[Congressional Record Volume 140, Number 115 (Tuesday, August 16, 1994)]
[Senate]
[Page S]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: August 16, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
                          HEALTH SECURITY ACT

  The Senate continued with the consideration of the bill.
  Mr. BROWN. Mr. President, the discussion on the health care bill has 
involved a large number of terms, and it must be confusing to people. 
But I want to cover just a couple of them at the outset, because I 
think they go to the very heart of the matter.
  We have heard discussed repeatedly that we need to have universal 
health care coverage, and the suggestion is that without universal 
health care coverage, people will go without health care. Everyone 
listening should know that is not accurate. Health care coverage is 
dramatically and significantly different than health care. How so? You 
may not have health care coverage in the form of an insurance policy, 
but you do qualify for health care treatment at a low-income health 
care clinic. Those clinics are spread across the Nation.
  When people do not have an insurance policy, it does not mean they 
suffer from a lack of health care. It means they do not have that 
mechanism for paying for it. You may not have an insurance policy, but 
you can go to an emergency room in a hospital and receive the 
treatment. If you are unable to pay for it, ultimately that debt will 
simply be written off. Again, you do not have an insurance policy but 
you can receive health care treatment.
  Someone asked me why in the world are we debating and talking about 
health insurance when what we ought to be concerned about is health 
care.
  Mr. President, I do not know if there is an easy answer to that. Some 
of the folks who brought this bill to the floor are interested in 
Government control of health care because they feel it will improve it. 
That by forcing people to have health insurance, the vision of 
government control is accommodated, the need to control health care 
met. The focus on insurance is merely a device, not to provide health 
care, but to control this portion of our economy. That is what this is 
all about, a sincere and honest belief that this country would have 
better health care if indeed we had more Government control.
  I thought tonight it might be worthwhile to spend a few minutes and 
simply take a look at what our experience has been in that area. The 
view is widely held that more Government control, dominance, and 
regulation of health care and its cost can improve the situation. It is 
clear that many of the legislators who favor the bill before us 
sincerely and deeply believe this.
  Mr. President, we should not have amnesia. We ought to be willing to 
at least look at the facts and face them honestly and see whether or 
not that thesis holds water.
  One of the major moves after the World War occurred in 1946 in the 
area of health care. It was the Hill-Burton bill. The Hill-Burton bill 
was designed to provide grants for construction and modernizing health 
care facilities. Many of the grants ran from one-third to two-thirds of 
the entire cost of the project. The thesis was if you have Federal 
Government assistance, then you would be able to provide additional 
health care through those facilities. It was a very large program, and 
between 1946 and 1974, $4 billion was spent in it.
  Now, did it solve the problems of health care? Well, read what the 
Democratic-controlled committee said about it in 1974. This is the 
House Interstate and Foreign Commerce Committee. The Democrat-
controlled committee found that after $4 billion of public funds had 
been spent on Hill-Burton, about 60,000 unnecessary hospital beds had 
been built, costing as much as $20,000 a year in overhead.
  Mr. President, this is what happened with Government intervention 
that was meant to solve the problem. The Government came up with money 
to hand out to solve the problem and what they did is by their own 
evaluation was build 60,000 unnecessary hospital beds costing in 
overhead alone, not the costs of the bed, in overhead alone, up to 
$20,000 a year. The overall cost was over $1 billion a year in extra 
overhead costs.
  Members of this body will remember, because many of them were members 
of the State legislature in 1974 and thereafter, when the Federal 
Government passed new laws to correct that problem. But did we do away 
with all the Federal grants that had caused the oversupply? No. What 
Congress passed was a new act, a national health planning bill ``to 
prevent unnecessary development, establish priorities for development 
of needed facilities and monitor the use of Federal dollars.''
  Appreciate what happened. You have a Federal program to solve a 
problem which instead it makes it worse, and the answer is another 
Federal program with more Federal control. You cause a problem with 
Federal control, and then to solve the problem you created with Federal 
control, you go with more Federal control.
  Why should I mention this? It is because this is a pattern. What we 
have done on a regular basis for the last 50 years is interfere 
arbitrarily in the controlling of health care, cause a problem, and use 
that problem as an excuse for additional Federal interference instead 
of going back and solving the problem to begin with.
  It is as if this Chamber and some of its Members had amnesia, that 
they forgot that it was the Federal action that caused the problem.
  Many will remember the health planning program because it involved 
the certificate of need process. It involved spending millions and 
millions of dollars on new regulations, on new controls. But incredibly 
the big cost did not come at the Federal level. It came tragically and 
incredibly on the State and local level to try and comply with the 
Federal bureaucratic requirements.
  Mr. President, just an example, because I think it speaks for itself, 
in 1975 the health care planning legislation authorized $125 million 
for construction and modernization grants to help build facilities. 
However, the health care planning legislation in 1975 also authorized 
$119 million for planning processes--red tape, bureaucrats, paperwork, 
offices.
  What did we really get for the $119 million of paper shufflers? How 
many people were cured of their illness because of the new bureaucracy, 
the new offices and the new paperwork? Mr. President, none were. Almost 
as much money as was authorized for the grants for construction and 
modernization, was authorized for the bureaucracy. Federal action, 
Federal control, developing a problem, using it as an excuse for more 
Federal control.
  In 1965 Medicare was enacted. It was designed to provide health care 
coverage for our senior citizens. Our distinguished majority leader 
referred to the program earlier and characterized some of those who 
have criticized his plan.
  Mr. President, I will not deal with that other than to say that the 
distinguished majority leader has not been with me in my State. He did 
not accurately characterize what I say to my constituents. I would hope 
that we would not be involved in personal attacks.
  It seems to me, the question here ought to be to deal with the facts 
and the issues, not question the character of others. The question 
before the body is the legislation and I think that is the appropriate 
approach.
  One should not forget what happened in 1965. When the Medicare 
Program came up and was passed, legislators rightly asked how much is 
it going to cost, not just that year but the next year and the years 
out. The figures are there. Medicare part A--not part B, just part A--
alone was estimated to cost $9 billion a year by 1990. Some will 
remember it actually cost $66.9 billion in 1990, more than seven times 
greater than what had been estimated; seven times greater.
  We also ought to look at what happened along the way. As the costs in 
the Medicare Program began to go out of control, skyrocket out of 
control, Congress tried to act. In 1983, as the CPI and the medical CPI 
diverged and the medical CPI grew much faster than the regular CPI, 
Congress began to realize that there was a problem.
  Let me just for a moment mention those CPI figures because they tell 
an interesting story. For those who honestly believe that Federal 
regulation is the answer to control costs, please look at the facts. 
Before Hill-Burton, going back as far as we have separate figures for 
the overall CPI and the medical CPI portion, we see this.
  From the period of 1939 through 1946, before Hill-Burton, the average 
annual increase in year-to-year figures from the Department of Labor 
was 4.2 percent for the overall CPI. But the medical portion of this, 
before the Hill-Burton law was enacted, for the same years averaged 2.5 
percent. The medical portion was 1.7 percent under what the actual CPI 
was. That is fairly logical, when you think about it. Medical care was 
dragging dramatically. Industry, where you have rapid advances in 
technology, tends to have a lower increase in the cost. But that is 40 
percent less, comparing 4.2 percent annual average increasing cost 
generally to 2.5 percent in medical cost for those 8 years.
  What happened when we went to more Government regulation and more 
Government control under Hill-Burton? For those of you who honestly 
believe that regulation is the answer, please look at it.
  From 1947 through 1965, the average CPI increase was 2.6 percent. But 
this time, the medical CPI, instead of being below the average overall 
CPI, was not less, it was more. It was 3.8 percent, 1.2 percent higher, 
or 46 percent more. The facts are this: Before you had the added 
Government regulation, the medical CPI averaged 40 percent less than 
the regular CPI. After you added the Hill-Burton programs and the 
regulations, it was 46 percent higher.
  What happened when you passed Medicare and Medicaid? Did it hold down 
the costs? Because that is what they talked about. Take a look at it.
  In 1965, the medical CPI was 2.4 percent. In 1966, it almost doubles 
to 4.4 percent. In 1967, up to 7.2 percent. In the years since we 
adopted Medicare and Medicaid, the average CPI has been 5.6 percent. 
The medical CPI was 7.6 percent. That is 2 percent a year higher on the 
average.
  For those who honestly believe that regulation from the Federal level 
is the answer to controlling costs, please look at the facts. They 
indicate exactly the opposite. They indicate clearly and unequivocally 
that the greater regulation that is involved in this enormous bill is 
not going to hold down prices. It is going to increase them. And I am 
going to go into exactly why it will increase them in just a moment. 
But it should not be lost on Americans, as we consider even more 
regulation, that the medical CPI has been 36 percent higher than the 
full CPI since we passed Medicare and Medicaid.
  By the time we got to 1983, it became clear that the Medicare costs 
were simply out of control, that we had to do something.
  Federal failure; problem. What is the answer? Congress decided what 
was needed in 1983 was more Government regulation, and they enacted the 
Medicare Diagnostic Related Groups, the DRG's, designed to control the 
payment to hospitals by prospectively setting rates based on similar 
diagnoses. So DRG's were held out as the new regulatory tool to control 
costs.
  For those who are watching, they can see the chart. This is the 
increase in Medicare outlays, and here is where DRG's came in. It was 
meant to stop the increase. That is how it was billed--more Government 
regulations to stop the increase.
  What happened? In 1984, the consumer price index was up 4.3 percent, 
but the medical CPI was up 6.2 percent. The medical CPI was up almost 
50 percent more than the regular CPI.
  In 1985, the regular CPI was 3.6 percent and the medical CPI, 6.3 
percent, almost double after you passed the 1983 DRG Act.
  In 1986, the regular CPI was 1.9 percent. The medical CPI was 7.5 
percent, more than three times as much.
  Mr. President, please, please, our Members should take a look at the 
results of more Federal regulation and the impact on this process. To 
believe, as I know many Members do, that if we simply have more 
regulations, more controls, more statutes, that we are going to reduce 
costs is simply fantasy.
  Let me share something with the Members, because I think many of us 
come from various walks of life and have not had a chance to deal with 
operating a medical office or a hospital. But, Mr. President, let me 
share one thing with you that I think is typical in every Member's 
hospitals at home.
  Twenty years ago, the Greeley Hospital in my hometown, or the 
Northern Colorado Medical Center, as it is now called, had more beds 
than it has now. With more beds, they had five full-time people in 
medical records. Mr. President, after reducing the number of beds in 
the hospital, they now have 50 people in medical records. They have 
gone from 5 to 50.
  Why have they gone from 5 to 50? Because the flood of new Federal 
regulations and the variety of ways in which they have responded to get 
paid and expand their income. If you want to reduce costs, you do not 
reduce it by increasing the number of people in medical records from 5 
to 50.
  Let me just share with the Members one quick thing. If you are trying 
to comply with the regulations we already impose on people, just for 
Medicare and Medicaid, not for Blue Cross/Blue Shield, not for the 
private insurers because those are additional to it--just for Medicare 
and Medicaid, one of the items you are going to want to have is a 
Medicare Topical Law Reports. They are put out by the Commercial 
Clearinghouse. These are simply the laws and regulations and practice 
guidelines. There is no fluff in here. These are simply what we impose 
on people. For those of you who have used these volumes you know they 
are on extremely thin paper and very small print. This is simply the 
regulations and the laws and the practices put forth. I put them here 
because I hope Members will take a look at them. On very thin paper 
with very small print, there are almost 15,000 pages of laws and 
regulations and practices. Why do the health care costs go up? Why does 
Greeley Hospital go from 5 to 50 in their medical records division? Why 
is it almost impossible to monitor this in a proper way? It is because 
we have buried the health care profession in paperwork and red tape.
  The thesis that the way to deal with costs is through another giant 
bill and more regulations and more Federal control is just plain goofy. 
Before Members impose this on the American people, please take a look 
at what we have done to the American people already. Please take a look 
at what the system has to respond to. The reason costs go up is because 
of what the Federal Government has imposed on them in the mistaken 
belief that if we just add some more Government regulations we will 
solve the problem.
  There are 5 volumes here on thin paper with small print; 15,000 
pages. As I count it they average about 915 words per page, probably a 
little more. That is kind of a low average. If you read regulations and 
statutes at 300 words per minute--Mr. President, I know you are an 
attorney. I know there are many attorneys here. I do not know of an 
attorney who would dream of reading a statute or regulation at 300 
words per minute; a novel, perhaps. But let us say you could and you 
did, and you read at 300 words per minute for these laws and these 
regulations, and you read 8 hours a day without a coffee break, and you 
read 5 days a week with no holidays, and you read week after week after 
week with no vacations. It would take you 5 months to simply go through 
this once--not memorize it, not know it, not work with it--simply to 
skim through it.
  Can anyone honestly believe that what we need is more regulation to 
control cost? What has happened is we have added to the cost.
  Congress did not stop after their failure in 1983, and after their 
answer of more regulations. In 1986 Congress came back to it again and 
they noted the huge continuing increase of medical costs higher than 
the CPI. In 1986 Congress responded once again--a Federal failure, a 
problem--responded with more Federal controls. In an attempt to control 
physician charges under Medicare, Congress passed a reconciliation bill 
which establishes maximum allowable actual charge limits, MAAC's. I am 
sure all Members are intimately familiar with that.
  How can we even talk about more of this stuff? We cannot even 
remember the names or the acronyms that we use. MAAC's, here it is on 
the chart. In 1986, did it stop the increase in prices? Of course not. 
Prices continued on up. In 1987 the CPI went up 3.6 percent, but 
medical costs went up 5.6 percent, 2 percent higher. More regulation 
meant more cost, not more control. So, in 1989, after experiencing the 
failure of 1946 and the failure of 1967 and the failure of 1983 and the 
failure of 1986, in 1989 we came back and Congress, in response to the 
Federal failure and the problem, responded by adding more Federal 
control. Congress instituted the Resource Based Relative Value Scale. 
For those who like acronyms, it is the RBRVS. And the Medicare Volume 
Performance Standard, MVPS. This was to cover payments to physicians.
  (Mr. ROCKEFELLER assumed the chair.)
  Mr. BROWN. The RBRVS is a fancy fee schedule. It takes into account 
time, skill, overhead differences. MVPS was an attempt to control costs 
by discouraging volume increases for services Medicare was paying less 
for under the RBRVS's. Did this solve the problem? The effort in 1989 
resulted in this: In 1990 the CPI was 5.4 percent and medical CPI was 9 
percent. That is right--it was almost double. Far from reducing the 
cost of medical care it increased it. Why did it increase it? It 
increased it because it added more regulations, more controls, more 
paperwork, more bookkeepers.
  In 1991 the regular CPI was 4.2 percent and the medical CPI was 8.7 
percent. In 1992 the regular CPI was 3 percent, medical CPI 7.4 
percent, well over double, almost 2.5 times as high.
  To contend that the answer to our problems is yet more Federal 
control and regulation simply is to ignore the cold, hard facts in 
front of us. When the President came to office he promised four things. 
He promised the American people health care reform, welfare reform, 
deficit reduction, and the downsizing of our Government.
  It appears he may scuttle all three to achieve health care reform. To 
pretend that this is a downsizing of the Government is silly. It is a 
dramatic increase. Distinguished speakers on this floor have talked 
about how this is not socialized medicine. But no one has said that it 
is not intimate Government control of the very details of the way 
almost every aspect of health care is administered and provided. To 
suggest this fits with downsizing of Government is simply not true.
  Mr. President, here are the facts. The Clinton-Mitchell bill provides 
55 new bureaucracies. Does anybody really think that is downsizing? It 
involves 177 new State mandates. It involves 815 new powers for the 
Secretary of Health and Human Services. It involves 83 new duties for 
the Secretary of Labor. It involves 6 new responsibilities for the 
Office of Personnel Management. It involves 49 new responsibilities for 
employers to comply with.
  Let me repeat that. Employers who are trying to be competitive in a 
world market now have a list of 49 new responsibilities that they have 
to comply with. There are fines and penalties and potential prison 
sentences if they do not get the paperwork right.
  Does anybody honestly believe that will make America more competitive 
in the world marketplace? Does anybody understand what it takes to 
comply with this?
  To suggest this is the way to reduce cost is a joke. Here is what CBO 
says. These are not Republicans. The CBO folks are appointed by the 
leadership of both the House and the Senate and that leadership as 
everyone in this Chamber knows are both Democratic. Here is what CBO 
says:

       For the proposed system to function effectively new data 
     would have to be collected, new procedures and administrative 
     mechanisms developed, and new institutions and new 
     administrative capacities created.

  They conclude by saying:

       There is a significant chance that the substantial changes 
     required by this proposal and other strategic reform 
     proposals could not be achieved as assumed.

  That is what CBO says. That is not what Republicans say. That is what 
CBO says. Under the Clinton-Mitchell bill, the Federal Government would 
regulate virtually every aspect of health care. Let me repeat that.
  Under this bill, the Federal Government would regulate almost every 
aspect of health care, from what kind of insurance package people are 
allowed to buy, to where they get it, to how many specialists can be 
trained in a given year.
  It restricts the choices of health care benefit packages. Earlier, 
the distinguished majority leader talked about what he felt were 
inaccurate descriptions of his package. Mr. President, there is no 
doubt that it does restrict the choices of health care benefit 
packages.
  Under the Clinton-Mitchell bill, small employers are required to join 
a purchasing cooperative, and employers with fewer than 500 employees 
are prohibited from self-insuring.
  Under Clinton-Mitchell, medical students may not be able to choose 
their future. The Government will decide how many of any specialty are 
trained in any year.
  Under Clinton-Mitchell, health plans may have to accept certain 
providers, even though they are not the best or most efficient provider 
of a service.
  Under Clinton-Mitchell, many people will have to give the Government 
details about their most intimate personal lives to qualify or continue 
to qualify for subsidies. Are the American people ready for that? This 
is a country that balks at having an I.D. card.
  Mr. President, one of the things that concerns me most is a 
discussion we have had with regard to insurance coverage. I have 
already talked about the commitment we have to health care and the way 
insurance coverage is used as a mechanism to expand Federal control. 
But one of the concerns I have is the language we use.
  I have served 10 years in the House and 4 in the Senate. Every year I 
have been here, I have fought and urged and cosponsored measures that 
would extend to small businesses the same breaks that the giant 
corporations get. Under the Democratic Congress, large corporations can 
deduct 100 percent of their health care insurance costs. There are some 
limits with regard to policies, but big corporations can deduct it all. 
But under the Democratic Congress, small businesses that are 
unincorporated can only deduct 25 percent.
  That is not fair. When I say ``Democratic Congress,'' I say it 
because that has been the controlling mechanism, but one should not 
believe that Democrats in this country do not want that change, and 
many Democratic Members of the Senate want that change, as well as 
Republicans.
  But each year that I have cosponsored that bill, it has gone to the 
Finance Committee in the Senate or the Ways and Means Committee in the 
House, and they have turned it down. The majority of people without 
insurance in this country today work for small businesses or have a 
member of their family work for small businesses. The number one thing 
we could do more than anything else to expand insurance coverage, if 
that is the goal, is to give small businesses the same deductibility as 
giant corporations get. It is not only fair but it is good policy. It 
is not overwhelmingly expensive, but it makes a big, big difference in 
insurance coverage.
  How is it, how can it be that the Clinton-Mitchell bill does not give 
that equal deductibility to small businesses? If that is really the 
goal--if that is really the goal--to expand insurance coverage, why is 
it this bill does not have 100 percent deductibility for small 
businesses that big companies have? Once again, small entrepreneurs, 
individual entrepreneurs are being discriminated against. Ironically, 
giving them the same deductibility would do more to expand insurance 
coverage than all the mandates we can talk about here.
  The Congressional Budget Office notes as follows:

       Senator Mitchell's proposal would discourage certain low-
     income people from working more hours or, in some cases, from 
     working at all because subsidies would be phased out as 
     family income increases.

