[Congressional Record Volume 140, Number 116 (Wednesday, August 17, 1994)]
[Senate]
[Page S]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: August 17, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
                          HEALTH SECURITY ACT

  The PRESIDENT pro tempore. The Senate will resume consideration of 
the bill, S. 2351, which the clerk will report.
  The legislative clerk read as follows:

       A bill (S. 2351), to achieve universal health insurance

  The Senate resumed consideration of the bill.
       Pending:
       Mitchell Amendment No. 2560, in the nature of a substitute.
  Mr. KENNEDY addressed the Chair.
  The PRESIDENT pro tempore. The Senator from Massachusetts.
  Mr. KENNEDY. Mr. President, yesterday we enacted a guarantee that 
every insured child in America would receive comprehensive preventive 
benefits as a matter of right. Today we will be considering whether 
every child in America and every adult also should have at least the 
same reliable comprehensive benefits that every Member of Congress 
receives. The Mitchell bill is a triple guarantee.
  First of all, in the Mitchell bill, you will not be cheated out of 
what you have today by insurance company fine print or loopholes in 
your policy that do not protect you when serious illness strikes. The 
examples of how that fine print has excluded the insurance companies 
from covering, whether it has been infants in their first days of life, 
or whether it is other individual families members that are in great 
need, has been illustrated time in and time out during the course of 
this debate. And the Mitchell bill addresses that particular feature of 
existing abuse that is taking place in too many insurance policy issues 
today.
  Second, as long as you buy a standard insurance policy, you will 
never have less than the comprehensive benefits provided to every 
Member of Congress, and the President, too.
  That has been the stated policy of the Mitchell proposal. There is a 
very similar concept in terms of even the Dole benefit package to make 
it actuarially similar to what we have in Federal employees health 
insurance. That is I think a standard which the American people would 
certainly be willing to accept. For 10 million Federal employees, 
including obviously the Members of the Senate and the House, it is a 
good program. I with a family pay $101 a month. It is an excellent 
program to provide for my family with two children. I daresay that most 
Americans having heard that would pretty much sign on for that program 
even today. It is certainly the objective of those of us who support 
health insurance reform to make that kind of a possibility for other 
Americans.
  Third, the Government would never require you to buy less 
comprehensive coverage than you have today. You can always buy greater 
coverage if you want it. The basic concept is that a standard, not a 
Cadillac standard, or even a Gramm standard, but a minimum standard. In 
this case it is about the bottom quarter of the Fortune 500 in terms of 
the benefit package which would be the kind of minimal standard which 
can be added to, which can also be enhanced by individuals if they so 
desire because of certain kinds of needs; but a standard that would be 
available to Americans without the fine print of insurance policies 
that exist today.
  I would like to review for the Members what the Mitchell bill does, 
and to contrast it to the alternatives. First of all, it establishes 
the comprehensive lists of benefits that must be covered. That is done 
on pages 95 to 104. In measures that were reported out of our human 
resource committee, we identified very, very precisely the benefits. 
The Federal employees programs are more general in terms of the types 
of benefits that ought to be provided. The leader reached I think a 
worthwhile adjustment in terms of those two ways of approaching this. 
It is illustrated on pages 95 to 104.
  Second, it requires that these must be equal in total value to the 
Blue Cross-Blue Shield policy that covers most Members of Congress 
today. That is written into law at page 93.
  It allows the vast majority of Americans to buy their coverage from 
the Federal Employees Health Benefits Program, the same program that 
provides coverage to every Member of Congress. That is at page 158. We 
will in terms of the two various pools be blending those, phased in 
over a limited period of time. But effectively that benefit package of 
benefit programs will be available to Americans and be consolidated in 
the next several years.
  It also allows you to buy additional coverage if the standard 
benefits alone do not meet your needs. That is on page 88. It provides 
coverage for cost-effective preventive services without copays and 
deductibles. That is on page 123. We reviewed those in some detail over 
the period of the past days when we were considering the Dodd 
amendment.
  I see the Senator from Delaware who supported that amendment on the 
floor at the present time. Basically, we were trying to ensure the 
kinds of preventive health care benefits which result in an enhanced 
health condition for individuals--particularly in the instance of the 
Dodd amendment for children--which would enhance health conditions for 
all Americans. And the results have been illustrated several times by 
the excellent presentations that have been made by the two Senators 
from Hawaii, where they have very extensive preventive health care 
programs.
  It is designed to better meet the special needs of women, children, 
and the disabled in many current insurance programs and insurance 
policies. This is addressed on various pages. The coverage as it 
relates to preexisting conditions is illustrated on pages 61 through 
64. The Mitchell bill prohibits such abuses as the preexisting 
condition limits, lifetime limits, denial of coverage, rate hikes if 
you get sick, and exclusion of essential services.
  The lifetime limits are addressed on page 124, and the other part is 
on pages 60 and 61 and the pages following. I daresay you could ask how 
many of the Members of this body would know what the lifetime limits 
are, or whether there are lifetime limits in their own Federal 
employees insurance. We had a meeting earlier in the morning talking 
about this with our colleagues here. And there are some tragic 
incidents where some of our colleagues talked about insurance policies 
that were available to their constituents, and then they would find out 
that they had some serious health needs and suddenly the insurance 
company would say, well, look, you have the lifetime limit and you have 
exceeded it. We found that particularly in examples used involving 
children--the kind of hardship was placed upon that family.
  It guarantees you the right to choose a plan that provides free 
choice of doctor and hospital. This is included in both if you go 
through the cooperatives, page 151, or through employer programs at 
page 137. This is an essential part of the Mitchell proposal. Under the 
Dole provision, there is no reference to the choice of a doctor or a 
hospital.
  So here is the contrast of the Mitchell bill to the status quo.
  Today, any insurance company can, first of all, deny you coverage.
  Secondly, they can impose a preexisting condition exclusion. They can 
say if you have a preexisting condition, we can exclude you for that 
coverage.
  They can limit your lifetime benefits so that your protection runs 
out when you need it the most.
  They can cancel your coverage when you get sick. We have had several 
examples in very recent weeks of employees with good companies that had 
their health care canceled for all of their employees because of the 
incidence of illness among just a few of their employees effectively 
canceled out within a 2- or 3-month period.
  There is also the exclusion of any service from coverage, even a 
service that might turn out to be most important to you if someone in 
your family becomes seriously ill.
  No American is guaranteed choice.
  I think these following points are worthwhile to keep in mind. If 
your employer does not offer a plan you like, you can be out of luck. 
Eighty-four percent of employers offer only one plan. Of the employers 
that make available health insurance to their employees, they provide 
one plan, and you are effectively out of luck if you want an 
alternative choice. You can take it or leave it.
  Second, if your employer does not offer a plan that allows you to 
keep your family doctor, you are also out of luck.
  You say, look, I want to be able to keep my family doctor. The real 
life, real world today says: This is your plan. If your family doctor 
is not covered by that particular kind of plan, you are out of luck.
  The Dole plan is better than the status quo alternative, but I do not 
believe it is good enough. The insurance companies can still impose 
preexisting condition limitations, and they can sell you a policy that 
does not cover the service you may need the most, because policies are 
not required to provide comprehensive coverage. You do not have the 
guarantee of choice.
  We are likely to see an amendment offered sometime, perhaps today, or 
sometime in this debate, that will claim to protect the benefits the 
American people have today by effectively scrapping the requirement 
that every insurance policy must offer basic comprehensive benefits.
  What it will do is effectively gut the protections that the Mitchell 
bill provides. It will allow every insurance company the abuse that 
exists today to continue with the preexisting condition limitations or 
the right of the company to terminate or not renew the policy.
  There may very well be lifetime limits, inadequate protection for 
children and the disabled. One of the favorite provisions for many 
insurance companies, particularly those covering young families, is the 
exclusion of a child's coverage for the first 10 days of life. That is 
where about 93 percent of all medical complications arise.
  I think of the scores of young couples that looked over the insurance 
policy and saw they got prenatal care, and then had these difficulties 
in the first few days of life, found out there was no coverage. That 
has been one of the continuing tragedies in too many instances.
  Mr. President, any kind of an amendment that effectively would 
undermine the guarantee of at least a minimum package of benefits would 
undermine the amendment that we passed yesterday to protect children, 
because the guarantee of preventive services will turn out to be no 
guarantee at all.
  The widely respected Actuarial Research Corp. estimated that because 
of adverse selection, if these benefits are available but not standard, 
it could cost a family an extra $450 a year. If they are included in 
what everybody buys, they would cost only $2 per month per child.
  The supporters of this amendment will say that they are trying to 
preserve choice. But that is the same old argument that has been used 
to protect the profiteers of the status quo since the beginning of 
time. The opponents of change have always hid behind choice. Child 
labor laws deny children the choice to work 12 hours a day in mines and 
factories.
  We will hear: Why should we have this standard benefit package 
available? Why do we know better than the people back home in local 
communities? Well, that debate was there at the time of the child labor 
laws.
  In my own State of Massachusetts, in Lawrence and Lowell, you could 
go into the various plants and factories--and they still have museums 
up there containing little poems of children 10, 11, 12 years old, who 
used to work 10 or 12 hours a day, 6 days a week, and they would 
describe looking out the window at the parks, and so forth. Their life 
experiences had passed them by. They would generally last 8 to 10 years 
in those plants and no longer, for a variety of different kinds of 
tragic reasons. So when we hear, ``We want to preserve choice,'' we can 
say that issue was addressed years ago. We had the child labor laws. 
They said, ``Why should you in Congress pass child labor laws?''
  Why do not we permit those who are in charge of the children have the 
choice of working more extensive time? Why deny us that kind of choice?
  We have the same argument with the Fair Labor Standards Act which 
denies men and women the choice to work at less than the minimum wage. 
Why do not we permit men and women the choice of working less than the 
minimum wage?
  There is basically a social compact which has been accepted by 
Republicans and Democrats alike that men and women who want to work 40 
hours a week, 52 weeks a year ought to not be put in a position of 
poverty in this society. They ought to be able to have sufficient 
income to provide for their families, put a roof over their head, food 
on the table, afford a mortgage for their home, and live in some peace 
and in dignity. That was the concept.
  We could say, well, let us eliminate any minimum wage laws. Let us 
just let the market go. Why do we know more than what is happening out 
in these local towns? We can find people who will work for less than 
the minimum wage.
  We say, well, on the issues we have a sense of a common good about 
what our society is about. We care about men and women who want to 
work, will work and will work for low wages, but they ought to be part 
of the American experience that they are going to live in some kind of 
peace and dignity.
  We address the issues of choice on the Social Security Act, which 
denied people the choice to forgo pensions. Why not say, well, we had 
that debate. We are going to say under Social Security we are going to 
make that an option for people. We will give them the choice of having 
no Social Security, no pensions when they retire. Why not give them the 
choice of that so that they do not have to conform?
  We have accepted the concept that we have a respect for those who 
have really been the architects of this great wonderful blessed land 
who really toiled in the fields and worked in the factories, fought the 
wars, built the country. They are part of our society. They are our 
parents. We are their children. And as a society, the only way that we 
could get it was the development of a Social Security system that was 
part of the social compact.
  We have accepted in recent years what we call the lemon laws and deny 
the people the choice to buy cars that broke down all the time. Why not 
let anyone go out and buy whatever car they want, let it break down, 
touch the fender and it collapses, drive out of the parking lot and the 
engine is no good? Why not permit everybody the free choice to be able 
to do that? Why expect that there ought to be at least some requirement 
that would represent what the seller and the purchaser understand to be 
the value of it? We could say why have that kind of law, why have that 
kind of legislation, why have that kind of requirement? Let us just let 
the buyer beware when they go back out to those parking lots.
  We had it for a period of time in the medical device legislation. We 
just said let women beware. Let women beware. We had 2,700 women who 
died from a perforated uterus. Let women beware, until we finally had 
some at least protection in terms of medical devices that were going to 
be implanted to show they were going to be safer and efficacious. We 
said there is at least some requirement and some responsibility.
  So now the opponents of change want to give the American people the 
choice of substandard insurance coverage. They want to give the 
families the choice of denying their children preventive health care. 
They want to give mothers the choice of going without preventive 
prenatal care. They want to give people the choice to buy policies that 
will turn out not to cover the very serious that will need the most if 
they become sick. This kind of choice is really no choice at all. It is 
effectively an excuse to defraud the American people of the health 
security they deserve, and I believe it will be rejected.
  Several days ago, one of the opponents of the Mitchell bill called it 
a health scare bill, and that is exactly what the proponents of this 
amendment are trying to do. They are trying to scare the American 
people into rejecting change. It did not work with Medicare a 
generation ago, and it will not work with the Mitchell bill now.
  Mr. President, I yield the floor.
  The PRESIDENT pro tempore. The Senator from Delaware [Mr. Roth].
  Mr. ROTH. Mr. President, for the first time in its history, the U.S. 
Senate has before it legislation to reform the Nation's entire health 
care system. Without a doubt, this is a historical debate. We must not 
lose sight that what we are debating will have tremendous repercussions 
on health care as we know it today.
  The bill before us is immensely complex, in part, because it deals 
with an immensely complex issue. Even at this stage of the legislative 
process, it is not clear what direction the debate will take, and the 
final implications of whatever shape the legislation takes on are, 
therefore, unpredictable. In any event, let me make very clear that I 
strongly oppose the Clinton/Mitchell bill in its present form. Even the 
way this legislation was put together concerns me. And I am not alone.
  In a recent column, Robert J. Samuelson quoted CBO chief Robert 
Reischauer, who warned that trying to find a compromise health care 
bill by combining provisions from different bills might make the health 
system worse. ``You can't say I want a piston from Ford, a fuel pump 
from Toyota, and expect the engine to run.'' That is precisely what has 
happened with this bill.
  There is a great deal that concerns me in this proposal. And I intend 
to look for answers, because what is contained in this legislation will 
not only dramatically affect the American people, but almost $1 
trillion in medical services and about 15 percent of our economy.
  At the top of my list of concerns is how this bill will affect the 
people of Delaware. In our State we have a population of about 660,000 
people living in 3 counties. Right now, we have important and good 
health care services, delivered through partnerships and community 
involvement. Certainly, there are steps that we can take to improve 
access and affordability to these services, but they are delivering 
quality care--state-of-the-art care--to men, women, and children who 
depend on them.
  Frankly, I am concerned with the effect this legislation will have on 
the balance of care now being provided--and, I am concerned with the 
effect the tax increases contained in the proposal will have on the 
economy and jobs in Delaware. This bill--one way or another--will have 
a dramatic impact on the system that currently exists. It will have a 
dramatic impact on employees, employers as well as family security.
  For example, in Delaware, the New Castle Chamber of Commerce, in 
cooperation with the University of Delaware's Bureau of Economic 
Research, conducted a study that shows:

       Mandated health care could lead to the loss of 27,800 jobs 
     in New Castle County, due to layoffs and workers displaced by 
     employers going out of business.

  A second study, recently issued by the Family Research Council, 
states that families with children in Delaware bear the brunt of job 
losses due to employer mandated health care proposals. I would like to 
read from that study:

       Employer-mandated health care refers to the Federal 
     government's requirement on employers to purchase 80 percent 
     of their employees health insurance. * * * The impact of job 
     losses in families is particularly acute when children are 
     involved. The maximum number of impacted children would be in 
     excess of the number of jobless parents with dependent 
     children * * * Under the Clinton plan, 1,500 of the estimated 
     2,600 jobs lost in Delaware would be shouldered by families 
     with dependent children* * *. Under the Senate Labor 
     Committee plan, * * *, 3,200 of the estimated 5,600 jobs 
     lost--would be shouldered by families with dependent 
     children.

  A third study, conducted by two Ohio University economists for the 
American Legislative Exchange Council [ALEC] projects that ``Delaware 
would lose 3,200 jobs under the Clinton health care plan.''
  And a fourth study, conducted by CONSAD Research Corp., a firm that 
performs economic studies, estimates that ``2,593 Delaware workers 
would lose their jobs, and another 72,977 would face reduced wages, 
hours or benefits'' under the Clinton mandate.
  These are real Delawareans with families that depend not only on a 
strong economy, but on competent health care providers. And as we 
consider legislation that will literally rearrange their environment we 
must see them in the most personal way and honestly determine how these 
1,400-plus pages will alter how they live and do business. We must 
understand how this legislation will impact their health care 
providers. It is interesting to note that Delaware serves as a 
microcosm of America. In our State we have about every kind of health 
care practitioner, about every kind of hospital with their own unique 
services, characteristics, and needs. Rural hospitals, urban hospitals, 
religious, philanthropic, research hospitals, educational hospitals, 
veterans and childrens hospitals--we have them all. And it is revealing 
to assess this Mitchell-Clinton plan according to how it will affect 
these providers.
  Let me give a few specific examples:
  In our State, we have the Medical Center of Delaware, our largest 
facility which has a special relationship with Jefferson Medical School 
in Philadelphia. I want to know how the medical education requirements 
of this proposal that will limit the total number of physicians in the 
United States will effect our medical center's ability to attract and 
retain new physicians-in-training.
  We have Riverside Hospital, an osteopathic hospital serving northern 
Delawareans. I want to know the effect the bill has on osteopathic 
facilities.
  We have St. Francis Hospital, which has a strong bond with the 
Catholic Church. The facility has a religious mission not to perform 
abortions. Again, this matter has not been clarified in the legislation 
before us.
  We have Kent General Hospital in Dover and the military hospital on 
Dover Air Force Base--both of which serve Kent County. How will this 
legislation affect access to health care offered in both of these 
facilities for military personnel--active and retired?
  We have a children's hospital heavily funded by an endowment from the 
Alfred I. du Pont Institute. In addition to the care it delivers to 
hundreds of children in the hospital, it has taken on a partnership 
with the State to expand access to care for Delaware's children. This 
is a creative partnership between public and private institutions. How 
will incentives for private groups to continue to donate and contribute 
toward providing needed health care be affected by both the tax and 
health policies contained in this legislation?
  We have a veterans' hospital caring for thousands of veterans who 
have valiantly served our country. How will this legislation affect the 
continuity of care provided in that facility?
  We have Beebe Hospital near our Delaware beaches which has an 
emergency room which must be able to serve both the year-round 
residents as well as the thousands who visit to our beautiful coastline 
each summer. Beebe serves a community where there has been an immense 
growth of individuals over the age of 65. Medicare reimbursements to 
the hospital have been, and continue to be, critical. How will the 
Medicare costs reductions included in this legislation affect Beebe's 
need to meet the needs of our seniors?
  We have Milford Memorial and Nanticoke Hospitals serving rural 
populations in very innovative ways. It does not appear that this 
legislation will facilitate their abilities to create partnerships to 
share medical equipment and high-cost technology. Will this legislation 
continue to perpetuate the virtual medical arms race that is needlessly 
increasing the cost of health care delivery?
  And, finally, we have the State hospital, which serves Delaware's 
chronically ill. What will be the State's future requirements to meet 
the needs of those now being cared for? Will there be an unafforable 
disruption in services?
  In addition to these hospitals, we have many other organizations and 
people actively involved in the delivery of health care--three 
federally qualified community health centers, hundreds of physicians, 
nurses, chiropractors, psychologists, several medical research 
facilities, nursing homes, home health care agencies, hospice care 
givers, and many, many others. The list is very long--only exceeded by 
the numbers of men, women, and children who depend on the health care 
services they provide.
  I am pleased to say that I have heard from Delawareans from top of 
the State to bottom; I have heard from these organizations. I have 
heard from many of our families. And I have benefitted from hearing 
their concerns. Their primary question is quite simple: How will all 
the new changes included in the Clinton-Mitchell plan affect me? Beyond 
this, they want to know how much will it cost. How many new Government 
employees it will require to run it. They want to know if it will limit 
their ability to choose the physicians they feel comfortable with. They 
are concerned about the future growth of such a program. Will it grow 
into an enormous and possibly unfundable entitlement with a life of its 
own? They want specifics concerning how Congress intends to pay for it 
with the deficit already so large. Others have asked if it is necessary 
to change the entire U.S. health care system--a system that currently 
covers 85 percent of all Americans--to reach the last 15 percent. They 
want to know if those remaining 15 percent could be covered in other 
ways.
  These are all legitimate questions that must be answered as we move 
forward with this critical debate. And it is critical. We do need to 
make some important changes to our health care delivery system. The 
costs of providing health care are high. There are vulnerable Americans 
who are not receiving the coverage and medical care they need. 
Something must be done to control costs, to make health care coverage 
more affordable, to provide needed coverage to those now uninsured. I 
agree with this. As I have said many times, there are several very 
important steps that we should take to reform our Nation's health care 
system. Specifically, there are five points that we need to keep in 
mind as we move forward with health care reform.
  First, that while there are major improvements that need to be made 
in our health care system, these improvements must be made without 
putting at risk the many good features that are working in our current 
system. As all doctors know, as we treat those conditions ailing the 
current system, we must first do no harm. Our health care system may 
have some shortcomings, but it is not broken. Consequently, it needs to 
be fixed or improved, not eliminated and substituted.
  Second, acknowledging that improvements can, and should be made, we 
must focus on making those improvements. The areas that must be 
improved concern insurance coverage, removing the barriers that now 
exist. Reform should eliminate preexisting condition exclusions, and it 
should guarantee portability. Reform should empower small businesses in 
the marketplace and make coverage more affordable. These are all 
important steps, and I would like to address them individually:
  Elimination of preexisting conditions: if a person has an illness or 
once was sick, they should still be able to get health care coverage;
  Portability: Americans must not be locked into jobs, unable to change 
employment, because they may not be insured elsewhere;
  Small business empowerment: small groups have very little leverage in 
the marketplace; any reform must provide them easier access;
  Affordability: through the combined effect of cost containment 
measures--malpractice reform, cutting fraud and abuse, and 
administrative simplification--and an appropriately financed subsidy, 
real reform must assist low-wage workers in the purchase of health care 
insurance.
  The third point we must keep in mind is that competition and choice 
have been fundamental influences in making our health care delivery 
system the world's flagship. Reform must build on market principles. 
Injecting more Government, creating more mandates, and hiring more 
bureaucrats is no way to make the system more efficient and effective.
  Does this mean that Government has no place in this debate? 
Absolutely not. In fact, I have introduced a proposal that would put 
the strength and size of Government to work to benefit the small 
business man and woman. The Federal Government has the largest pool of 
privately insured individuals in the current system. Nine million 
Federal employees, retirees, and their dependents participate in the 
Federal Employees Health Benefits Program [FEHBP]. My proposal would 
put this pool to work by opening it up to others.
  Small businesses and groups could buy into the Federal program, 
receiving the same rates that Federal employees receive. I understand 
that Senator Mitchell's bill does contain a provision to use my idea to 
open up FEHBP, but as written, his utilization of my plan raises some 
concerns that I will address a little later.
  Another measure that Government can and should make at this time is 
to give Americans the incentive to establish medical savings accounts, 
or MSA's. I have proposed legislation to establish medical savings 
accounts, and it has found broad support. Similar legislation was even 
voted out of the House Ways and Means Committee.
  A medical savings account is a savings account that is designed to 
pay for medical expenses. Under my legislation, individuals or families 
can convert the money that they and their employers spend on their 
health insurance policy into a less expensive catastrophic insurance 
policy, and put the balance into a medical savings account. For 
example, if a family has an average insurance plan costing $4,500 
annually, they could convert those funds as follows: Part of the money 
would be used to buy a catastrophic policy for $2,000 to cover big 
expenses from, for example, cancer treatment or a heart attack. The 
balance of $2,500 would be put in a medical savings account. As long as 
the family spends less than $2,500 for routine health costs that year, 
all of their health expenses would be paid with pre-tax dollars from 
the MSA. In case of a medical emergency, the high deductible health 
insurance policy would begin paying the health costs once they exceed 
$3,000.
  After a few years of low health expenses, excess MSA funds would be 
available in the account to pay for unexpectedly high health costs, for 
long-term health insurance or to make COBRA payments to extend coverage 
in case of unemployment. In fact, workers can use the money to pay for 
braces or eye care for their children, which often are not covered in a 
normal health care policy.
  What makes my amendment work is the fact that Americans will know 
that whatever they do not spend on health care expenses, they can keep 
for themselves. Beyond offering patients choice, MSA's will help 
control health care costs.
  The reason why is simple: it will encourage consumers of medical care 
to shop wisely, reject unnecessary treatment and conserve scarce 
medical resources because it is the consumer, not a third party such as 
an insurance company or the Government, who will be paying the bills.
  In testimony before the Finance Committee, one company testified that 
in only 8 months after initiating an MSA program the average employee 
had savings of $602, and total savings for the company was $468,000. 
They stated that employees have been able to save because they are 
shopping around for medical care. In fact, one employee negotiated 
close to $4,000 off her hospital stay before she entered.
  Already, six States have passed legislation enacting tax-favored 
medical savings accounts. They are Arizona, Colorado, Idaho, 
Mississippi, Missouri, and Michigan. Jersey City has implemented them 
as an alternative for their city employees, and the State of Ohio is 
contemplating a test program next year for State employees. Clearly 
medical savings accounts offer Americans a choice about their health 
care that should be fundamental in a country built on free market 
principles. It is the Federal Government that must now move ahead with 
this new idea.
  Opening up FEHBP and creating incentives for Americans to participate 
in medical savings accounts--this is what Government can, and should, 
do. This is positive; it is achievable. It builds upon the proven 
strengths of the current program without creating mandates, without 
increasing taxes, and without creating large, overbearing government 
bureaucracies.
  The fifth and final point we must remember is that America can ill 
afford new and higher taxes, new mandates, and new bureaucracies. The 
bureaucratic age is over. Small, lean, and efficient organizations--
they are the future. It is no surprise that the engine of economic 
growth in America is small business. These businesses and the trends 
they set must be nurtured. Creating more Government won't do that; 
opening the benefits of a government program already in place to 
include them will.
  Our answers to the the problems that do exist in our current health 
care deliver system must be innovative. But again, they must build on 
those principles within the system that are working. We must remember 
that in an entirely voluntary system, Americans still have reached a 
rate of almost 85 percent insured population.
  Almost 20 million of the reported 38 million uninsured individuals 
are working, or are in a family where someone is working for a business 
which has 1 to 100 employees. What Government must do is make health 
care coverage more affordable for these small businesses.
  One of the primary contentions of those supporting comprehensive 
national health care reform is that if we do nothing, our health care 
system will self-destruct. This is not true; it is a scare tactic. The 
truth is that in the past year, growth in health care costs have been 
at a 20-year low. Delivery of care is changing and efficiencies are 
emerging indicating that this is not a temporary trend.
  The secret to successful health care reform is to build upon these 
trends and the principles that have made the American health care 
delivery system the foremost system in the world.
  Mr. President, I would like to conclude by reading into the Record a 
letter of endorsement I received from the National Federation of 
Independent Business that supports my plan to open up the Federal 
Employee Health Benefit Plan. It reads:

       On behalf of the over 600,000 members of the National 
     Federation of Independent Business (NFIB), I am pleased to 
     support your efforts to allow small business owners to 
     purchase health insurance through the Federal Employees 
     Health Benefits Program (FEHBP).
       Since 1986, the cost of health insurance has been the 
     number one concern of small business. Small firms often pay 
     at least 30 percent more than large businesses for health 
     insurance for their employees.
       Your proposal to allow small businesses to voluntarily buy 
     into an insurance pool with approximately 10 million people 
     that offers a variety of plans is a terrific opportunity for 
     many small businesses. It gives small businesses access to 
     affordable health insurance.
       Small business owners voluntarily buying insurance through 
     the large FEHBP would have more purchasing power and lower 
     administrative costs, leading to lower premiums. Pre-existing 
     condition exclusions, sudden cancellation and rate hikes 
     would no longer be problems--the risk would be spread over 
     millions of people. In a recent survey of NFIB members, 70 
     percent believe small business owners should be permitted to 
     buy health insurance through the federal program.
       NFIB cannot support attempts to mandate small business 
     participation in FEHBP. Additionally, businesses choosing to 
     buy into the FEHBP should be able to purchase the same 
     benefits at the same cost as federal employees and retirees, 
     there should not be separate, higher rates for small 
     business.
       Thank you for leading the fight to help small business 
     owners obtain affordable health insurance. We look forward to 
     working with you. Sincerely, John J. Motley III, Vice 
     President, Federal Governmental Affairs.

