let me tell 
you about a policy sold to the daughter of one of my staff in the State 
of Florida. It was offered to graduate students--she had become a 
graduate student at the University of Florida--by a private insurance 
company. She is a 24-year-old single woman. The policy excludes sports 
injuries, reproductive services, injuries associated with the use of 
drugs and alcohol, and has a lifetime limit of $200,000, and no 
coverage for outpatient services. The policy excludes 90 percent of 
what a 24-year-old woman is likely to use and, God forbid, she gets a 
serious illness, because in Florida, a $200,000 lifetime limit is not 
going to get her through a catastrophe. So the price is low, only $500 
a year. She is going to discover that it is not real coverage when she 
experiences health problems.
  We need some standardization so consumers can exercise real choice, 
and we need it so we can protect consumers from risk selection through 
benefit design.
  The Senator from Texas said earlier that 85 percent of Americans have 
health insurance, and most of them are happy. That is not true. It is 
true they have health insurance, but they are not happy. Many do not 
have any choice. Others know they are paying a higher price for the 
same product than somebody who lives next door and works for another 
company in the same town. We would not have started doing health 
insurance reform 4 years ago if all the Americans who had insurance 
were happy with it. They are not.
  My friend, Don Nickles, has a 22-year-old daughter who bought one of 
those $500 plans. He does not know yet what she bought. I hope he is 
listening. What Don does not know if, in fact, the law permitted him to 
include her on the FEHB plan, or whatever it might be, it would 
probably cost him and his wife $100 a year, maybe not even that.
  Whether people buy an HMO or PPO, or whatever it is, everyone 
choosing a plan in this program knows what they are buying. What am I 
talking about? I am talking about the Health Insurance Plan of 
California, HIPC. This is like the Federal Employee Health Benefit 
Plan, an HMO product. They have indemnity products, and so forth. This 
is the HMO product. What this has is a list of the benefits on the 
left-hand side, and then what you must pay to get that benefit, and 
what some of the services are that are described in that. But the 
important thing is over here on the left-hand side.
  This is not a list of all the services available to you; it is a list 
of the basic benefits to which you are entitled. And all this does is 
help you as a consumer compare among all the plans that are offered. 
Somewhere in the back of this book it lists each of the plans. You can 
go through each, the Sharp Health Plan, the Qual-Plan, the Smart Care 
Plan, and so forth. And you can get the detailed information of those 
plans. This is the heart of it. This is the comparison. Benefits are 
over here--1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, up to 14 
benefits. By comparison, the Mitchell plan has 16 benefits and myriad 
services. The Finance Committee bill has 12 benefits. But it does not 
have a whole lot of services listed.
  Well, the benefit plan really got its origin around here in the 
Federal Employee Health Benefit Plan. While we are debating whether our 
benefits ought to be 61 pages in length, which is a whole list of 
services, or just one page in length, like the Finance Committee 
package. Let me remind everybody that the Federal Employee Health 
Benefit Plan, which all of us have, is described also on one page. We 
do not need 61 pages of services. We do not need--and I will get to 
this in a minute--all of this stuff the Senator from Connecticut wants 
us to ram into every health plan in America. Yet, the FEHBP benefit 
plan is pretty simple: Hospital, surgical, in-hospital, ambulatory, 
supplemental, and obstetrical. Under the indemnity benefit plan are 
similar categories. In the Finance benefit package, there are: 
Inpatient and outpatient care, including hospital and health 
professional services, emergency services, and clinical preventive 
services, mental illness and substance abuse, family planning services, 
family planning services and services for pregnant women, prescription 
drugs and biological, hospice care, home health care, outpatient lab, 
radiology, and diagnostic, outpatient rehabilitation services, vision 
care, dental and hearing aids for kids under 22. That is it.
  Where do the services come? They sure do not come in here, if you are 
smart. The services come in the plan you buy in the District of 
Columbia, northern Virginia, or Maryland. That is where you find all of 
the services. Every year you determine how well your plan is doing with 
the services they have agreed to provide to you. But benefits are 
categorized like these 12 basic benefits for the purposes of 
comparison, not for the purposes of making sure the chiropractors get 
in every plan, or that we have, as the Senator from Connecticut 
suggests, a periodicity schedule in all of our insurance plans in 
America. That is not the purpose. The services come from the plan you 
buy. The services are developed by your relationship with the medical 
professionals in your community. The benefit package is put in the 
statute in its 12 components, and in the case that we recommend, 
elaborated on by a benefit commission.