  Here is one of the problems with the bill. If you work for a living, 
in many jobs, particularly if they are with a corporation, you get 
health care insurance. Some of the plans are good and some are not so 
good, but generally they have health care insurance. But if you do not 
work for a large business, chances are you might not have health care 
insurance unless you buy it yourself.
  You might have health care and you might have Government assistance 
for health care, but you do not have health care insurance. One of the 
reasons to go to work, one of the reasons to get out of bed in the 
morning, one of the reasons to roll up your sleeves is because you are 
better off and your family is better off if you go to work.
  This takes one of the advantages of going to work and staying off 
welfare and shoots it right in the head. The clear message of this bill 
is if you are lower middle income, the Government has come up with a 
new way to discourage you from getting a job and getting out of 
poverty. That does not make sense.
  We have talked about the desperate need to change the welfare system, 
and this is the biggest welfare program that has ever been talked 
about, in this bill. What it says is if you work for a living, you are 
going to get treated the same way as if you do not work for a living, 
even though you are able bodied, even though you are able to work. Mr. 
President, if you are able to work, I think you ought to live better 
than if you do not work. To destroy one of the incentives for people 
being productive and creative is foolish policy. The CBO, I think, has 
it right when they criticize it this way.
  The CBO analysis goes on, and I quote again:

       CBO estimates the effects of this proposal are unavoidably 
     uncertain.

  It is a giant bill. I can understand that. It is a difficult process. 
We can all understand that. But look back at what happened with 
Medicare part A. It was supposed to be $9 billion by 1990, and it ends 
up being more than seven times that high.
  In 1987, Congress created a disproportionate share program to assist 
hospitals serving the disadvantaged. CBO estimated that in the third 
year after enactment, the program would cost less than $1 billion. In 
reality, it actually cost $10 billion. That is a 1,000 percent mistake. 
Let me repeat that. The program 3 years out was literally 10 times what 
the CBO estimate was. And we start off with a CBO estimate in which 
they say that their estimates of the effect of the proposal are 
unavoidably uncertain. Is that good management? Is that good 
government?
  The costs that are identified in this bill for businesses in the 
State of Colorado in the year 2002 are over $1 billion. Let me repeat 
that. In Colorado, in the year 2002, Colorado businesses will be hit 
for over $1 billion just to cover their portion of the cost of this 
bill. $1,015,439,000. Colorado is a small State, Mr. President, 
certainly in population, not in area.
  The cost of this bill is gigantic and it is uncertain. The impact of 
more regulations, I believe, is going to be to increase costs, not to 
reduce them or control them. The history of Government action makes it 
very clear that this is not going to slow down costs. And why do costs 
go up as we regulate and regulate and regulate? We have already looked 
at the CCH reports, the Commerce Clearing House reports.
  The CPT-94 is for reporting service codes for services and procedures 
performed for fees. It is 859 pages. In other words, if you are going 
to bill somebody, you cannot say I saw Mr. Jones and I treated her. You 
have to look up the codes, 859 pages of it.
  The Medicare part B answer book, 1,600 pages of regulations. If the 
bill passes, this goes up, not down. The ICD-9-CM--does that sound like 
Martian talk?--two volumes of it, approximately 1,143 pages. These are 
simply classifications of diseases--a code book of classifications of 
diseases. Does anyone wonder why costs are skyrocketing? We cannot even 
get all of these things on a desk.
  The HHCPCS-Cannons, Procedures and Codes, 226 pages. Does anybody 
think this is an efficient way to run a railroad? Medicare Physicians 
ID Number Manual--this is simply to identify them, and it is only for a 
few States--172 pages. Physicians' Desk Reference, this is a drug 
compendiums. These are not the Library of Congress. These are simple 
things that physicians and health care providers have to deal with 
every day if they are going to provide health care and bill Medicare. 
What we have done is take the greatest medical minds in the world and 
see if we could bury them in paperwork. Drug Evaluation Subscriptions, 
three volumes, 1,720 pages.

  Mr. President, if regulation was the answer, if more laws were the 
answer, if Federal control were the answer, surely our health care 
would be free by now. How many more of these books and volumes do we 
have to impose on people before we figure out that they are part of the 
problem.
  What we ought to be doing is not repeating the mistake we have made 
in 1946, in 1965, in 1983, in 1986, and in 1989. We should not be 
recognizing the problem and deciding to deal with it by more Federal 
control.
  What we ought to do is sit down for a moment and go back and get real 
solutions. What are they? I sponsored five major health care 
resolutions, legislation that was offered here, but I want to go 
through quickly a couple of the proposals that I think are important.
  It would be inappropriate for me not to mention at this moment that 
last year, on April 27, 1993, after continuous delays by the majority 
in bringing up health care, Senator Specter brought forth his amendment 
to S. 171. Senator Specter was ready and able and willing to debate 
health care right then and there. He had asked continuously and 
repeatedly, and repeatedly the leadership of this body had turned him 
down.
  Finally, he came to the floor and, in spite of their wishes, offered 
his amendment to reform health care, and I joined him, not because I 
agreed with everything in his bill but I agree with much of it. This 
body decided more than a year ago that they would not consider it. All 
this gnashing of teeth because we have not finished a bill that we just 
simply received the final copy of last Friday seems strange when you 
understand that more than a year ago the leadership of this 
deliberative body refused to let Senator Specter even bring the subject 
up.
  S. 1865 by Senator McCain and S. 493 by Senator Cohen are bills to 
enable health care facilities' cooperation to better serve their 
markets, either allowing them to join or to form joint ventures to 
share equipment or by forming community health authorities. In other 
words, Mr. President, the proposal which is picked up in a number of 
other bills is to modify our antitrust laws and to see if we cannot get 
people to share facilities and equipment. It increases the usage and 
reduces the cost. That is a good idea and that will reduce cost. We 
ought to do it.
  Senator Gramm has talked about insurance reforms to address the 
problems of portability, and that is a good idea. I think that can make 
the system more efficient.
  Senator Chafee has introduced a bill that I joined him to have ob/
gyns be designated as primary care givers. I believe that should be 
passed.
  We have already talked about how we ought to change our tax laws to 
allow full deductibility for small businesses. That should be passed.
  There is a proposal in a number of these bills to provide for a 
medical savings account. What it does is simply allow people to have 
some discretion about how their health care money is spent, and that 
should be passed. I believe it would help reduce cost.
  We ought to allow small businesses to pool together to get health 
care insurance buying power, just like large corporations do, and that 
can help reduce cost.
  We ought to have meaningful tort reform, and every Member here knows 
it. That would help reduce frivolous lawsuits, speed up the time for 
payment when there is medical malpractice, and eliminate some of the 
waste and abuse in the system. And yet this bill, instead of making 
progress on medical malpractice, would take it the other way. It would 
gut a number of proposals that Colorado has made which are more 
advanced than the Federal level.
  Colorado has made real progress in this area. In 1988, Colorado 
enacted a package of medical malpractice reforms that assured that the 
resources are available if the provider injures a patient but puts 
appropriate limits on how such claims are brought. Physician 
malpractice premiums have fallen by 53 percent since Colorado enacted 
its reform.
  Mr. President, let me repeat that. Since Colorado enacted those 
reforms, the physician malpractice insurance has dropped 53 percent. 
This bill would have the effect of repealing some of Colorado's 
reforms. That is not progress. That is not reducing cost. It is 
increasing it.
  Mr. President, I am convinced that we ought to provide incentives in 
the way we administer Medicare and Medicaid for providers to reduce 
cost. We ought to be smart enough to provide real incentives so if 
someone really does reduce the cost of a health care procedure, they 
share in that cost savings. Incentives will do much more than 
regulation to get us back on the right track.
  We ought to reduce unnecessary paperwork requirements. Senator Bond 
has introduced a bill that will do just that, to simplify it. And I am 
glad to see some other proposals have picked out a portion of that.
  Mr. President, this body voted on and all but one Senator in this 
body voted for legislation on the blood pathogen regulations. For those 
Members who remember that vote and remember how they voted, I urge them 
to review those regulations. Does someone going to medical school for 4 
years or 7 years know enough to wipe off the table his patients change 
on?
  Well, I hope so. Yet we passed these regulations that mandate and 
check on it and require more paperwork. Those blood pathogen 
regulations were some of the nuttiest, wasteful, abusive procedures 
that we have passed. If you talk about unnecessary paperwork and 
ridiculous expenses, they epitomize it. There was only one vote in this 
Chamber against those silly regulations. But if we were serious about 
controlling costs and expanding real medical care to people, those are 
the kinds of things we ought to look at.
  But we should not look at another flood of regulations and statutes 
and controls and guidance. We ought to look at real reform. We ought to 
look at real medical malpractice changes. We ought to look at real 
incentives to reduce the cost. We ought to fight for ways to make this 
system more efficient, not less efficient.
  I am in favor of medical reform, but it is not this bill. It is a 
bill that has a dramatically different purpose. It is one that 
recognizes the answer to problems created by Federal regulation is not 
more Federal regulation. I do not know how anyone living in the latter 
half of this century could look around at what has happened in the 
world and come to the conclusion that central Government planning and 
regulation is the answer to economic problems.
  The simple fact is in every country on the face of the Earth that has 
tried it, it has been a failure. What is needed are incentives for 
individuals to be productive and creative. This bill does the opposite. 
In short, I believe we ought to put our faith in the hands and the 
minds and the creative spirit of individuals and expand their freedom 
and opportunity and choices, and that we ought to turn our back on the 
efforts to regulate the minute details of how our medical system works.
  I yield the floor, Mr. President.
  The PRESIDING OFFICER. Who yields time?
  Mr. MOYNIHAN addressed the Chair.
  The PRESIDING OFFICER. The Senator from New York.
  Mr. MOYNIHAN. Mr. President, by previous agreement, I yield the 
remainder of our time, indeed, the time equally divided this evening, 
to the distinguished Senator from Florida, a former Governor, deeply 
involved in these matters.
  May I say, Mr. President, that the Senator from New Jersey [Mr. 
Lautenberg], may come to the floor and may wish to speak. But after the 
2 hours has expired, the floor is open for those who wish to speak.
  Mr. MURKOWSKI. Mr. President, I am just going to make an inquiry.
  The PRESIDING OFFICER. The Senator from Alaska.
  Mr. MURKOWSKI. If I may ask the Chair, what is the remaining time?
  Mr. MOYNIHAN. I believe 47 minutes. Well, I will ask the Chair.
  The PRESIDING OFFICER. The Senator from New York controls 45 minutes.
  Mr. MOYNIHAN. Forty-five.
  The PRESIDING OFFICER. And the Senator from Oregon controls 8\1/2\ 
minutes.
  Mr. MURKOWSKI. I thank the Chair.
  The PRESIDING OFFICER. The Senator from Florida.
  Mr. GRAHAM. Mr. President, in the past few days we have had a chorus 
of pronouncements that national health care reform was moving from the 
intensive care ward to the morgue, that Congress is hopelessly 
gridlocked, that partisan bickering has escalated into warfare, that 
the American people have given up in disgust in our collective 
inability to accomplish anything significant, and that we have 
fundamentally abandoned any expectation that we can act in their 
interest.
  Mr. President, I disagree. The distinguished majority leader has, in 
my opinion, skillfully moved the debate forward by introducing a solid 
and constructive proposal that moves the Nation forward towards the 
goal of universal coverage. And many reasonable people, on both sides 
of the aisle, are now recommitting themselves to work towards a 
nonpartisan prescription for the widely acknowledged ills of America's 
health care system--excessive cost, inadequate personal and family 
health security, and gaps in services provided, particularly those 
which maintain health.
  Some examples: Senator John Chafee, a long-time leader in the area of 
health care reform, and now a leader of the Senate's mainstream 
coalition, has said:

       It is essential that any health care reform measure pass by 
     a very, very strong majority in this body . . . I seek a 
     program that is going to pass here 80 to 20 or 70 to 30, a 
     healthy, strong, bipartisan support for that measure on the 
     floor of the Senate.

  Senator Boren agrees when he says.

       . . . the only way we're ever going to get the deficit 
     under control and sustain a long-range approach is to have a 
     bipartisan plan, one that will have the support of a vast 
     majority of the American people in both our political 
     parties. And the only way . . . that we're going to have 
     health care reform carried through in an efficient and 
     effective way is to reach a bipartisan consensus so that the 
     plan can be sustained for many years. . .

  And to quote one additional of our colleagues, Senator Cohen has 
stated:

       The decisions we make in the coming weeks are going to have 
     a profound consequence for every single American. They are 
     going to control the future direction of one-seventh of our 
     Nation's economy. And we shouldn't even begin to contemplate 
     enacting sweeping reforms unless they're broad-based and 
     bipartisan.

  Mr. President, I believe there is a clear formula for this bipartisan 
prescription, the basis for which is already in the majority leader's 
bill. We should build upon the genius of the Federal system. We should 
equip States and localities with the appropriate tools so that they, 
working with their citizens, can tailor health care reform to their 
unique circumstance. The role of the national Government should be to 
establish goals and to monitor the attainment of those goals.
  The case for a decentralized health care system is compelling. Some 
of the points which make that case compelling include diversity as the 
key underpinning of the American health care system. Health care is 
particularly suitable to the establishment of national goals with 
decentralized implementation, and sensitivity to local cultural, 
geographic and institutional variations. States, and communities within 
States, have different health care needs based on societal factors such 
as the quantity and nature of health care providers.
  For example, Nebraska, North Dakota, and South Dakota have twice the 
number of hospital beds as Alaska, New Hampshire, and Hawaii. Varying 
demographics, especially among the most health intensive populations--
for example, Florida, Pennsylvania, Iowa, Rhode Island, and the State 
of the Presiding Officer of West Virginia--have 50 percent more elderly 
than do Alaska, Utah, Colorado, and Georgia.
  Current levels of insurance coverage is another area of extreme 
difference. In Nevada, Oklahoma, Louisiana, Texas, and Florida, 
approximately one-quarter of the population under 65 is uninsured. 
Whereas, in Hawaii, Connecticut, and Minnesota, less than one-tenth of 
the population under 65 is without insurance.
  Mr. President, clearly State circumstances require different 
solutions and different timeframes. For example, what would work in a 
rural area would not work in a highly urbanized area. The means of 
achieving universal coverage and access are undoubtedly different in 
Florida than they are in Wyoming.
  Another point which I think makes the argument for a federalized 
system compelling is that the Federal Government is frankly ill-
equipped to build or operate a unitary health care system.
  The experience of nations with a long history of universal access 
health care systems--just to mention two, Germany and Canada--have 
shown that implementation requires decentralization. Our Nation is 
significantly more populated, geographically larger, and infinitely 
more diverse than either Germany or Canada. A successful plan would 
have to accommodate the broad diversity of the United States through 
decentralization.
  Yale professors Theodore Marmor and Jerry Mashaw make this point in a 
July 7, 1994 Los Angeles Times editorial:

       Given the diversity of States, their varied experience with 
     health care and intense local preferences, why enact a single 
     brand of national health care reform, especially if it's the 
     poorly-considered compromise that we seem to be headed 
     towards? By moving compromise in the direction of preserving 
     goals rather than defining means, we can allow States the 
     further thought and experimentation that are needed for 
     effective implementation.

  Mr. President, States have also demonstrated their creativity and 
ability to implement complex health care initiatives, often in the face 
of stiff resistance from the same Federal agencies that would be placed 
in charge of a proposed unitary system.
  In health care reform, States have significant experience and 
success. The summer 1993 issue of Health Affairs chronicles health care 
reform successes at the State level in Hawaii, Maryland, Minnesota, 
Oregon, Washington, and Florida. Significantly, each of these States 
have adopted reforms that differ in terms of scope, anticipated 
outcome, and processes. These variations reflect the diverse needs, 
ideology, and stage of health care evolution in each of those States.
  So should national reform. Only then will we have real 
accountability, and responsiveness to the needs of consumers, 
businesses, and providers. Only then will we have health care reform 
that actually is able to deliver sustained accessibility to high-
quality, affordable health care for all Americans.
  Hawaii offers the best example of a State's creativity and ability to 
accomplish the goals of positive health care reform. In 1974, Hawaii 
passed a comprehensive health care reform proposal that included 
virtual universal access, financing through a shared responsibility 
between employer and employee, and a serious commitment to the 
prevention of illness.
  As we celebrate the 20th anniversary of this State's initiative, we 
should take note of the following: Hawaii has the highest percentage of 
its citizens covered by insurance--over 96 percent. In Hawaii, the cost 
of insurance coverage for small businesses is 30 percent below the 
average for small businesses in the United States. Hawaii's infant 
mortality rate is 6.7 deaths per 1,000 live births. This compares to 
9.2 deaths per 1,000 live births for the Nation as a whole. I believe 
the President would agree that those are compelling statistics of a 
success which started at the State level, started with citizens in a 
particular State responding to that State's circumstances to meet the 
goals and aspirations of its citizens.
  Hawaii was fortunate in being able to develop and implement its 
health care reforms with the cooperation of a Federal administration 
also committed to health care reform--that of President Richard Nixon. 
Hawaii's reform system was also implemented prior to the enactment of 
significant restraints on the State's ability to innovate, such as the 
Employee Retirement and Income Security Act [ERISA].
  Other States have not been so fortunate. My own State of Florida has 
experienced the frustrations of many States that have attempted to 
innovate, to be a center for reform, to be that laboratory of 
experimentation which is at the heart of the Federal system.
  In the mid-1980's while I was Governor, Florida was unsuccessful in 
its attempt to receive a waiver from the Federal Government for a 
Medicaid buy-in program. The purpose of that program was to allow the 
working poor who were otherwise without insurance to be able to share 
with the State and the Federal Government in accessing the Medicaid 
Program. The waiver that would have been necessary to make that 
possible was denied by the Reagan administration.
  The current Governor of Florida, and our former colleague, Lawton 
Chiles, is making a similar effort, called Florida Health Security, to 
provide health care coverage again to the working poor. Florida Health 
Security would provide subsidies to uninsured working Floridians to 
purchase private health insurance. Participants would contribute a 
portion of their premium based on their incomes. Employers could 
voluntarily contribute a portion of their employees' premiums. The 
program would be paid for using Federal and State savings in Florida's 
Medicaid Program, realized primarily by enrolling Medicaid recipients 
in managed care plans. Florida Health Security would provide 1.1 
million uninsured Floridians with health insurance coverage, and 
through this single initiative, this one initiative, raise the 
percentage of Floridians with coverage from the current 82 percent to 
92 percent.
  However, just as was the case a decade ago, Governor Chiles is now 
faced with foot-dragging and ho-humming from the Health Care Financing 
Administration, the agency that must grant the waiver. Why? Why has 
there been this reticence to allow States to innovate? A New York Times 
article dated June 12, 1994, may provide an answer. According to the 
article, Mr. Bruce Vladeck, administrator of the Health Care Financing 
Administration, warned in a June 1993 memorandum:

       The waiver authority could become a way of relaxing 
     statutory or regulatory provisions considered onerous by the 
     States.