  Mr. President, I yield the floor.
  Mr. GRASSLEY addressed the Chair.
  The PRESIDENT pro tempore. The Senator from Iowa [Mr. Grassley] is 
recognized.
  Mr. GRASSLEY. Mr. President, for a couple weeks now, the newspaper 
articles reporting on the debate in the Congress about health care 
reform have been permeated with the politics of Capitol Hill. There is 
always going to be some politics on Capitol Hill on almost any issue.
  I would imagine that the people out there at the grassroots really do 
not care about the politics of this issue. By politics, I mean 
Republican and Democratic sides of the issue.
  I firmly believe that the people do not care whether a Democratic 
bill passes or a Republican bill passes or a bipartisan bill passes. I 
think what the American people are concerned about is that if we are 
going to pass legislation--and I say if because there seems to be a 
growing tendency on the part of people to be a little more skeptical 
about what we do and whether we should do anything. But I think the 
American people feel that if we are going to pass something, that the 
measure of whether or not it is good is not whether it is Republican or 
Democratic or bipartisan, but whether it is, in fact, a good piece of 
legislation. I think that is what they want us to struggle to 
accomplish, passing a good piece of legislation.
  On the other hand, I think there is a political situation in 
Washington in which the strategy for this bill is that the other side 
of the aisle, the Democrats, along with the White House, must pass a 
bill that the President will sign and that we will stay in session long 
enough during this summer break to do that, or we will stay here long 
enough until the other side can blame the Republicans for not passing 
such a bill.
  That sort of strategy does not produce good legislation. It is not 
going to enhance the credibility of our institution, and it is not a 
very good position to be in and one that I hope we can get out of but 
probably cannot. So this sort of strategy could bring us to a position 
where we pass a more partisan bill rather than a good bill.
  I hope that if we pass a bill that is as massive as this 1,400-plus 
page bill, that everybody in the country who thinks about their health 
care and their health insurance, on that day that it is passed, would 
write down in their diary--and tell the truth in your diary--of how you 
yourself view the health care system in the United States in 1994. 
Write it down. Write it down for yourself, write it down for your 
children and grandchildren. Describe your view of the American health 
care system and everything that is associated with it, including 
insurance, your doctor, your hospital, because you may look back in 
your diary and compare what you wrote in 1994 to what you have in 2000 
or 2010 and find that in the future, you do not have anything of the 
quality or the quantity and the satisfaction that you had in 1994.
  I think we owe it to ourselves to write that down because when you 
talk about passing a piece of legislation this size, do not forget it 
deals, to some extent, with veterans care paid for by the Government, 
Medicare, and Medicaid. All of these costs of Government, plus the cost 
of the private sector, add up to $900 billion plus in costs. One dollar 
out of every $7 of our gross national product is spent on health care 
in America, and a bill this size--and a lot of other bills that have 
been introduced, as well, some of them even Republican--is going to 
redirect every one of those dollars, to some extent.
  That is Congress passing one piece of legislation, attempting to do 
it for a segment of the American economy that equals the entire economy 
of the country of Italy. Think of the U.S. Senate since March or April 
1789 being in session 205 years. I do not think the Congress of the 
United States has ever before in the history of our country passed one 
piece of legislation having such sweeping impact upon the economy, both 
the private sector and the public sector.
  We have tried in health care areas to do a lot less, and we have come 
up short of accomplishing what we wanted to accomplish. Remember in 
1988, we passed catastrophic health care reform, just a small segment 
of some of the things that we are trying to accomplish in this 
legislation. I voted for it. It passed, I think, 87 to 11. I voted for 
it feeling I was doing not only what was right, but I voted for it 
doing what I felt my constituents wanted me to do.
  It was not long when we went home and all of us ran into a buzz saw 
of discontent about that legislation, and we were back here within 1 
year repealing that by almost the overwhelming margins by which we 
passed it in the first place.
  So in another area of health care reform legislation, we passed a lot 
less in the 205-year history of our country and were not successful at 
it. I think the public is skeptical of Congress' ability to pass such a 
massive piece of legislation and do good in the process and do good for 
everybody. I think that skepticism has permeated the thought that has 
been filtering up to us from the grassroots from our townhall meetings, 
from our telephone conversations and, most particularly, from our mail.
  Whether or not Congress can pass such a sweeping piece of 
legislation, guaranteed for everybody, and move forward, redirecting $1 
out of every $7 spent in America and they have questions about it, I 
believe those questions lead to skepticism, and that skepticism at the 
grassroots has been affecting the debate on Capitol Hill over the last 
several months.
  That is why I feel that if we do pass a piece of sweeping legislation 
like this, that perhaps you ought to write in your diary your thoughts 
about health care today.
  It is my view that you will look back and say you wish you had those 
days with you again, that sort of environment for the quality and 
quantity of health care in America, albeit not perfect, not equitable, 
not entirely fair, as some people might view it.
  Massive pieces of legislation like this, 1,400-plus pages are being 
promoted by people who have great faith that Government always does 
good. People who have opposition to this sweeping enactment, plus, I 
think, a majority of the people at the grassroots, are skeptical, 
question that faith in Government and probably have a greater faith in 
the marketplace. And I will just use one example that has been thrown 
out here of one approach in this bill of an employer mandate or a 
trigger that could bring an employer mandate that is working so well.
  It is thrown out to us that Hawaii for 20 years has had an employer 
mandate, and that sets a good example for us as a nation as a whole to 
have one. My State of Iowa does not have an employer mandate, and by 
the Current Population Survey of 1993, Hawaii has 80.1 percent of its 
population with private health insurance. Iowa, without an employer 
mandate, has 80.3 percent; 80.1 for Hawaii, 80.3 for the State of Iowa. 
So you can get high participation in health insurance without an 
employer mandate, because we do not have one in my State. I think that 
is probably why the Iowa poll, which is a Des Moines register poll, 
shows high opposition to an employer mandate. I believe that is why our 
Governor Branstad of my State and his health task force have come out 
against an employer mandate. But an employer mandate is an example of 
having great faith in Government as opposed to having great faith in 
the marketplace.
  Well, as has been said so many times, Mr. President, this big bill 
that I have held up, 1,400-page bill, is the third 1,400-page bill, or 
I should say the third draft of a bill that has appeared since its 
original introduction 2 weeks ago, I believe. It is difficult for staff 
and members to keep up with these changes. Senators are often heard to 
say that complicated legislation should not be done on the Senate 
floor, that that is the job of committees.
  Now, of course, we have a completely now wrinkle in the process here. 
Legislation is being made in some never-never land between the 
committees and the Senate floor, and I suppose it is proper; the 
majority leader wants to develop majority support for his bill both 
inside the Senate and outside, and I suppose that is why it is 
necessary for some of these changes to be made.
  But there is a question that is very pertinent to the debate, whether 
it is on the first draft, the second draft, or third draft. Why is it, 
when we are about to act on reform of our health care system, which has 
so much potential for good, that so many Americans are fearful of what 
we might do? And they are uncertain and they are fearful, Mr. 
President. Recent polls show it.
  The Wall Street Journal/NBC poll released August 2 found that 52 
percent of the respondents disapprove of health care reform, only 40 
percent approve. To the question of whether or not Congress should pass 
a bill this year or debate now but act next year, 61 percent in that 
poll said we should act next year. And a more recent Newsweek poll 
found fully 65 percent want us to come back to this matter next year.
  On last Wednesday afternoon, CNN reported that 54 percent of their 
respondents had said they thought they would be worse off if Congress 
passed a bill, and 32 percent--only 32 percent--said that they would be 
better off. Other Senators have cited other polls with similar results 
on this floor.
  It is not only the polls that are showing this uncertainty. I have 
heard it loud and clear in over 25 listening posts, or town meetings as 
some of my colleagues call them, that I have had in towns, large and 
small, all over my State. In many of the meetings I have had, not 
devoted just to health care reform but to any issue that might come up, 
this issue is always raised, and it is always raised with the same 
kinds of concerns. I do not believe that this uncertainty and fear is 
just the result of propaganda campaigns of interest groups devoted to 
preserving the status quo. Certainly, such efforts are underway and 
have been made for some time on both sides of the issue. We know that. 
Certainly such campaigns can confuse and mislead. Maybe they are meant 
to confuse and mislead. But there are a number of reasons why our 
fellow citizens are justified in their concerns about this legislation. 
Our fellow citizens are asking whether we can possibly know what is in 
this big bill and, more broadly, whether we really know what we are 
doing with such a comprehensive proposal.
  The Presiding Officer knows Chancellor Bismarck's quip about 
legislation-making and sausage-making being similar. That remark was 
made over 100 years ago, but it is pertinent today maybe even with this 
legislation.
  As our fellow citizens focus upon this legislative sausage factory at 
work on health care reform, they have every right to wonder what in the 
world is going on in the Senate. And some of us wonder why the public 
holds people who are in politics in low esteem.
  But citizens are also concerned about the fundamental changes that 
would result in our health care system were the Clinton-Mitchell bill 
or the Gephardt bill in the House enacted.
  Maybe the way to begin is to remind those who are listening what it 
is that Americans value in their health care. I am referring to the 
choice of personal physician. I am referring to the physician's 
traditional patient-centered ethic. I am referring to ready access to 
the most advanced diagnostic methods and to quick and easy access to 
the most competent specialist. I am referring to easy and convenient 
access to high quality care in general, and I am referring to the 
flexible private health insurance tailored to individual and family 
needs.
  Now, remember, surveys of the American people have always found that, 
whatever their concerns with the way the system as a whole works 
generally, large majorities say that they are satisfied with their 
doctor. Large majorities say that they are satisfied with their 
hospitals. And, yes, most are even satisfied with their insurance 
companies. Our citizens are concerned because they understand that very 
fundamental changes are being proposed that could profoundly affect 
these things that they value so highly. They understand that the 
Clinton-Mitchell bill is going to lead to too much Government 
involvement in health care as well as higher taxes, lost jobs, and 
rationing. They realize that there is a very big question as to whether 
these changes can really work in the real world. And the people are 
completely justified in their concern, Mr. President.
  When I read the review of the Congressional Budget Office of the 
Clinton administration's health reform plan last year, I was struck by 
the skepticism that the writers exhibited in the face of the 
nationalization of health care system that plan called for. I want to 
say I have spoken about the skepticism from the grassroots, but now I 
am referring to the skepticism of Government analysts, people inside 
the beltway.
  The CBO asks:

       . . . whether it would be possible to implement the Clinton 
     purpose fully in the timeframe envisioned, and whether there 
     might be unintended consequences that could affect the 
     system's viability.

  This is CBO-speak for: ``Is it really possible to implement such a 
scheme, and could it possibly ruin the health care system?"
  They went on to say, and these are their words:

       Policymakers and analysts can only speculate about such 
     questions because of the magnitude of the institutional 
     changes being proposed.

  Continuing to quote:

       Thus, the potential for unforeseen consequences, both 
     favorable and unfavorable, would be significant.