  A category of covered benefits is a general term, like I have 
illustrated--hospital, outpatient care, whatever. It incorporates 
thousands of items, such as bandages, pacemakers, cancer surgery, 
office visits. You do not have to put that in a statute in order for 
you to be entitled every year to a choice of plans that will give you 
that service. But you need a basic benefit set by which each of these 
plans can be described so that you can be protected from the skimming, 
so that you have the information to which you are entitled as a buyer 
at which you can compare all of these plans.
  So what has happened to the concept of a basic or standard benefit 
package? It fell into the hands of the task force at the White House, 
and it was captured by special interests of all kinds. What was once a 
tool to help the market work better for people got subverted into a 
giant entitlement program.
  Clinton had 61 pages of detailed and specific items and services. I 
am going to read to you just one of those pages. This is under 
``Durable Medical Equipment and Prosthetic and Orthotic Devices.''

       (a) Coverage.--The items and services described in this 
     section are--
       (1) durable medical equipment, including accessories and 
     supplies necessary for repair, function, and maintenance of 
     such equipment;
       (2) prosthetic devices (other than dental devices) which 
     replaces all or part of the function of an internal body 
     organ (including colostomy bags and supplies directly related 
     to colostomy care), including replacement of such devices;
       (3) accessories and supplies which are used directly with a 
     prosthetic device to achieve the therapeutic benefits of the 
     prosthesis or to assure the proper functioning of the device;
       (4) leg, arm, back, and neck braces;
       (5) artificial legs, arms, and eyes, including replacements 
     if required because of a change in the patient's physical 
     condition; and
       (6) fitting and training for use of the items described in 
     paragraphs (1) through (5).

  What is the point of all this? What is the point of all of this? What 
it does is handicap your doctor and your plan from being creative 
because once it is put in the law you cannot change it. We have not 
changed the statute and other descriptions of the health benefit plan 
since 1960. So once you decide colostomy bags are in and out that is it 
for colostomy bags.
  So, this looks like Congress making promises to provide lots and lots 
of specific items and services. Whatever happened to the doctor making 
judgments? What happens to innovation? What happens when there is a new 
procedure or treatment?
  My friend Connie Mack is right to be concerned about this. He 
expressed concerns on Saturday. It is bad enough that the President 
wanted Congress to draft benefit contracts in legislation, not 
satisfied with Congress creating a benefit contract in legislation. 
Senator Mitchell goes even further. He has removed some legislative 
detail, but he creates a huge regulatory bureaucracy called the 
National Health Benefits Commission with a long list of powers and 
regulatory activity.
  And instead of having all this detail, or quite all this detail, he 
creates his National Health Benefits Board which will:
  First, promulgate regulations and establish guidelines;
  Second, establish and update periodicity schedules for items and 
services, including clinical preventive services;
  Third, design mental illness and substance abuse services;
  Fourth, establish criteria for determinations of medical necessity or 
appropriateness;
  Fifth, set up procedures for determinations of medical necessity and 
appropriateness;
  Sixth, issue regulations and guidelines to be used to make 
determinations of whether items or services are medically necessary and 
appropriate;
  Seventh, recommend to the Secretary specific areas for which 
priorities should be given to undertake clinical trials or establish 
practice guidelines;
  Eighth, establish cost-sharing schedules;
  Ninth, develop legislative proposals for modifications to the 
actuarial equivalence provisions;
  Tenth, undertake studies on the costs of adding dental benefits for 
adults, in vitro fertilization coverage, substance abuse cost sharing.
  This is not private insurance. It is a big Government bureaucracy 
just like all my colleagues have been describing it. It smells like 
HCFA, which is a huge bureaucracy employing over 4,000 people in 
Baltimore to price 7,000 medical services and nearly 500 hospital 
billing codes called DRG's.
  What do we do now, Mr. President? We must go back to basics.
  So do we junk the concept because it has been completely subverted by 
our left.