  He added that waivers ``will be used to slow down nationwide 
reform.''
  Mr. President, after over 6 months of review, Florida's waiver 
application is still pending in the Health Care Financing 
Administration bureaucracy.
  Mr. President, I applaud the majority leader for his able leadership 
in moving the Senate toward consensus on health care reform. I believe 
his proposal provides the basis for a decentralized health care reform 
system. His bill allows for compliance with the national intermediate 
goal of 95 percent coverage by the year 2000 on a State-by-State basis. 
The majority leader's proposal rejects the concept that there must be a 
single national standard by which compliance is judged.
  Specifically, Senator Mitchell proposes that by January 1, 2000, 95 
percent of the population in each State must have health care insurance 
coverage. In those States that fail to meet that goal, businesses would 
be required by the year 2002 to pay half of the cost of insurance for 
their employees and their families. Businesses with fewer than 25 
workers would be exempt from that requirement.
  I applaud the architecture of the majority leader's proposal. This 
State-by-State evaluation will fundamentally shift incentives and 
challenges. The plan will motivate States to develop their own reforms 
exactly to avoid the Federal prescription, while at the same time 
providing health care insurance coverage to their citizens.
  Again, if I could, Mr. President, I believe there is a case study of 
this in Florida. Ask any provider, insurance, or business association 
in the State, and they will tell you that it was the threat of Federal 
action which was the impetus that brought all of the parties to the 
table to develop Florida's health care reform plan. Fifty individual 
State triggers, rather than a single national trigger, will cause 
States to accelerate their activities in order to achieve a 95 percent 
objective and avoid falling into a Federal mandate. States will also 
clearly understand that they cannot adopt policies which tolerate, much 
less contribute to, additional health care costs, without jeopardizing 
their ability to achieve the prescribed 95 percent level of coverage by 
the year 2000.
  Senator Mitchell's call for a State-by-State approach acknowledges 
variations among the States and recognizes that innovation must be 
tailored to the circumstances of individual States and communities.
  Mr. President, this State-by-State evaluation gives States 
substantial control over their own destinies. Only through a 
decentralized evaluation of performance will States feel compelled to 
take aggressive action to reach the 95 percent coverage by the year 
2000.
  While Senator Mitchell's bill lays the groundwork for a decentralized 
system, some modifications are necessary to reach his proposal's 
maximum potential. Such modifications could be grouped around the 
following principles: We should avoid Federal action which increases 
health care costs and then shifts those costs to the States. For 
example, S. 2357, the majority leader's proposal, would create three 
subsidized programs. One would be for mothers and children. A second 
would be for individuals who were formerly served through Medicaid, and 
a third would be a general subsidy program. These three would be in 
lieu of a single streamlined subsidy program. States would be required 
to administer the subsidy programs without Federal assistance for 
administrative costs. The Congressional Budget Office estimates that 
States will be required to spend an additional $50 billion to 
administer these three programs over the next 10 years. We should also 
avoid policies that restrict the abilities of States to chart their own 
course.
  For example, S. 2357 would calculate State maintenance of effort 
payments using an annual growth factor based on the rate of increase in 
national health care spending.
  Using a national calculation rather than a State-by-State calculation 
penalizes those States that have already taken steps or will be 
encouraged to take steps to reduce health care costs and rewards those 
States that have not acted to control costs.
  Also, States should not be held accountable for cost factors that are 
beyond their control, including federally prescribed increases in 
benefits and increases in the quantity of health care services due 
largely to the population's aging.
  We should also avoid measures which have the unintended effect of 
punishing States which are implementing or proposing initiatives to 
expand coverage, to move toward that goal of universal coverage.
  Under S. 2357, currently eligible Medicaid beneficiaries would not 
have their benefits reduced under the new subsidy program. While this 
is a laudable goal, I believe this provision penalizes States which 
have chosen to provide optional services beyond those required of 
Medicaid.
  Such States would then be locked into those benefits while States 
that provide only the minimal Medicaid services would not.
  In addition, States would be required under the majority leader's 
bill to provide benefits over and above the standard benefits package 
to individuals currently enrolled in the Medicaid program. These so-
called wrap-around benefits would be matched by the Federal Government 
at the State's Medicaid match rate.
  This requirement will add to State administrative costs, but more 
importantly, it raises a fundamental equity question by subdividing the 
low-income population into two groups, one group those who had 
previously been under the Medicaid program, the other group those who 
had not been under the Medicaid program, and provides a differential 
level of benefits at State administration and significant State cost to 
the former Medicaid eligible population.
  We should, also, Mr. President, provide broad waiver authority from 
Federal statutes and regulations to facilitate State innovation.
  This is not a new concept. In 1992, our colleagues, Senator Leahy and 
Senator Pryor, introduced legislation that would provide incentives to 
States to achieve comprehensive, State-based health care reform. I was 
pleased to be a cosponsor of that legislation.
  This proposal should serve as a basis for an expanded waiver 
authority in S. 2357 so that States who want to take control of their 
destiny different from the Federal plan would be permitted to do so.
  Mr. President, we should also eliminate requirements for which 
national uniformity is not essential.
  Federal preemptions of State laws and Federal standards should meet 
the following fundamental test: Does the desired goal require national 
uniformity in process or procedure, or can the desired goal be 
accomplished without Federal mandate and prescription?
  Two examples within S. 2357, in my judgment, fail to satisfactorily 
answer this question. They are the essential community providers 
provision. This is a provision which will require a certain group of 
providers to be covered under all plans. I see no reason why States 
should not have the flexibility to determine whether there are within 
that State essential community providers and, if so, who they are. 
There is also a preemption of State licensure laws for medical 
professionals. States have traditionally exercised authority in this 
area. I see no reason why that authority should be shifted.
  Mr. President, States should also be given a broader range of options 
should they fall short of the 95-percent coverage goal by the year 
2000.
  Under S. 2357, a State that fails to meet the 95-percent goal would 
be subject to new Federal standards adopted by Congress after 
considering recommendations from the newly created National Health Care 
Commission.
  Should Congress fail to enact such provisions, the State would be 
required to adopt an employer mandate with employers paying half the 
cost of coverage for employees and their families. Employers with fewer 
than 25 employees would be exempt.
  I believe a State which fails to achieve the 95 percent goal should 
have an opportunity to present a corrected plan to the Health Care 
Commission. The plan would be subject to Commission approval and would 
detail how the State would reach the 95 percent goal by the year 2002.
  Under this construction, the employer mandate would be triggered if, 
and only if, the State plan is rejected by the Commission or if 
approved by the Commission the State fails to accomplish the goal of 
95-percent coverage in its implementation.
  States that take this second chance option would have the opportunity 
to learn from those States that had been successful in meeting the 95-
percent goal. The Health Care Commission could also use these success 
stories of those States that had met the 95-percent goal to evaluate 
and assist deficient States in achieving the goal of 95-percent 
coverage.
  Mr. President, health care reform is too important to the fundamental 
objectives of individual Americans and our Nation as a whole to 
languish or to be lost. I believe that we are close to a course of 
action which offers considerable promise of accomplishing our 
collective goals.
  However, our goals will only be realized if we allow for maximum 
decentralization in their implementation. It only will be realized if 
we avoid impeding the imagination and the commitment of millions of 
Americans to health care reform in their communities and in their 
States.
  These are good citizens who, with a spirit of community and common 
sense, will find not one but a thousand roads which will merge at the 
common national destination of an affordable health care system that 
will provide quality health care services for all Americans.
  Thank, you Mr. President.
  The PRESIDING OFFICER. The Senator from Alaska.
  Mr. MURKOWSKI. Mr. President, I thank the Chair.
  (Mr. GRAHAM assumed the chair.)
  Mr. MURKOWSKI. Mr. President, let me note for the Record, as this 
debate continues, everybody on both sides of the aisle is truly 
supportive of health care reform. So really the issue is, how to 
achieve that in the best interests of the American public.
  I am sure that many who have followed this debate are somewhat 
concerned with the mechanics of the health care proposals because 
indeed they are quite complex, but there are a few things that the 
American public understands.
  They understand availability of health care. They want availability 
of health care, and they want that availability at the minimum cost 
with the most coverage. Availability also is synonymous, of course, 
with portable. They want the assurance of being able to have their 
health care insurance follow them from job to job.
  But the American people are also concerned about aspects of the 
Mitchell bill, which is before us. And one aspect that certainly has 
caught the attention of a lot of people is the suggestion that 
approximately 100 million people will be subsidized by the Mitchell 
plan. That is out of a population in 1990 in the United States of 248 
million people. Approximately 100 million will be eligible for some 
type of subsidy.
  That does not ring very well with the American people because they 
are also concerned about the expanded bureaucracy. They do not want to 
see any more agencies. They do not want to see some 34 new Federal 
boards and commissions. They are concerned about just what 117 new 
mandates really mean, and the States are concerned because some of 
these mandates are directives to the States that are unfunded.
  What the public really wants in a health care plan, in addition to 
cost control and availability, is the assurance that there is some 
accountability. You know how Government responds with accountability. 
Government runs off and hires more compliance officers in each agency 
as opposed to holding the head of that agency accountable for the 
actions of that agency.
  And the public is concerned, of course, about the Government going 
into the health care business. The point has been made sometime in this 
body that if you like the Post Office system in Washington, DC, you 
will love the Government once it takes over health care.
  What can we learn from observation of our neighbors in Canada? We can 
learn some interesting things, Mr. President. One that strikes me is 
that approximately 21 percent of the budget in our neighboring nation 
of Canada is interest on their debt. What is that attributed to, Mr. 
President? That is attributed to escalating health care costs 
associated with the Canadian system.
  They are also concerned with the realization that in Canada today, in 
Saskatchewan, many hospitals are being closed. Many Canadians come from 
Vancouver to Seattle, come from Toronto and other areas to Buffalo, NY, 
for health care simply because of availability and quality.
  So as we embark upon this effort, Mr. President, let us keep in mind 
what the American public wants. They want availability. They want cost 
controls.
  And the task before us is a monumental one in trying to achieve that. 
We are achieving that in the sense of working in a bipartisan manner 
for health care reform. But it is how we go about this task. And we 
must continually remind ourselves that good intentions are not enough, 
because good intentions will not make up for bad policies.
  In our desire to improve access to what is already the highest-
quality health care system in the world, we cannot afford to turn that 
system over to an army of bureaucrats and well-meaning idealists. We 
have to look very carefully at the reform proposals before us before we 
leap into a full-scale change.
  What we want to do is obviously maintain the quality that we have and 
make the improvements when they are needed. But we do not want to throw 
out the baby with the bath water, so to speak.
  The health care reform debate has evolved dramatically over the last 
9 or 10 months. It is kind of interesting to reflect on the public 
approval of the President's reform proposal, because the fact is that 
public opinion for approval of the President's program has fallen 
steadily, as the implications of a major overhaul become more and more 
clear. As a consequence of this extended debate and the efforts of my 
colleagues to try to bring out the particulars, the public is beginning 
to understand and is becoming more concerned with availability and 
escalated costs and Government bureaucracy. And it has affected the 
President's reform proposal and its acceptance.
  A majority of Americans now want incremental, targeted reforms or no 
reforms at all until we better understand the sweeping social changes 
that we are proposing.
  The fact is that none of us can fully understand the implications of 
this legislation without this extended debate. The Clinton-Mitchell 
bill is predicted now to cost up to $1.1 trillion over the first 8 
years in new entitlement spending, becoming the third largest 
entitlement program in our budget.
  How do we fund that, Mr. President? Well, if the past is any 
indication, we fund it by deficit financing. What is deficit financing? 
It is simply everything else you need to add to the deficit and you pay 
interest on it as part of the budget process. You could not do it with 
your own checkbook, Mr. President. But we can do it here in Government.
  Have we not learned from the Medicaid and Medicare spending 
explosions of recent years that we cannot accurately predict the true 
burden of this massive new entitlement and what effect it is going to 
have on our future generations? We are mortgaging the future of our 
children and grandchildren, Mr. President.
  The bipartisan Commission on Entitlement and Tax Reform, cochaired by 
my colleagues, Senator Kerrey and Senator Danforth, reports that, by 
the year 2012, existing entitlements and interest on the debt will 
consume all of our Federal tax revenues.
  Think about that for a minute. By the year 2012, existing 
entitlements--we are not talking about entitlements for health care--
existing entitlements and interest on the debt will consume all of our 
Federal tax revenues.
  Mr. President, you and I both know at that stage, we are broke.
  A major new Government-run health care program will, in all 
likelihood, bring us to the point of national bankruptcy even sooner 
than the year 2012 if we do not address up front just how we are going 
to pay for it.