  If I can put that into CBO speech, it would say this: ``All we can do 
is guess what might happen if we implement this plan.''
  More recently, the CBO and the Joint Committee on Taxation finished 
reviewing the health reform proposal of the Committee on Finance, not 
the one that is before us. I do not want to mislead you; I am speaking 
of the committee's proposal.
  I was struck in reading this analysis by the same note of skepticism 
that the earlier authors displayed about the Clinton plan last year.
  The authors seem to appear as doubtful that the reform plan as 
envisioned, even by our Senate Finance Committee, could actually be 
carried out. What they said was that in CBO's judgment, however, there 
exists a significant change that the substantial changes required by 
this proposal and by other systematic reform proposals could not be 
achieved as assumed.
  If I can put those words into CBO speech, it would say this: We have 
no real world example of this managed competition system, and it will 
not work.
  So now we have Senator Mitchell's bill before us, this 1,400-page 
bill, the third printing of it. Mr. President, it is another risky 
proposal to comprehensively transform the American health care system, 
redirecting $1 out of every $7 in America, to some extent, greater or 
less. Great effort has been made to claim that this bill has no 
relationship whatsoever to President Clinton's original bill that I 
quoted CBO's analysis of. But the Mitchell bill seems to have more than 
a passing resemblance to what President Clinton offered. The health 
insurance purchasing cooperatives are back. They are not in this bill 
mandatory. But let me predict on this very day that they will end up 
being mandatory.
  A national board, which the President created, with very major and 
sweeping powers is in the Mitchell bill. The mandates are there, even 
though they would only be invoked if certain target levels of coverage 
were not achieved. The standard benefit package proposed by the 
President is in bill. The budgets and the premium caps are there, or 
something darned close to them. The complicated subsidy schemes for 
individuals and families are there. When you talk about subsidies for 
business, and lower-income people to buy health insurance, remember 
when it comes to the Government they want you to accept a mandate 
because there is a subsidy connected with it. Remember that mandates 
are forever, but subsidies tend to be temporary.
  Subsidies are supposedly going to soften the blow of the mandates. 
But after a period of time, the mandates continue. The subsidies are 
fleeting.
  The Mitchell bill is at least as complicated as earlier bills. It is 
even longer than President Clinton's bill, 1,410 pages compared to 364 
pages. I forgot, because now the bill is up to 1,443 pages.
  There are at least 30 major health-care related topics on which the 
bill proposes major changes. I want to list them to give our listeners 
some idea of the scope of this legislation.
  Major change No. 1, employer mandates with triggers;
  Major change No. 2, new subsidies for 100 million people;
  Major change No. 3, a number of new taxes or tax increases, 18 at 
last count;
  Major change No. 4, many new Government bureaucracies, 49 last count. 
That is my count. Yesterday I saw another count that it was up almost 
to 60;
  Major change No. 5, a new Medicare prescription drug benefit;
  Major change No. 6, abortion coverage;
  Major change No. 7, administrative simplification requirements;
  Major change No. 8, antitrust and medical malpractice law changes, 
including repeal of McCarran-Ferguson as it relates to health 
insurance;
  Major change No. 9, changes in the employee benefits law;
  Major change No. 10, new rules for health insurance plans;
  Major change No. 11, proposals for rural and urban underserved 
populations;
  Major change No. 12, proposals for Medicare reform;
  Major change No. 13, integration of the Medicaid program into the 
private sector health care system;
  Major change No. 14, major changes in the way that our medical 
teaching institutions do their work;
  Major change No. 15, new proposals for medical research;
  Major change No. 16, long-term care provisions;
  Major change No. 17, antifraud and abuse provisions;
  Major change No. 18, expansion of many existing public health 
programs, and the creation of some new ones;
  Major change No. 19, changes in the workers compensation programs;
  Major change No. 20, some changes in health insurance as related to 
automobile coverage;
  And major change No. 21, for the Federal Employees Health Benefits 
program.
  Each of these topics--and there are more, but I do not want to 
continue the list. All of these topics has any number of major topics. 
So we are in fact, Mr. President, contemplating literally hundreds of 
major changes that will affect our health care system.
  In any normal legislative session, passage of a bill with provisions 
similar to those of Senator Mitchell's bill on any one of these topics 
would be a major legislative achievement.
  Do we all know what major items might be buried among these hundreds 
of subchapters? For example, how many of my colleagues are aware of the 
fact that the national benefits board created in this bill is 
specifically exempt from the Federal Advisory Committee Act? You want 
to remember that what that means is that the board is going to make 
decisions about what benefits Americans are going to receive through 
the standard benefits package. And this is the same Federal Advisory 
Committee Act the First Lady's health care task force refused to comply 
with, and the White House is now being sued in Federal court over 
because the meetings and records were not open to the public. This 
means that some of the most basic decisions of health care can be made 
in secret proceedings, with no notice of meetings and no access to 
information.
  This might be Star Chamber health care, Mr. President, but it is not 
surprising coming from those who believe in Government-run health care, 
because they do not want that to be scrutinized by the public.
  There is a question of access to the courts raised by the 
legislation. I do not know whether this has been discussed yet on the 
floor, but access to the courts ought to be very important to anybody. 
When you are passing this sweeping piece of legislation, it ought to be 
more of a concern. Colleagues who vote for this bill will have to tell 
their constituents that if those constituents believe that they have 
had a constitutional right violated, they are going to have to come all 
the way to Washington to vindicate that right--not there in the local 
district court of their particular State, but right here in Washington, 
DC.
  I think that provision has some implications that ought to be 
elaborated on, because if a person believes that some part of this bill 
is unconstitutional, the first thing he or she will have to do would be 
to come here to Washington, DC, to appear before the U.S. district 
court here, and even if that person demonstrates that he or she will 
suffer immediate or irreparable harm as a result of some part of this 
act, and even if that person shows that there is a substantial 
likelihood that the act or one of its provisions is unconstitutional, 
this bill renders the court powerless to grant temporary relief.
  When it comes to health care, Mr. President, I am sure that we can 
all think of examples where an individual might suffer irreparable 
harm. Maybe it is some needed treatment that this bill curtails; some 
may be denied choice of a particular physician. Whatever the case is we 
are talking about, we are in fact talking about people's health and 
their lives, and any delay could prove critical. But this bill prevents 
the court from granting immediate temporary relief by limiting its 
power to grant ``any temporary order or preliminary injunction 
restraining the enforcement or execution of this act or any provision 
of this act.''
  So one whose health may be impaired will have to wait until a panel 
of three judges can convene, wait until they finally decide the merits 
of the case--wait, Mr. President, for who knows how long.
  Yes, as unbelievable as that might sound, the Clinton-Mitchell bill 
engages in court-stripping and forum-shopping of the rankest kind. It 
even deprives the court of authority to issue injunctions against 
operations of the act that might be unconstitutional. So now we will 
have health care that can never be taken away, not even by a court that 
might think some parts of this bill violate the Constitution. Whether 
you are a liberal Democrat or liberal Republican, there are a lot of my 
colleagues who have spoken eloquently against similar attempts to strip 
court jurisdiction and to eliminate form shopping. I hope that those 
people will be consistent and read through this legislation and speak 
just as loudly against those provisions, whether they are in this bill 
or some other piece of legislation.
  There is even more, Mr. President. How many know that squirreled away 
among these hundreds of provisions is what can only be described as a 
naked power grab by the American Trial Lawyers Association and its 
high-priced lobbyists? Although it is titled ``medical malpractice 
reform,'' it would be more accurate to label this as medical 
malpractice ``deform.'' Written of, and by, and for the trial 
attorneys, it would arguably preempt the laws of 21 States which placed 
some limit on noneconomic and economic damages and replace it with no 
limit on damages. I say ``arguably'' because the provision has changed 
in Clinton-Mitchell three.
  Apparently, the trial lawyers' greed went too far and was too 
obvious, and they hope no one would be able to read this bill, the 
third version, and notice what they were up to. Make no mistake about 
it--because you should be concerned about the intent of this 
provision--it is a stealth preemption of State law, and those States 
with malpractice reform laws will be the ones which suffer.
  While this bill may be a windfall for trial lawyers, it would be a 
disaster for the health care system and the American people. It would 
stifle medical innovation, reduce the accessibility of health care, 
particularly in rural areas, and keep more money out of the hands of 
injured patients. Those States like California, which have enacted 
progressive liability reform that has succeeded in reducing health care 
costs, would see their efforts go up in smoke under this bill. But even 
that is not enough. These lawyers have succeeded in putting into this 
bill new civil actions with unlimited punitive damages, which creates 
the potential for explosive litigation--again, to the benefit of the 
trial lawyers and to the detriment of cost containment within the 
health care system.
  It just goes to show that those who scream the loudest about special 
interest groups are the ones who have the most to hide.
  I want to make my position clear on this issue. While there is some 
genuine, meaningful medical malpractice reform language in the health 
care bill, it will have failed to address one of the primary causes of 
escalating health care costs, and for that reason alone, it should be 
opposed.
  There is another provision in this 1,443 pages about which I am 
concerned, and that is the proposed modifications of McCarran-Ferguson. 
And as far as health insurance reform and workman's comp and 
hospitalization as it relates to car insurance, there is a preemption--
I should not say a preemption--there is a repeal of those provisions of 
McCarran-Ferguson. This act recognizes that certain cooperative actions 
were essential to the nature of the insurance business and provided for 
State regulation of such actions. The enormous growth of State 
insurance laws and regulations show that the States have been 
performing that function, as intended by Congress 49 years ago, very 
well.
  There are few industries as competitive as the insurance business: 
over 3,400 companies selling insurance with no company having more than 
9.2 percent of the market. In my State of Iowa, the insurance industry 
is a thriving component of the State's economy with many, many small 
firms competing for business. The net effect of repeal of this part of 
McCarran-Ferguson would be to drive the small- and medium-sized 
insurers of Iowa and other States out of business, leaving insurance 
concentrated in the hands of a few giant companies. Without industry-
wide data collection and rate advisory services, smaller companies will 
not survive. This would be a severe blow to my State, and I am opposed 
to that provision.
  Mr. President, there are some good provisions in this 1,410 page 
health care proposal, no doubt about it. But that is not really the 
point. Do we really have even the foggiest idea of how any of this 
would actually work in the real world were we to pass it? And I think, 
just like CBO said several months ago, we ought to stop kidding 
ourselves. We have absolutely no idea at all, because again I think we 
need to emphasize again that, in the 205-year history of the Senate, 
there has never been legislation that would redirect $1 of every $7 in 
the American economy.
  Remember again what the Congressional Budget Office found in their 
analysis of Senator Mitchell's bill. These are their words: ``There is 
a significant'' chance that the ``substantial changes required by this 
proposal . . . could not be achieved as assumed.''
  As many Senators have pointed out, we really have not had sufficient 
time to study and analyze Senator Mitchell's bill. But a quick review 
suggests that it has any number of provisions that are going to create 
serious problems for many Americans.
  A quick review also suggests that it is very likely that the original 
bill proposed by President Clinton would have those same problems and 
that this bill is very much like that bill.
  The bill includes a delayed employer mandate which we have to assume 
will go into effect and will have a negative effect on small business 
and the employees of small business.
  It includes a complicated tax on the rate of increase of health care 
premiums. This tax on the rate of increase in health plan premiums is 
really the Clinton global budget and premium cap concept, however, in 
disguise.
  It is a global budget concept because aggregate national per capita 
health care expenditures in 1994 would become the total amount of 
spending from which national health care spending could increase in the 
future.
  Then the Congressional Budget Office at that time would determine the 
acceptable rate of increase for the years until 1997. Thereafter, 
control of health spending would be on semiautomatic pilot. When 
finally implemented, it would be allowed to increase only at CPI plus 2 
percent, restricted by what the Congress said in this bill the country 
can spend on its health care.
  These cost containment features of the bill are almost surely going 
to drive right out of the market plans that allow you to go to any 
doctor you want and pay, through your health insurance, for the care 
you and your doctor decide you need.
  I heard the author last night take some exception to our reading of 
his legislation that way. I heard every word he said. I still stand by 
this statement.
  Even if health plan sponsors are required by the Mitchell bill to 
offer such fee-for-service plans, such plans may cease to exist, or 
people will not be able to afford them. People are going to be driven 
by economic pressure into low-cost managed care plans, or insurers will 
no longer be able to offer fee-for-service plans. The remaining managed 
care plans are going to be under great pressure to vigorously economize 
in the delivery of health care services, and that is the beginning of 
rationing.
  The health insurance purchasing cooperatives called for in this bill 
have been described as voluntary, but they are not really going to end 
up that way. They probably will end up in reality as mandatory. All 
employers with under 500 employees must enroll their employees in this 
cooperative and may offer a choice of 3 private plans. But why would an 
employer attempt to negotiate with other plans if the employees can 
take the employer contribution and join any plan in the local 
cooperative?
  If I understand the bill correctly, no insurer may charge a premium 
different than that negotiated for that insurer's plan through any 
purchasing cooperative. So why would an insurer even bother to offer a 
plan outside of the purchasing cooperatives?
  Mr. President, Iowa is a rural State, and I want to digress just a 
moment to view this legislation from the perspective of my State and 
any rural State of America. From this standpoint, I believe that 
Senator Mitchell has worked hard to include in this bill many 
provisions designed to help rural areas. We on this side of the aisle 
may have some problems with this or that rural-specific provision, but 
those differences can probably be worked out between us. In fact, many 
of the rural-specific provisions that have found their way into Senator 
Mitchell's bill were developed earlier by both Democratic and 
Republican Senators, including myself, and were included in the Finance 
Committee bill and the Labor Committee bill.
  Many of these same or similar provisions, by the way, are in the 
Dole-Packwood bill.
  Unfortunately, I have to say to my colleagues that the question for 
those of us who represent rural areas has to be whether the major 
elements of Senator Mitchell's bill are good for rural States, even 
though some of those specifically directed to certain specific problems 
in rural America are very good. Are those good provisions offset by 
some bad aspects of this major bill? I think the answer to that is yes, 
that they will. I think Senator Mitchell's bill, as a whole, will not 
be good for rural areas.
  I wish I could say otherwise as an answer to that question. I want to 
tell you why I cannot give a confident yes to this question.
  The bill continues to discriminate against the self-employed. It 
fails to provide 100 percent deductibility of health insurance premiums 
for the self-employed.
  A greater percentage of people in rural areas are self-employed than 
in urban areas--around 13 percent compared to 7\1/2\ percent of urban 
workers.
  In farm areas and all over main street, small town, America, there 
are ordinary self-employed people who buy individual insurance and pay 
for it out of pocket after tax dollars. Now there is that 25 percent 
deductibility today, but even that ran out at the end of last year. We 
have let it run out before so that cannot even be counted on.
  So these people's ability to afford their health insurance would be 
considerably enhanced with 100 percent deductibility. For instance, the 
American Farm Bureau Federation has estimated that for a typical family 
of four at the 15-percent tax level a full tax deduction could generate 
over $1,200 in savings per year.
  Now, as a matter of fairness, large businesses get to deduct what 
they pay for employee health insurance. The employees of large 
businesses get a health insurance benefit tax free. Why should not our 
rural citizens and small business people get the same tax treatment?
  In addition, the bill does not include medical saving accounts, and 
the distinguished Senator from Delaware spoke well about that issue 
before so I will not go into that. But medical savings accounts would 
help very much, maybe even more so in rural America than in urban 
America.
  The bill outlaws funding self-funding of insurance for any business 
with fewer than 500 employees. Many small businesses found in rural 
towns now self-fund and are doing a good job offering insurance to 
their employees and cost containment. This ban on self-funding for 
employee groups of that size is going to disrupt health care coverage 
of all of them. Why should we not retain the self-funding option for 
rural areas as one more way of getting people covered?
  I just cannot understand when we have such a high percentage of 
people in America and particularly employers self-insured that we want 
to hurt that approach. It seems to me what we ought to do is build on 
what private initiative has already accomplished in America and not do 
harm to it.
  If the mandates laid out in the bill do get triggered in and are 
eventually required of small businesses, I think it could be 
devastating for more fragile lower wage economies of rural areas.
  The cost of private health insurance in rural areas is almost 
certainly going to rise as a consequence of this bill. If I understand 
how some of the features of this program are going to work, it looks as 
though they will conspire together to seriously disadvantage rural 
residents.
  Fee-for-service plans are still more common in rural areas. And they 
probably will be for some time to come. Medicare payments tend to be a 
bigger factor of health care life in rural areas than in cities. Under 
this legislation, the Government is going to continue cheating on what 
it owes for Medicare services even more than it does now. Thus, 
providers are going to cost-shift to the fee-for-service plans more 
common in rural areas. The premiums of those plans are going to go up. 
As the premiums go up, the total amount of money taken by the 1.75-
percent tax and shipped away to the east coast increases. As the 
premiums go up, they run right into the 25-percent excise tax called 
for by Senator Mitchell's bill.
  Furthermore, this 25-percent tax is really a global budget and 
premium cap provision. This is going to unfairly freeze providers in 
low-cost States at low levels of reimbursement. It seems to me that the 
same thing is going to happen to some of these States, including my own 
State of Iowa, that happened when the Medicare Cost Containment System 
was put in place. Unfairly low reimbursement levels were put in place 
and held in place by Federal law and Federal agencies. Only this time 
it would be not just the Medicare Program that is affected, but the 
entire private health care system in some of these States.
  This provision is probably going to kill any hope of private 
investment in health care systems in rural areas. It is well understood 
here in the Senate that a substantial investment in rural health 
infrastructure and in rural health workers is needed. In fact, most of 
the bills recognize this by including provisions designed to do exactly 
that, including Senator Mitchell's bill and Senator Dole's bill.
  The problem is that private health plans are not going to want to 
incur the additional cost of investment in health care if they face a 
tax on their premiums when they try to achieve a return on those 
investments. This is going to be true generally, not just in rural 
areas.
  But the problem is going to be more acute in rural areas. Those areas 
do not have the population density that could make it easier for health 
plans to get back a return on the investments they make. They will 
almost surely face higher costs if they wish to invest their own 
resources in rural areas. Those costs will have to be reflected in 
their premiums.
  Why should a private insurer take the risk of investing in an 
underserved rural area if they are going to face a 25-percent excise 
tax on the premiums they have to charge to cover the higher cost 
involved in investing in such areas?
  So I hope that we can do something about making that very clear.
  I would like to call the attention of my colleagues to two letters, 
one from the American Farm Bureau and the other one from 115 other 
organizations. Those organizations have concluded just the Mitchell 
bill is not going to be good for rural areas. They include some of our 
most important national farm organizations.
  Mr. President, I ask unanimous consent to have these letters printed 
in the Record.
  There being no objection, the letters were ordered to be printed in 
the Record, as follows:

                                                  August 12, 1994.
     Hon. Charles Grassley,
     U.S. Senate,
     Washington, DC.
       Dear Senator Grassley: On behalf of more than 100 farm and 
     rural organizations we would like to voice our concern with 
     the Health Care Reform Proposal offered by Senator Mitchell, 
     as presently written.
       We have spoken forcefully in favor of 100 percent tax 
     deduction for the self employed and against an employer 
     mandate * * * and against mandatory alliance.
       We cannot support any plan that:
       1. Does not achieve a 100 percent deduction.
       2. Lays out the foundation for an Employer Mandate.
       3. Sets up ``required'' participation in purchasing 
     alliances, a ``de-facto'' Mandatory Alliance.
       But there are other rural concerns that require bi-partisan 
     attention.
       Paperwork. It sets up administrative and reporting 
     requirements that will be highly burdensome for small 
     employers.
       Cost of insurance may rise. Farmers traditionally buy plans 
     with high deductibles. The Mitchell Plan limits this option. 
     Community rating pools are broadly defined so that--in many 
     instances--rural citizens will subsidize the health costs of 
     their urban and suburban cousins, places where medical costs 
     are not only higher, but so is utilization. In addition, age 
     banding is unnecessarily restrictive. States have the option 
     of setting up a community rate for the entire state.
       It limits choice. It would allow states or the D.O.L. to 
     determine, based on unstated definitions, that there is 
     insufficient competition in certain rural areas so they are 
     not required to even offer more than one plan to their 
     employees. That one plan must always be the HIPC, and the 
     HIPC must always include the FEHBP. This amounts to a 
     potential back-door single-payor system for rural states.
       Cost-shifting. It cuts into projected Medicare 
     expenditures, which will hurt many rural hospitals, and 
     because it shifts billions in Medicaid costs to private 
     insurers, cost-shifting will take place. Net result: a 
     massive, unintended cost-shift that will fuel insurance costs 
     of fee-for-service plans--the primary insurance vehicle for 
     rural communities.
       Taxes. The new tax on plans with fast growing health 
     premiums will hit fee-for-service plans hardest, especially 
     those in rural areas, for reasons already noted in previous 
     paragraph.
       Association Plans. About 1 in 3 farmers and very-small 
     rural small businesses have their health insurance through 
     ``association plans'', which pool businesses or individuals 
     in a form of voluntary cooperative. These plans are more 
     likely to have begun to negotiate PPO and cost-savings with 
     providers. However, these plans are essentially made 
     ineffective by making them a part of a community rated pool, 
     and not part of an experienced rated pool, despite the fact 
     that many of these plans have more than 500, and some more 
     than 5,000 individuals enrolled. Solutions: allow large 
     association plans to be experienced rated, but require an 
     annual open enrollment for members. The long-range impact of 
     weaker private sector pooling arrangements is to eventually 
     force very small businesses, and the self-employed into the 
     state or federal-directed HIPCs--which may be the insurance 
     of last resort for the poor.
       Subsidies. Subsidies do not clearly distinguish the 
     realities of farm income, in which it is true that farmers 
     have relatively high ``gross income'' but ``low net income''. 
     Careful consideration should be made for agricultural 
     producers, especially young farmers, because ``gross 
     incomes'' may not be the best determination.
       Health Board. It gives enormous power to several new 
     agencies, especially the National Health Board, but it does 
     not include provisions that would guarantee rural 
     representation on those boards. Health care is not 
     necessarily better, or worse in rural America, but it is 
     different. The composition of any agency with important 
     health powers should include stronger rural representation.
       Medical Savings Account. It does not include Medical 
     Savings Accounts. Farmers would benefit from MSAs, and have 
     been pioneers in the use of the MSA concept by blending high 
     deductible plans with personally-funded tax deferral savings 
     vehicles. MSAs are a proven ``concept'', the Mitchell Plan 
     does not acknowledge their value in any way at all.
       There are many positive enhancements to the recruiting of 
     health professionals to rural areas and grants for 
     demonstration projects, but on balance is not a plan we can 
     embrace.
           Sincerely,
       American Agri-Women; American Dry Pea and Lentil 
     Association; American Sod Producers Association; 
     Communicating for Agriculture; Farm Health Care Coalition; 
     Farmers Health Alliance; International Apple Institute; 
     National Association of Wheat Growers; National Barley 
     Growers Association; National Cattlemen's Association; 
     National Contract Poultry Growers Association; National 
     Cotton Council; National Cotton Council of America; National 
     Council of Agricultural Employers.
       National Council of Farmers Cooperatives; National 
     Christmas Tree Association; National Christmas Tree Nursery; 
     National Grange; National Milk Producers Federation; National 
     Pork Producers Council; United Agribusiness League; United 
     Egg Producers; United Fresh Fruit & Vegetable Association; 
     Women Involved in Farm Economics; Agricultural Council of 
     Arkansas; Agricultural Producers; Alabama Contract Poultry 
     Growers Association; AZ Cotton Growers Association.
       Arkansas Association of Wheat Growers; Arkansas Contract 
     Poultry Growers Association; California Association of Wheat 
     Growers; CA Cotton Ginners Association; CA Cotton Growers 
     Association; California Farm Bureau Federation; California 
     Grape & Tree Fruit League; Colorado Association of Wheat 
     Growers; Florida Contract Poultry Growers Association; 
     Florida Fruit & Vegetable Association; Florida Nurserymen & 
     Growers Association; Georgia Contract Poultry Growers 
     Association; Idaho Grain Producers Association; Idaho Onion 
     Growers Association.
       Illinois Cattlemen's Association; Kansas Association of 
     Wheat Growers; Kentucky Contract Poultry Growers Association; 
     Kentucky Small Grain Growers Association; LA Cotton 
     Association; LA Cotton Producers Association; Louisiana 
     Contract Poultry Growers Association; LA Ginners Association; 
     LA Independent Cotton Warehouse Association; Delmarva 
     Contract Poultry Growers Association; Minnesota Association 
     of Wheat Growers; Mississippi Contract Poultry Growers 
     Association; Mississippi Delta Council; Montana Grain Growers 
     Association.
       Nebraska Wheat Growers Association; New England Apple 
     Council; New Mexico Wheat Growers Association; North Carolina 
     Apple Growers Association; North Carolina Small Grain 
     Growers; North Carolina Sweet Potato Commission; North Dakota 
     Grain Growers Association; North Dakota Stockmen; Ohio 
     Contract Poultry Growers Association; Oklahoma Contract 
     Poultry Growers Association; Oklahoma Wheat Growers 
     Association.
       Plains Cotton Growers Association; South Carolina Contract 
     Poultry Growers Association; South Dakota Wheat Incorporated; 
     Southern Cotton Growers Association; Southeastern Cotton 
     Ginners Association; Tennessee Contract Poultry Growers 
     Association; Texas Cattle Feeders Association; Avian 
     Cooperative of Texas; Texas Citrus & Vegetable Association; 
     Texas Wheat Producers Association; South Texas Cotton & Grain 
     Association; Rolling Plains Cotton Growers; Virginia 
     Agricultural Growers Association; Virginia Contract Poultry 
     Growers Association.
       Virginia Small Grain Growers Association; Washington 
     Association of Wheat Growers; Washington Cattlemen's 
     Association; Washington Growers Clearinghouse Association; 
     Washington Growers League; Washington State Horticultural 
     Association; Washington Women for the Survival of 
     Agriculture; Western Growers Association; Western Pistachio 
     Association; Wisconsin Christmas Tree Producers Association; 
     Wyoming Wheat Growers Association; Curtice Burns Foods/Pro-
     Fac Cooperative; Dovex Fruit Company; Eastgate Farms, Inc.
       El Vista Orchards, Inc.; Florida Citrus Mutual; Forrence 
     Orchards, Inc.; Grainger Farms, Inc.; Grower-Shipper 
     Vegetable Association of Central California; Hood River 
     Grower-Shipper Association; Johnny Appleseed of Washington/
     CRO Fruit Company; Knouse Fruitlands, Inc.; Lyman Orchards 
     Country; Newman Ranch Company; Nyssa-Nampa Beet Growers 
     Association; Princeton Nurseries; Rocky Mountain Apple 
     Products Company; Torrey Farms, Inc.
       Valley Growers Cooperative; Ventura County Agricultural 
     Association; Wasco County Fruit & Produce League; Yakima 
     Valley Growers-Shippers Association.
                                  ____