  No, we go back to basic principles.
  In his remarks Saturday my colleague Connie Mack praised the FEHBP 
program for the choices it provides.
  FEHBP has a standard benefit package. I have just described it to 
you. It is one page in length, same size as the Finance Committee, only 
the Finance Committee has 12 amendments in it.
  The FEHBP has an implementing body. It is called the Office of 
Personnel Management. OPM has approximately 118 people in it like the 
huge resources department in a large corporation.
  It issues what looks like a set of guidelines or instructions. It is 
called a call letter. They take this one page that is in the statute 
and then they issue to all the health plans in this area, for example, 
something called a call letter, in which they invite plans to submit 
annually what their bids would be. That is the way it works.
  It sets up the parameters upon which those health plans and insurers 
offering to see or compete in the FEHBP market, what conditions they 
must meet.
  Lots of insurers bid to offer the categories of benefits along the 
parameters that OPM sets forth in their call letter. OPM is not a 
regulatory agency.

  OPM has 117 employees working on all aspects of FEHPB. HCFA has 
4,000. OPM does not decide what your doctor can and cannot do as to 
specific items and services, specific procedures and treatment. OPM is 
the human resources department of the company we all work for.
  Thus, my friends Connie Mack and Don Nickles see that program as one 
that is the epitome of choice.
  So, Mr. President, this is the model for the mainstream moderate 
proposal. That was the intention in the original managed competition 
approach.
  How does it work?
  Congress sets forth the broad parameters--actuarial limits, broad 
categories of benefits, and a body like OPM to administer it.
  That is it. The board does not regulate. The board does not 
substitute its decisions for those of doctors. The board, like OPM, 
defines the structure in which the choices are offered.
  The result--the health plans, the doctors and the hospitals are free 
to provide the medically necessary or appropriate items, services, 
procedures that fall within the broad categories of benefits.
  People can choose on the basis of price and quality, on the basis of 
satisfaction, proven performance--that is, results. They can choose 
with reasonable certainty that there is real coverage, not selection on 
the basis of gamesmanship which benefits only insurers.
  No longer are people going to be cheated by insurers trying to cherry 
pick healthy people out of the pool and leave out the sick.
  My colleague Senator Mitchell assumes people cannot make choices of 
services in a health plan. It is true that they can't if we don't make 
benefits comparable, services understandable, and results public. This 
issue is not choice, the issue is informed choice through useful 
information.
  The result: consumer protection; consumer information; more 
competition on price, quality, and satisfaction.
  I want to point out to my colleagues that we are likely to have many, 
many amendments on the benefit package. They will likely require more 
items and services to be covered. These amendments came from the left 
and the right. On my side of the aisle, there was an amendment to 
include a specific service--flexible sigmoidoscopy--in the package. 
Later we heard angry voices from the barium enema supporters saying if 
you put in the flexible signoidoscopy benefit, you must put in the 
barium enema.
  Others pushed to get specific providers groups into the benefit 
package. My colleague from South Carolina [Mr. Thurmond] and an 
amendment to include chiropractors.
  On the Democratic side, mostly the push was for more specific 
benefits--more for women, more for children, more for the disabled, and 
so forth.
  This is just a replay of State-mandated benefits elevated to the 
Federal level. States have already mandated that every benefit package 
include a whole series of benefits. States are telling Don Nickles what 
he has to buy now. And many of those specific items and services--hair 
loss in Minnesota, for example, or massage therapy in Florida--are 
probably not high on Don's list or his family's list.
  They will be packaged in politically irresistible ways--more for 
children, more for the disabled, more for women, more for mentally ill, 
more for whatever other group in the society has champions in Congress.
  Members will be hard pressed to resist. We are not known for our 
ability to say no.
  We are famous for mandating services, not paying for them. That is 
why the FEHBP and HMO and five pages of benefits are bound by dollar 
limitations. Guess which competing plans have to bid for services? Do 
not be fooled, Mr. President. This is politics as usual.
  It is not surprising that the first two amendments that have been 
proposed are for more mandated benefits, one by our colleague from 
Connecticut, and the other by our colleague from Iowa, with whom I 
serve on the Labor Committee, and that one deals with people or persons 
with disabilities. That is where I want to conclude my remarks.