  As Robert Samuelson of the Washington Post recently stated, the 
``something for nothing'' deception being played out on the American 
people regarding new health care entitlements is an ``exercise in 
national make-believe.'' Well, he is right on target, Mr. President.
  The proposal before us would create at least 34 new or expanded 
federally run boards and commissions--and they cost money--to determine 
what benefits each American would be allowed, with the burden of 
implementing as many as 117--you have heard it before--new mandates 
passed on to individuals States. The Bi-partisan National Governors 
Association warns that:

       Under this bill, States will take on significant new 
     responsibilities to administer, monitor and enforce 
     compliance of a new restructured health care system . . . set 
     entirely by the Federal Government. It is expected that 
     States will have to administer . . . but have little 
     flexibility to set their own standards.

  This is tragic, because States are the laboratories for change and 
innovation in health care reform. It is critical that reform proposals 
recognize State autonomy and the need to be flexible.
  My State of Alaska, for instance, is carefully considering 
comprehensive health reform legislation, and already has in place high-
risk insurance pools to make insurance accessible to those who would 
otherwise be uninsurable under the current system. Alaska law currently 
prohibits denying coverage because of pre-existing conditions and we 
have established a Small Employer Reinsurance Association and several 
small business reinsurance pools. There is broad recognition, in my 
State, that some of the central principles being put forth in the 
Clinton-Mitchell plan, such as encouraging managed care models of 
health delivery, do not work in areas where there is limited or no 
access to even the most basic health care services. Alaska is not the 
only State with unique circumstances. Every State has unique qualities 
that can make Federal dictates counter-productive.
  But the plan before us does more than establish new bureaucracies and 
State mandates.
  While almost everybody agrees that one of the factors forcing health 
care costs up is the cost of litigation, it is my understanding that 
the Clinton-Mitchell bill actually provides funding for lawyers to help 
people sue their own States if, in fact, federally mandated health 
plans are not implemented properly. No wonder the American people are 
nervous.
  The premise behind the bill is misguided. It proposes to meet the 
need of insuring the 37 million people in this country who do not 
currently have health insurance by providing a Federal subsidy to more 
than 100 million people. I cannot understand the logic behind creating 
an entitlement program that will cover more people than are now covered 
by Medicare, Social Security, and Medicaid combined in order to resolve 
the uninsurance problem for 37 million people, many of whom will find 
insurance on their own without Government assistance.
  In creating this new system, the Clinton-Mitchell bill actually 
raises the cost of insurance to middle-income families. The bill raises 
the price of all insurance policies in this country by $145 billion 
through a new taxes on, of all things, health insurance. Even the 
Congressional Budget Office [CBO] finds one of these taxes--the 25 
percent tax on so-called high cost plans--so poorly designed that it 
will effect ``virtually all plans,'' and increase premiums so much that 
it will ``discourage participation'' in the health insurance market.

  That is a diplomatic way of saying that the taxes in the Mitchell 
plan will force more people to become uninsured. What is even worse is 
that the health insurance plans that will pay the biggest tax are plans 
that insure a large number of sick and old people, and efficient 
managed care plans. What is the logic of such an ill-conceived tax?
  And while the middle class pays more taxes, others get a free ride. 
In fact, starting in the year 2002, if the employer mandate is 
triggered, it appears that the cost of health insurance for individuals 
will become free. It may surprise my colleagues to know that, but 
according to section 10135 of the bill, which deals with health 
insurance premium payments, it states: ``In no case shall the failure 
to pay amounts owed under this Act result in an individual's or 
family's loss of coverage.'' In fact, the bill assumes that many 
enrollees will stop making payments and sets up a system known as the 
``Collection Shortfall Add-On'' which will raise premiums for all 
participants in the plan to cover the cost of those who fail to make 
payments.
  Mr. President, it is obvious to this Senator that many will simply 
not pay their health insurance premiums once they realize that their 
coverage cannot be canceled and they are assured that they will be 
covered for any health related expenses.
  I believe there is a better alternative to the legislation before us. 
An alternative which would make great strides in providing access to 
care for the uninsured, without sacrificing individual choice, State 
flexibility or radically restructuring one-seventh of the American 
economy. I heard my thoughtful colleague, Chairman Moynihan, comment on 
the floor last week that it would certainly be a shame if Congress did 
not at least act on those reforms which we know have a broad consensus 
of agreement--reforms such as making insurance portable, removing 
restrictions on preexisting conditions, voluntary insurance pooling for 
small business, and subsidies to help the most needy purchase private 
insurance. I agree. I think we may have lost sight of the areas where 
most of us agree, where we can tackle problems of rising costs and 
inadequate access today rather than spinning fragile webs of government 
run health care that don't go into effect for years down the line.
  Mr. President, I want to comment on a critical area of our health 
care system that also tends to get lost in the shuffle in the debate 
over national health care reform--that area is our Federal medical 
programs. Today the Federal Government is not just a payer of health 
care bills, as in Medicare and Medicaid, but is also a direct provider 
of health care through programs in the Departments of Veterans Affairs, 
and Defense, the Indian Health Service, and the Public Health Service. 
In Alaska, 34 percent of total health care spending is for Federal 
health programs. As the ranking Republican on the Senate Committee on 
Veterans Affairs, I notice that these programs, and the lessons we can 
learn from them, have largely been overlooked in the debate over 
reforming the private health care system.
  As most of you know, the Department of Veterans Affairs [VA] health 
care system is the largest single health care system in the United 
States. The VA health care system consists of 171 hospitals, 353 
outpatient clinics, 128 nursing homes, and 37 domiciliaries. The annual 
budget for VA health care is currently $17.6 billion, which provides 
care for approximately 2.2 million veterans and employs over 209,000 
health care workers. In addition to basic health care services, the VA 
provides specialty services like spinal cord injury, blind 
rehabilitation, post traumatic stress disorder and other mental health 
services, comprehensive homeless programs, and long-term care and 
geriatric programs. These are all excellent programs--their 
equals cannot be found in the private health care system.