                              American Farm Bureau Federation,

                                  Washington, DC, August 11, 1994.
     Hon. Howell Heflin,
     U.S. Senate,
     Washington, DC.
       Dear Senator Heflin: The Senate is poised to begin voting 
     on the most important social question of this Congress and 
     probably of the last 30 years. You have the responsibility to 
     represent the views and best interests of America and your 
     state's portion of the 4.2 million members of the Farm 
     Bureau. Your constituents expect and deserve a health care 
     reform law that remedies what is wrong and protects what is 
     right with our present system.
       Farm Bureau has closely followed and has attended numerous 
     meetings on the subject of health care reform, from the early 
     efforts by the White House to those of many members of the 
     House and Senate, as well as with various organizations and 
     coalitions. We have intentionally not joined any formal 
     coalitions nor have we aligned ourselves with any of the many 
     proposals that have surfaced. We have instead pointed out 
     what, in our view, would be valuable or detrimental to the 
     needed improvement of our system.
       Farm Bureau members have made this a priority issue and are 
     obviously users of the present health care system. As users, 
     we have benefitted from the unbelievable advances in medicine 
     and also have suffered through the unrelenting double-digit 
     medical cost inflation of the last 20 years.
       The farmer delegates to the American Farm Bureau 
     Federation's annual meeting approved two full pages of policy 
     regarding health care. The essence of Farm Bureau policy is 
     expressed as follows.
       We favor:
       1. Reform of the current health care system;
       2. Financial assistance to those unable to afford it;
       3. One hundred (100) percent tax deductibility of health 
     insurance costs paid by the self-employed;
       4. Medical savings accounts;
       5. Sensible insurance reform dealing with portability, 
     prior existing conditions and modified community rating;
       6. Malpractice tort reform;
       7. Targeted rural benefits, such as incentives for medical 
     professionals to locate and stay in rural areas, fair 
     reimbursements on Medicare and Medicaid, and greater use of 
     technology for modern ``telemedicine.''
       We oppose:
       1. Employer mandates, including triggers to impose them at 
     some future date unless the Congress must vote for the 
     imposition;
       2. Government-imposed price controls on the various 
     components of the health care delivery system;
       3. Massive new taxes; and
       4. Repeal of the McCarran-Ferguson Act.
       We are not opposed to any of the proposals in their 
     entirety and do not criticize any proposal completely. 
     However, some of the proposals have more points with which we 
     agree than others. Thus, we will support or oppose bills, 
     amendments and substitutes accordingly.
       The reform of health care in America is not a sporting 
     event that has one side winning or losing. We will all win or 
     we will all lose based on the outcome of this debate. We 
     don't believe either the next congressional election or the 
     next presidential election can be predicted based on this 
     issue. Therefore, a purely political vote will benefit 
     neither you nor America.
       We urge you to consider AFBF's policy as you vote on this 
     important question and support constructive change.
           Sincerely,

                                             Dean R. Kleckner,

                                                        President,
                                  American Farm Bureau Federation.
                                  ____


                 [From Farm Bureau News, Aug. 15, 1994]

              Congress Begins Debate on Health Care Reform

       Debate on legislation to reform the nation's health care 
     system began last week in the Senate. It had been scheduled 
     to start in the House this week, but House leaders have now 
     postponed it for at least another week.
       At the center of the debate are plans crafted by Sen. 
     George Mitchell (D-Maine) and Rep. Richard Gephardt (D-Mo.) 
     that contain controversial provisions requiring employers to 
     pay part of the cost for their employees' insurance.
       In the House, a bipartisan alternative that does not 
     include employer mandates has been put forward by Reps. Roy 
     Rowland (D-Ga.), Michael Bilirakis (R-Fla.), Jim Cooper (D-
     Tenn.) and Fred Grandy (R-Iowa).
       Becuase of different rules in each body, the Senate is 
     expected to consider dozens of amendments while the House 
     plans to consider only a handful of major proposals. The 
     first battle in the House will be a decision on the rule that 
     governs debate. Farm Bureau is urging House members to adopt 
     a rule that will give alternative plans a fair opportunity to 
     be considered.
       American Farm Bureau Federation President Dean Kleckner, in 
     a letter to all members of Congress, noted that Farm Bureau 
     does not oppose any of the proposals in their entirety but 
     ``some of the proposals have more points we agree with than 
     others.''
       ``The reform of health care in America is not a sporting 
     event that has one side winning or losing,'' Kleckner told 
     lawmakers. ``We will all win or we will all lose based on the 
     outcome of this debate. A purely political vote will benefit 
     neither you nor America.''
       The Gephardt and Mitchell proposals as they are currently 
     written fail to meet Farm Bureau policy, according to Hyde 
     Murray, an American Farm Bureau Federation governmental 
     relations director. The Rowland bipartisan measure comes 
     closer to meeting Farm Bureau's objectives, he added.
       Farm Bureau supports health care reform that provides 
     financial assistance to those unable to afford it; 100 
     percent tax deductibility of health insurance costs paid by 
     the self-employed; medical savings accounts; sensible 
     insurance reform dealing with portability, prior existing 
     conditions and modified community rating; malpractice tort 
     reform; and targeted rural benefits including greater use of 
     technology for ``telemedicine.''
       Farm Bureau opposes employer mandates, government-imposed 
     price controls, massive new taxes and repeal of the McCarran-
     Ferguson Act, which provides an antitrust exemption for the 
     insurance industry. A provision to repeal the act is included 
     in the Gephardt bill.

  Mr. GRASSLEY. Mr. President, I believe that many Americans are 
concerned about losing some of those features of the American health 
care system that they value so highly which I listed at the beginning 
of my statement.
  If the Clinton-style global budgets and premium caps go into effect, 
these things we now value so highly could be threatened. Health plans 
will have to strenuously economize in order to remain profitable. 
Economizing means that the quality of care could decline, access to 
care could be reduced and rationing could result.
  Doctors are at risk of becoming employees of big insurance companies. 
In the new managed care plans, there could certainly be at work a 
financial incentive to underserve. Those who serve as the gatekeepers 
through which people will have to pass to get health care will be under 
instructions to make people wait, to delay or deny access to 
specialists, to delay or deny access to sophisticated diagnostic 
procedures.
  I do not fear for the young and healthy, the kind of people found 
disproportionately in health maintenance organizations. I fear for 
those with costly and life-threatening or handicapping illness. I do 
not want to see a state of affairs come about in which such people find 
that their care is delayed, or their access to advanced diagnosis is 
put off, or their access to the best specialists is restricted.
  We all agree on the need for cost containment, Mr. President. I think 
all of us have presumed that cost containment is one of the major goals 
of reform.
  But there is an obvious tension between vigorous cost containment and 
these things we value so highly in our health insurance and health care 
arrangements. This tension cannot be sidestepped just by claiming that 
we are going to eliminate unnecessary care and drive out waste, fraud, 
and abuse, as worthy as those goals are and as necessary as it is that 
they be accomplished.

  Remember, in my opening comments, I said to write down in your diary 
the day this 1,400-page bill passes the Congress and is signed by the 
Senate what you think of your health care system. Because I do not 
think you will ever see it this great in the future.
  I want to quote Rudolph Penner. We all know him, unless you are a 
recent Member of this body. I think everybody knows him anyway; a 
scholar today, but former director of the Congressional Budget Office 
and a respected economist. He gave an assessment of price controls in 
health care for the Alliance for Management Competition. He cited a 
comment from the Congressional Budget Office that puts this tension 
pretty well, the tension that I cited between cost containment and the 
reduction of the quality of care and access to diagnostic treatment and 
to specialists; in other words, where we do not have rationing today, 
where we might have rationing in the future. This is what Rudolph 
Penner quotes from CBO.

       In the process of changing the present health care system 
     to achieve greater control over costs, some of the desirable 
     features of the current health care system would be adversely 
     affected. In particular * * * less spending on research and 
     development, longer waiting times for access to new 
     technology, and limitations on our existing choices of 
     providers, health insurance coverage, and treatment 
     alternatives.