  As I recall the amendment by my colleague, the amendment of the 
Senator from Connecticut reads as follows on behalf of himself, Mr. 
Kennedy, and Mr. Riegle:

       (1) In general.--During the interim standards application 
     period, a health plan sponsor may only issue or renew a 
     health plan in a State if such plan covers clinical 
     preventive services according to a periodicity schedule 
     established under paragraph (3), including prenatal care, 
     well baby care, and immunizations, for pregnant women and 
     children without imposing cost-share requirements on such 
     services.
       The Secretary shall establish a schedule of periodicity 
     that reflects the general, appropriate frequency with which 
     clinical preventive services should be provided routinely to 
     children.

  Do you know what this is going to end up becoming, if she ever gets 
it out? It will probably take 10 years to get out the regulation, and 
by then, all of the rest of this bill will have been implemented. But 
if she ever gets it out, it is going to be the best guess about how 
many visits she ought to have to a doctor before a delivery, and how 
many you want to have afterwards.
  I have to tell you, Mr. President, that is not the way the real world 
works. That is not the way the real world works.
  And I am just a recent expert, having lived with my first grandchild, 
through my eldest son's first venture as a father. The poor kid is so 
nervous, and every day there is something wrong, where their kid is not 
doing this, not doing that; she is drooling at the mouth and they want 
to rush to see the doctor. Fortunately, they have a health plan and a 
relationship with the doctor that has a way to express that. They pick 
up the telephone, dial a number, describe what is wrong, and get some 
reassuring advice.
  The Secretary is going to decide this.
  There is a schedule of services and so forth. It is flexible, 
depending upon the kid, depending upon the language barriers, depending 
upon the culture, depending on so much.
  Forty percent of Hawaii is Asian. I will bet you some of those 
children are somewhat different, and it is kind of different from the 
kind of clinic you are going to find in a predominantly Spanish-
speaking area--not drastically different, but hopefully different, 
adjusted to the family, the individual involved, and so forth.
  That is really what you want. You do not want the Secretary of HHS 
deciding this, when you have this precious little thing, whether it is 
not yet born or just born. You want a relationship between the mother 
and a caregiver to develop the kind of care that little kid needs. You 
want a health plan that is intended to help the mom carry that child to 
term. That is what you want.
  U Care--a Minnesota managed care program specifically designed to 
meet the needs of low-income individuals--will call women who miss 
prenatal checkups and, if necessary, will pay for taxis or babysitters 
so they can make their appointments. If the woman does not have a 
phone, they will even have one installed during the pregnancy.
  Why? Because if that baby delivers a couple of months short, a pound 
and a half, something like that, think of what the costs are to the 
health plan.
  Health Partners of Philadelphia has a program called ``Little 
Partners.'' Trained women from the local community--and this is why you 
take into this the race, culture, and community, in the most 
appropriate sense of the word--trained women from the local community 
make home visits to pregnant women and infants through their first year 
of life.
  Other plans lure patients to their appointments by providing free 
diaper service, baby care seats, or baby bunting. Baltimore's 
Prudential Health Care Plan found that what works best for their 
enrollees is to pay low-income pregnant women $10--pay them $10 --every 
time they come in for a prenatal visit.
  Now, there are some folks over here who would say, ``Why do they have 
to pay them to come in? They ought to pay to come in.''
  You know, this is the way it is. If you care about the kids, you have 
to go out of your way to care about the mom. And to have the Secretary 
of HHS decide by some rule and some regulation that all moms are alike 
and all pregnancies are the same and we can put it into law does not 
make any sense.
  But you cannot tell that from the bleeding-heart rhetoric which we 
have been hearing for the last 3 days from our colleagues--we are not 
doing enough for mothers and children, and infant mortality.
  I can show you infant mortality statistics that come down when you 
give a health plan--I got them from Kaiser; I can get them from other 
people--when you give the plan an incentive to keep moms healthy, they 
go out of their way to do it.
  Mr. President, I know this little explanation went longer than I 
thought. I am very grateful to you and other Members, and I am 
grateful, particularly, to staff for staying through this whole thing 
and allowing me to finish my comments.

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