  Because of our commitment to our veterans, taxpayers have made a huge 
investment in VA health care, an investment that we do not want to 
waste. But proposed health reforms may well provide those who now use 
the VA with alternative choices of care--GAO predicted that if 
universal coverage was passed, up to 50 percent of current VA users 
would go elsewhere for care. The effect is that the VA will have to 
compete with other providers or die on the vine--to consolidate and 
better manage care or lose patients.
  Unfortunately, the VA is not now in a position to compete--nor are 
they used to competition. The VA does not know basic cost and other 
information needed to establish premiums, sell services, or operate in 
other basic business ways. It will take 3 years before the VA has a 
system installed nationwide to determine even basic information on what 
it costs VA to provide specific medical procedures. The VA remains too 
facility oriented, as oppose to health care delivery oriented. It is 
burdened with underutilized inpatient hospitals, and lacks the 
outpatient capacity and the community presence to adequately meet the 
comprehensive needs of veterans and their families.
  Until we know what final product Congress will produce, be it the 
Clinton-Mitchell plan, the Dole-Packwood plan, the Gephardt plan or a 
little bit of everything, it is difficult for us to say what is needed 
for the VA. In the Veterans' Committee markup of VA health reform, I 
offered an amendment that would have delayed implementation of VA 
reforms until we knew what national health reforms looked like. While I 
did not succeed in passing this amendment, I believe its purpose still 
holds true--we are moving into uncharted waters.
  The Mitchell health plan does not clear up any of these unknowns--in 
fact, it creates new ones. Under the Mitchell plan, in order for 
veterans to receive a comprehensive benefits package, they would be 
required to enroll in a VA health plan. Core group veterans--such as 
the service-connected disabled and the poor--would receive free care. 
For veterans and their family members who have outside coverage, the VA 
would retain Medicare reimbursements and private third-party 
reimbursements. These reimbursements, in addition to regular health 
care appropriations, would supposedly pay for the comprehensive 
benefits for all core group veterans.
  The problem is that there is no way to know if the increased 
reimbursements will offset the increased costs. There are currently 2.2 
million users of the VA health care system. But as many as 7.5 million 
veterans would qualify for free care under the Mitchell plan. Most of 
these veterans do not currently use the VA system, but might if 
benefits were free. Third-party reimbursements and regular health care 
appropriations together may not be sufficient to cover the increase in 
enrollment and the extension of new, free benefits to those who are 
currently not eligible to receive them.
  I am also concerned that, the Mitchell bill, on the one hand seems to 
create a new entitlement program for veterans health care, while, on 
the other hand, it also makes expenditures subject to the ordinary 
appropriations process. The effect is that the Mitchell plan could 
result in a reduction of care to veterans. If appropriated dollars were 
not sufficient to pay for each veteran's care, then all benefits would 
be reduced to make up the shortfall. In essence, a veteran signing up 
for a VA health plan that promises a certain level of benefits would 
not be assured that those benefits will remain available. Furthermore, 
veterans who now receive comprehensive benefits from the VA might see 
their level of care reduced. Again, we are speculating because we have 
no idea how many new users a VA health plan would attract into the 
system. But a thorough reading of the Mitchell plan would suggest that 
the so-called reformed VA health system could be detrimental to the VA 
by not even protecting the level of care certain veterans enjoy today. 
I understand that the majority leader and Senator Rockefeller are 
considering an amendment to fix this problem and I look forward to 
seeing their solutions.
  That said, there are simple ways that we can help VA run its programs 
to better serve veterans and not break the bank. Earlier this year, the 
Senate passed a bill to let the VA participate as a provider in States 
that are undergoing health reform. The point of this legislation is to 
free up VA facilities from VA Central Office control, to let them 
innovate, to contract freely for health care and other services, to 
give directors of the medical centers more freedom from personnel 
regulations. In short, the pilot bill was designed to make VA more 
businesslike, more managed-care oriented, and therefore more 
competitive by placing considerable authority in the field. The Dole-
Packwood proposal includes many elements of this proposal and would 
expand it's scope to include any VA facility which wishes to 
participate in the plan, and allow the VA to collect from Medicare for 
non-core group veterans.
  These reforms hold promise. Minnesota now allow any department or 
agency of the Federal Government to organize an Integrated Service 
Network to compete with other health plans in the state. The 
Minneapolis VA Medical Center currently leases excess space to a 
private HMO for an outpatient clinic. Montana is also studying ways to 
integrate Federal health programs like VA, IHS, DOD, and Public Health. 
And there are other examples of states that are moving on their own. We 
want VA to be able to adapt to these changes.
  Mr. President, America's health-care system is the best in the world. 
It is the product of collective genius, scientific advancement, and 
modern technology, flourishing in America's private sector. There is no 
doubt that Government has aided and even fueled some of this progress, 
particularly in technology and science, but never before has 
government, especially the Federal Government, advocated to so directly 
manage the system, as the Clinton-Mitchell proposal would do, if it 
were to become law.
  As many others have stated and written, this is a historic time for 
the Senate and for the country. I disagree, however, with the pundits 
and some of my colleagues who say that it is time to abandon America's 
privately managed health care system.
  So we have many questions to answer with regard to the Mitchell bill, 
and just that one aspect of VA health care and how that is going to fit 
in as well. I could comment at great length as well on how the Indian 
Health Care Service is going to fit in to the proposed national health 
care plan because these, indeed, are going to provide groups that 
previously had utilized these systems exclusively with the opportunity 
to go out and have the choice of other alternative types of care.
  In conclusion, let me say what we want to do is what is right for the 
American people. But the voters are going to be our judge. I fear the 
judgment will be harsh, should we take the wrong course at this time, a 
course that, once taken, cannot be reversed.
  So I remind my colleagues the concerns of the American people, 
indeed, are health care reform but not at any price. Health care reform 
that addresses costs. Health care reform that addresses availability 
and portability. Not an expanded bureaucracy, not a subsidy for 100 
million American people. Not a program that establishes another 34 new 
Federal agencies. Not a program that establishes 117 mandates. And not 
a program that mandates to States certain policies that are unfunded.
  The public is concerned about health care. The public is concerned 
about the bureaucracy. Let us address a pattern of uniformity here that 
addresses the concerns of the American people.
  We should enact a bill that fixes what is wrong--and fixes only what 
is wrong. Let us not get in the way of what is right. Moderation and 
prudence are what the people expect of us, and no less. If we--with all 
good intentions--move America's wonderful, unique health care system 
down the road to a rationed, poor quality, one-size-fits-all system, 
what good have we done? Have we then fixed what is wrong or have we 
wronged a great system? Our voters will be our judge, and again, I fear 
that judgment will be harsh should we take the wrong course; a course 
that, once taken, cannot be reversed
  The PRESIDING OFFICER. The Senator from South Dakota.
  Mr. DASCHLE. Mr. President, we made progress today. I think we can 
all be pleased at the passage earlier this evening of the Dodd 
amendment. It sends the right message as we begin debate about health 
care reform. It says to the country, it says to all of those who are 
watching, it says in particular to children that, indeed, they are a 
priority.
  There is some symbolism in the passage of an amendment dealing with 
children as our first amendment, a statement that as we consider 
building a better health care system, we consider children. We are told 
they are 33 percent of our population but 100 percent of our future.
  Just last weekend my oldest daughter had her birthday. She is now 23. 
I cannot think of a better present than to say to her and to say to all 
of those who are beginning their young adult lives: We can promise you 
a better future, a more secure future, a future with an appreciation 
for the importance of preventive care.
  So as we begin this debate I hope it is an indication, not only of 
the symbolism that I believe it represents, but clearly a constructive 
beginning in a debate that ultimately will lead us to meaningful health 
reform.
  Earlier today many assembled not far from here to remind all of us 
that as we now debate this issue, since the beginning of the debate, 
since the day the majority leader laid the bill down, 500,000 
additional Americans lost their health insurance; 100,000 children were 
included in that 500,000 Americans. People from all over--people from 
Florida, people from South Dakota, people who are wealthy, people who 
are not, people who are sick, people who are healthy--but 500,000, half 
a million people have lost their health insurance since this debate 
began. About 48 a minute now lose their health insurance.
  During the time the Senate has been considering the children-first 
amendment, the amendment offered by the distinguished Senator from 
Connecticut, children, too, have continued to suffer.
  In those 4 days, 2,544 babies were born to mothers who received late 
or no prenatal health care; 3,204 babies were born at low birth weight, 
which was less than 5 pounds; 224 babies died before they were 1 month 
old, just in the last 4 days; and 440 babies died before they were 1 
year old just in the last 4 days.
  So, Mr. President, this is a problem that ought to be very clear to 
all of us. The ramifications of failure are stark. These profound 
statistics speak with an exclamation point that we must deal with this 
issue effectively.
  About 9 million children in the United States went without health 
insurance 2 years ago. It is about 15 percent of all the Nation's 
children. About 80 percent of uninsured children have at least one 
employed parent, and over the last 5 years, between 1987 and 1992, the 
number of children with employer-based coverage decreased by almost 5 
percent. Children now under 21 comprise almost 30 percent of the 
population, but 36 percent of the Nation's uninsured. And that affects 
utilization.
  Children without insurance are less likely than those who are insured 
to use the health services or to have any usual source of medical care. 
In 1992, the vaccination levels for children between the ages of 19 and 
35 months of age were 83 percent for measles containing vaccines and 
diphtheria, tetanus and pertussis, DPT, shots and 72 percent for polio.
  Three-fourths of the children in this country between the ages of 19 
and 35 months were able to achieve some meaningful vaccination levels, 
but one-fourth did not. In 1990, an estimated 3 million children under 
the age of 6 had unacceptably high levels of lead in their blood. And 
as of June 30 of last year, over 4,700 children in the United States 
had been diagnosed with AIDS. AIDS is now the fastest growing cause of 
death for adolescents.
  Deaths of children due to homicide have tripled since 1960, now 
becoming the fourth leading cause of death among children ages 1 to 9, 
the third leading cause for children ages 10 to 14, and the second 
leading cause of death for adolescents ages 15 to 19.
  Every dollar spent on measles, mumps, rubella vaccine saves $17.80 in 
direct health care costs according to the Department of Health and 
Human Services. It costs about $20 for a doctor's office visit to treat 
a child with strep throat, but thousands to hospitalize a child whose 
untreated strep throat develops rheumatic fever. Between 1989 and 1991, 
a measles epidemic struck over 55,000 Americans, more than 11,000 were 
hospitalized, costing lives and millions of wasted dollars.
  An estimated 3 million children under the age of 6 had blood levels 
so high that CDC considered it dangerous.
  So, it is very clear, the cost of preventive care has an astounding 
effect on the population, both in cost as well as healthwise. It 
returns tremendous investments to vulnerable children as well as their 
families.
  Improving health of infants and children early and comprehensive 
prenatal care alone saves $3 for every $1 invested according to a study 
by Health and Human Services. Children who receive regular health 
screening, such as those provided through Early and Periodic Screening, 
Diagnosis and Treatment Program, have health costs 7 to 10 percent 
lower than other kids.
  Cases of measles, polio and other diseases have decreased by over 99 
percent since the introduction of vaccines.
  The estimated benefit/cost ratio of vaccines--that is, dollars saved 
for every dollar spent--is over 21 to 1 for measles, mumps, rubella, 
and 30 to 1 for diphtheria-tetanus-pertussis. It is over 6 to 1 for 
polio vaccine.
  So given these facts, it is very difficult for me, or anybody else, I 
am sure, to understand our country's acceptance of such large numbers 
of uninsured children and families today.
  Yet, each year nearly one-half of all pregnant women go without 
health insurance at all. Nearly all of these are women in working 
families. About 5 million women have private insurance policies that do 
not cover maternity care, and so, therefore, pregnant women without 
health insurance are likely to have inadequate prenatal care, 
inappropriate arrangements for delivery and less than adequate care for 
their newborn babies.
  Fifty-one percent of teen mothers and 24 percent of all mothers in 
the United States last year received inadequate prenatal care. There 
cannot be a better argument for the Dodd amendment. I am surprised, 
given all these statistics and given the ramifications of what the Dodd 
amendment could really do, that it was not 100 to 0 tonight.
  Infant mortality in the United States has declined to 8.9 per 
thousand live births. The United States, however, still has a higher 
rate of infant mortality than 22 other industrialized countries, a rate 
more than double that of Japan. Over 90,000 babies were born to mothers 
who did not see a health care provider during pregnancy--90,000 just 
last year alone. These babies are three times more likely to be born 
with low birth weight than those whose mothers received a timely 
prenatal care.
  Unfortunately, Mr. President, close to 40,000 infants die each year 
because their mother had no prenatal care and because there were 
complexities and difficulties that they did not anticipate because they 
had no place to go, because they had no insurance and no options. That 
is what we are talking about tonight: An opportunity for pregnant 
mothers, for families to say never again, to say at long last we are 
going to do what we said we were going to do for a long period of time. 
We are going to cover them right from the start. We are going to do 
what other industrialized countries have done now for so long. We are 
going to try to improve that infant mortality rate, we are going to do 
better than being number 22 and we are going to start doing it this 
year.
  Mr. President, that is really what the Mitchell bill begins to do. It 
proposes that all children be covered with full coverage by the year 
1997. Almost immediately it begins to cover 6 million children. It 
covers additional millions of families with children who would be given 
discounted premiums for the first time, premiums recognizing that 
prenatal care in that basic benefits package is so important to us and 
to all of those who are struggling today.
  There are 2 million people who today are kept from obtaining health 
insurance because they have preexisting conditions, and the Mitchell 
bill says we are going to put an end to that. Upon passage of this 
legislation, that will no longer be allowed.
  So all told, Mr. President, we add those who have no coverage, we add 
those who have some coverage but cannot afford the pregnancy care that 
ought to be in every plan, along with those who have preexisting 
conditions, and we now total more than 9 million children who 
ultimately, if this legislation passes, will be covered.
  The coverage is designed for children with preventive services that 
include the immunization that I just discussed, with special services 
that recognize special needs, such as rehabilitation services for those 
who need them, an essential nutrition through the WIC program, 
recognizing first and foremost that with good health will come good 
nutrition, with good nutrition comes an opportunity to send the right 
message to young families today, that preventive care is dependent upon 
good nutrition, good meals, and healthy children.
  Mr. President, the Dole bill leaves out more than 6.2 million 
children. If that bill were to pass, there would be no insurance for 
more than 6 million of the 9 million uninsured today. Lewin-VHI, the 
analytical firm in Virginia, upon whom we have turned on many occasions 
for good evidence or good analysis of what plans will do under 
different circumstances, has reported to us that the Dole bill, at 
most, covers 2.8 million of the current 9 million children who are 
uninsured. But by 1997, as I said, the Mitchell bill covers them all. 
Children under 19, pregnant women living in families with incomes below 
185 percent of poverty will receive full premium subsidies. In other 
words, they will be given the full opportunity to acquire meaningful 
health care right from the beginning, phased in, as I said, through the 
year 1997.

  Under Dole, however, the insurance companies will dictate which 
coverage children will have. Insurance companies would be in the 
driver's seat. They decide which benefits to cover and which to 
exclude. Therefore, many children will still be prevented from getting 
the well-child visits, the prescriptive medicines, or the preventive 
services that are so critical if, indeed, we turn around the statistics 
that I outlined just a moment ago.
  Many children, though their parents' work, will continue to be 
excluded from coverage since parents will be covered by employee-only 
policies that do not cover dependents. But under the Mitchell bill, 
children are guaranteed solid coverage regardless of circumstances, 
regardless of for what employer their parents may work. Health plans 
cannot be terminated, limited, or restricted. They cannot charge more 
based upon a child's health status. Insurance companies cannot charge 
more for a medical condition. They cannot charge more for claims 
experience or a medical history. They cannot charge more if a child has 
a disability. Insurance companies have to treat all of our children the 
same. Nor can they limit, restrict, or terminate coverage, or charge 
more because a child has used a lot of health care services in the past 
for whatever reason.
  The bill closes loopholes that leave children uncovered today. It 
spells out coverage for children even if they are adopted, even if they 
live with grandparents, even if they have stepparents or other 
guardians. In all circumstances, Mr. President, children are covered. 
The priority that we laid out in the Dodd amendment is extended, 
enhanced, and completely covers the children that are left out in the 
cold today. It guarantees that no matter what, we will have an 
insurance policy that at long last covers them all, regardless of 
circumstance, regardless of age, regardless of health.
  The Dole bill provides no help for children in need of long-term 
care. It offers no new long-term program that provides for 
opportunities for children to live outside of institutions today. So 
without that opportunity to live in alternative care settings, many 
children under the Dole bill will be restricted to the institutions 
that they try to avoid now because they will have no other option.
  But the Mitchell bill creates a new long-term care program that 
provides individualized care for disabled children, provides for a 
Federal-State, home/community-based, long-term care program with 
emphasis on individual needs.
  So here again, Mr. President, as we have talked about the many 
differences between the Dole bill and the Mitchell bill, there is a 
recognition of the stark difference. We have talked on many days now 
about why it may be that the Mitchell bill is twice as long as the Dole 
bill. Simply put, it does twice as much--for children, for seniors, for 
working families, for small businesses, for insurance reform and 
creating the opportunities to do the real kinds of things that we all 
say we want: Containing costs, providing good universal coverage, 
making sure that we have meaningful insurance reform, and doing the 
kinds of things that we have all spoken about the need for for many 
months now. That is what the Mitchell bill does.
  So as I said at the beginning, Mr. President, we have made a good 
start today. We passed an important amendment. We recognize that there 
are 100,000 children today who had insurance when this debate began. 
How many more children will lose their coverage during the course of 
this debate? Will it be another 100,000, 200,000, a couple million? 
That all depends upon us.
  When all is said and done, when we have an opportunity to say at long 
last to those who wait for action, to those who truly believe that we 
can solve this problem, let us answer affirmatively, let us say that 
what we did today is more than just symbolic; that, indeed, it is 
indicative of the kind of strong belief we must demonstrate that we can 
solve this problem for children, for families, for all Americans.
  I yield the floor.
  Mr. GORTON addressed the Chair.
  The PRESIDING OFFICER. The Senator from Washington.
  Mr. GORTON. Mr. President, what is the state of debate in the Senate 
at this moment?
  The PRESIDING OFFICER. The 2-hour time period which had been 
allocated has expired. Any Senator is able to be recognized and to 
speak on the legislation.
  Mr. GORTON. Mr. President, I ask unanimous consent to speak for 
roughly 10 minutes on a different subject, on the crime bill.
  The PRESIDING OFFICER. The Senator has that right.

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