  Now, again, this person I quote is a person who understands 
Government. He understands the shortcomings of Government. If he has 
questions about these massive changes in our health care system, then 
is it any wonder people at grassroots America are skeptical of our 
deliberations and what we might do to that health care system with the 
passage of this legislation?
  If there is one thing of which I am very confident, it is that the 
American people--that broad stratum of well-insured Americans who are 
pleased with their doctor, their hospitals, and their insurance 
companies--are very much not of a mind to give up these things that 
they value so highly.
  With the power of Government behind you, it is possible to dream up 
practically anything in the mind's eye. It is possible to put those 
ideas down on paper. It is even possible to write legislation based on 
those ideas. Whether they will come even close, though, to working out 
there in the real world, that is a completely different matter. The 
plans offered by President Clinton, by the congressional committees 
which have reported bills, and by Senator Mitchell, would launch our 
people on a wildly experimental venture.
  As much as they want to see changes in our health care system, I am 
confident the American people do not want to be laboratory rats for 
some grand Government-dominated national social experiment. When people 
answer polls about wanting some changes made in the system I think it 
is summed up best by people in my State--and I will bet there are 
people like them in every State --who would say, in a very common sense 
approach, to their Senators or their Congressmen, something like this: 
``Well, we know that you have a problem out there in Washington. You 
want to do something about the health care system. You want to do 
something about cost containment. You want to do something about the 
people who do not have insurance.''
  In making that statement they are really asking a question: ``If you 
have to deal with those things, can't you find a way of doing it where 
you do not screw up our health care that we have today?''
  Many of our fellow citizens are, thus, trying to tell us they want 
improvements in the way our health care system works but they do not 
want to revolutionize that system. They want to see the uninsured are 
insured. They are moved, I think, by the plight of the uninsured. There 
was not one of us who listened to Mrs. Clinton last night, or listened 
to the people she had on the podium there with her, who had special 
problems, who would not be moved by that. But the people at the 
grassroots believe that these problems can be solved without vastly 
increasing the role of Government in the workings of the health care 
system. They believe these problems can be solved without throwing the 
entire system into turmoil. They want a reform that is done right. They 
do not want a contraption hurriedly stuck together with baling wire and 
chewing gum so we can throw something out to the voters this year to 
satisfy the electoral needs of politicians and that the bureaucrats in 
the Department of Health and Human Services will have to finish for us, 
fill in the blanks with regulations next year and for every year 
thereafter.
  The American people are telling us they want to put this entire 
health care reform project off. That is what a majority of people are 
now saying in those polls. A year ago they did not say that. A year ago 
they did not know any more than we did what we were talking about in a 
1,400 page bill. We know that they have now had a chance to look at it. 
I still do not think it has to be put off. I think we can pass some 
incremental legislation this year and build on it. We can have some 
useful reform this year, a good bill: Not a Democrat bill, not a 
Republican bill, not a bipartisan bill--but just a good bill. I am of 
the view we should not proceed with what might be called a big bang 
approach to health care reform. We should pass those limited reforms 
that will do some good. Then see what happens. Then we should return to 
the task next year and the year after, making adjustments that seem 
appropriate in light of what incremental reforms have been 
accomplished.
  In other words, not to make the mistake we did in 1988, as sincere as 
that was. We had the ability to do this up right, pass one big bill 
redirecting $1 out of every $7 spent in America--the most massive 
impact on the economy of any piece of legislation ever passed in our 
history. If we could do that and people had confidence we could do it, 
that is one thing. But the people are skeptical about it now. That 
should cause us to be skeptical. But more so the track record of 1988 
ought to signify to us we should make changes where there is very wide 
agreement among us on those things that can pass almost unanimously and 
then in the future--in the very near future--do more; in that very near 
future do some more. But do it slowly so we do not make mistakes.
  I yield the floor.
  The PRESIDENT pro tempore. The Senator from New Hampshire [Mr. 
Smith].
  Mr. SMITH. Mr. President, this has been and will continue to be a 
long, extended debate on an issue that is very, very important to the 
American people. As we look at where we are and why we are here, we 
started, of course, with health care being an issue in the last 
Presidential campaign. To the credit of the President and the First 
Lady, they made it an issue, and because of that we now have this 
debate at center stage.
  Like most of my colleagues, I go out and get involved in the process, 
trying to understand the issue as much as possible. It is a very 
complex issue and takes a lot of work to do it. My office has received 
thousands of phone calls and letters--more phone calls and letters, I 
think, on the issue of health care reform, both sides, than on anything 
since I have been in the Congress. I hosted a statewide health care 
conference earlier this year, in April, that featured leading policy 
experts from every facet of the health care delivery system. There were 
doctors, there were providers, nurses, patients--everyone who in some 
way had an impact or was impacted by any change or legislation in the 
health care industry was there. It was a fascinating seminar, to say 
the least, to listen to the concerns and the recommendations that were 
made by these people.
  In addition to that I have 10 counties in my State. I held a town 
meeting in each of those counties. We do not call them town meetings in 
New Hampshire. There is only one town meeting in New Hampshire and that 
is the one held by the town. But I called them citizen forums. In these 
forums we were there to hear directly from constituents regarding the 
issue of health care reform. They spoke out. There were hundreds of 
them there in all of those town meetings, more than attended any of my 
citizen forums on any other issue.
  In addition, as I said, I have met privately with numerous doctors, 
nurses, administrators of hospitals, insurance executives, private 
citizens and patients, as we have all done. This is not something that 
has been unique to me. All of us here in the Senate have tried to do 
this because of the complexity of the issue. In short, I guess the 
fairest thing to say is I have heard New Hampshire speak to me, and 
with me, on this issue. Overwhelmingly what they are saying is they do 
not want the Government any more involved in health care than it is 
already involved now. In other words, less Government involvement. I 
think there is a concern, unfortunately, that comes through as we 
listen to these constituents and providers and all of those who are in 
any way affected by this pending legislation--there is a concern that 
the Government is going to do something to me on this issue. I think 
that is coming through loud and clear, and it is a very valid concern. 
Rather than helping us, they are going to do something to me that may 
cost me my good quality health care.
  The national polls--which have changed dramatically from overwhelming 
support for what President Clinton had proposed to the opposite, now--
show America shares those same feelings as the people in New Hampshire.
  (Mr. KERREY assumed the chair.)
  Mr. SMITH. Mr. President, I do not think there is a great difference 
between the States--no matter what State you represent --on this issue.
  I believe, based on what I have heard from the people I have talked 
with, that most Americans would oppose not only the underlying finance 
bill, which is technically on the floor, but also the Clinton-Mitchell-
Gephardt or Clinton-Mitchell bill as we have here.
  Fifty-three percent, according to the polls, worries Congress will 
pass a plan that gives the Federal Government too much control. And 
that is a very valid concern. They are suspicious because Government 
has proven again and again that it is not efficient, it is not 
compassionate, it is not thrifty; therefore, should not be trying to 
provide health care needs of people--least of all health care.
  If a mistake is made by a Government official in perhaps the 
administration of the IRS or some other program, or the Post Office is 
late delivering the mail, it is a problem, maybe, but it is a minor 
problem compared to some slipup in the treatment of your health.
  I think of the thousands of times--we all have done it--I tried to do 
an estimate, but it is in the thousands of people that have contacted 
my office in the past 10 years in the Congress to seek help with the 
Government bureaucracy. Sometimes we help them, and sometimes we 
cannot. It is as simple as that. It is a complex maze that citizens 
have to go through.
  I think of those huge numbers of cases--veterans, Social Security, 
immigration--all of the things that we deal with. I think, OK, it is a 
hassle, it is a problem, it is a mess. We try to straighten it out. We 
go here, we go there and help them get straightened out to get them out 
of the country, back into the country, get their Social Security check, 
whatever. And they are important to them, but they are not as important 
as their health.
  I cannot imagine having the caseload of our offices increased because 
somebody was having problems with the Federal Government's involvement 
in health care and seeking our office's help, or any help, to try to 
help them when they have been denied access or some other problem which 
may crop up.
  They are worried. People are concerned. They are worried that they 
are going to lose their choice in their health care providers, they are 
worried that the quality of their health care will go down, they are 
very worried that their personal freedom will be diminished, and they 
are worried that they will be denied access to health care under 
certain circumstances, and that their costs will go up. These are very, 
very legitimate concerns: Costs, access, personal freedom, quality. 
These are concerns, and they are legitimate concerns of every single 
American.
  I would also point out that this type of legislation we are 
discussing today is something that is going to impact every single 
American in one way or another. Very few people go through life from 
cradle to grave without having to meet a doctor along the way. It may 
happen, but not too often, if it happens at all. So somebody is going 
to be affected at some point in the chain. We need to understand that 
people are very concerned about that.
  So that is why this is a controversial issue; it is a tough debate. 
People with good intentions on both sides have brought it to the 
forefront. The debate has been, I think, fair and pretty spirited at 
times, but I think it is necessary.
  Let me talk a little bit about the process and what brought us here, 
and then get into the substance of the issue.
  Because it affects every man, woman, and child in America in one way 
or another, I am a bit concerned about how we have gotten here in the 
process. I mentioned the fact it was brought up in the campaign. Then 
we had the White House Task Force on Health Care Reform, which 
essentially met in secret, as you all know, and for the most part 
precluded many who would like to have been involved, from being 
involved.
  As a matter of fact it is now, probably, a violation of law and will 
be before the courts for a while to see how that will be resolved as to 
whether or not any laws were violated. Then after that, the so-called 
Clinton bill gets knocked around for almost a year, taking a downward 
spiral in the polls because of the debate that ensued. Then we have a 
meeting. Some decision is made by some in the Government--not on our 
side of the aisle from what I have been able to understand--that this 
bill, the Clinton bill, cannot make it, is not what the American people 
want. It is obvious. So there is a secret meeting or some type of 
meeting at the White House between the President and the majority 
leaders in the House and Senate, and then the decision is made to 
present two bills to the Congress: One the so-called Gephardt bill and 
one the so-called Mitchell bill.
  I will just say, and I know there has been a lot of debate on this 
and I am not going to go into it to any degree, but this is a big bill. 
There are a lot of big bills that come through here, as Senator 
Mitchell said the other day, and he is right. Do we get a chance to 
read them all? No. This is a bill with a huge impact on the American 
people. I might tell you, I started going through this thing. This is 
not a Tom Clancy novel we are talking about here, and it certainly is 
not John Grisham either.
  This is tough reading. You need to have the television off and the 
music off and the kids in bed when you start reading this baby because 
this is really complex stuff. It takes a lot of time and it takes a lot 
of focus. It is 1,400 pages.
  I just feel that when we talk about immediately moving to the bill, 
talking about threatening all-night sessions if we do not get 
amendments offered, if we do not do this, do not do that.
  To the President's credit, his bill was debated for a year or longer 
out there. We knew pretty much what was coming down. Then suddenly the 
doors close, the President's bill is declared dead and out comes this 
one, out comes this thing. We now are told if we do not get to this 
thing and get it voted on shortly, we are going to stay in session all 
night until we do it. Then there was some blinking, and we wound up 
with some amendments being offered.
  I do not have a problem with amendments being offered, but I want to 
make sure this thing is debated fully and every Member of the Senate 
has a chance to read it. What disturbs me even more, I would like to 
have the opportunity after I read it, after this debate, and before the 
vote, to go back to New Hampshire and talk with my constituents about 
it, because they have no idea what is in it.
  They had some idea what was in the Clinton bill. That was done in a 
correct way. That was debated. This is not the Clinton bill. Not 
exactly. There are a lot of Clinton provisions in it. We do not know 
exactly what this bill is, nor do we know what the impact of it is.
  I think the people all over the country--not just New Hampshire--
ought to know what is in it. The only way that is going to happen is if 
we have the opportunity to go back and speak with them, after having 
read it and learned what is in it.
  So we are now going to move to this bill, which we have done, with 
the threat of all-night sessions. So here we are. It is clear the push 
for health reform now has acquired a life of its own. It is no longer 
just a simple piece of legislation. It is breathing on its own.
  Robert Samuelson pointed out in a Washington Post column last week 
that the Democrats are much more interested in putting together a bill 
that can pass for political reasons than doing what is right for our 
country. I do not know that I would totally subscribe to that, but I do 
think that the point is that what is politically expedient is not 
always necessarily what is right for the country.
  So, again, I hope that reason will prevail; that perhaps those of us 
who have had to cancel plans might have the opportunity to get back 
home, talk with our constituents about this, come back here, take a few 
more weeks to allow this thing to be debated fully and make an 
intelligent decision. I am not optimistic that is going to happen, but 
I hope that it happens. We have to wait and see how that plays out.
  Let us take a look at what some of the concerns are on this 
legislation. We know that this bill contains employer mandates. We know 
that the majority of businesses in this country, especially the small 
businesses, are opposed to that; that it is a problem. Whether you are 
talking about Clinton or Gephardt or Mitchell, they all have the 
employer mandates in one form or another.
  The bill introduces a Government-chosen standardized benefits 
package. That is another provision. The Mitchell bill allows a 
commission to set the package with certain guidelines, so Americans 
will never know, really, until after the law is passed what is in 
there. This is another situation where we have not dealt forthrightly 
with the issue up front. We have just created a commission, and this 
commission now is going to establish some guidelines. So we are not 
going to know what is covered and is not covered until after the bill 
becomes law. That is not a good way to legislate.
  The Mitchell bill does pave the way for direct Federal control of 
health care. There is no question about that. Any reasonable look at 
this is obvious. The Federal Government, under Mitchell, establishes an 
exclusive alliance for certain workers in areas where States do not 
create their own alliances and rules governing this system would be 
drawn up in Washington.
  Washington. Why is it always Washington? The Mitchell bill introduces 
price or spending controls. It gives vague powers to a new national 
health care coverage and cost commission, which is going to recommend 
ways to hold down costs and require Congress to vote on its 
recommendations in an expedited up-and-down process. And then the bill 
claims a fail-safe provision to prevent any increase in the deficit. 
But if the bill's sequester mechanisms actually were invoked, according 
to CBO it could make previously eligible people ineligible for 
subsidies and would reduce the extent of health coverage.
  Some problems. The bill is going to discourage self-insurance. No 
question about it. And the bill will create a new, huge new bureaucracy 
and place unfunded mandates on the States.
  When we are courted, and we all are, on our votes, whether or not it 
is by the majority leadership--for the most part it would be the 
majority leadership courting votes, and not too many of us are getting 
courted on our side, although some are--there are claims being made 
that this is not the Clinton bill; this is something different. But do 
not be fooled by that because it is essentially the same. Supporters of 
the Clinton plan are trying desperately to gain votes for bills which 
in isolation and by careful reformulation have problems obtaining 
access to health services and need community health centers and other 
safety net programs. So there is a problem.
  Now, this standard benefits package is a real problem. By adopting a 
comprehensive standardized benefits package approach rather than trying 
to assure that all Americans can obtain at least a basic catastrophic 
plan, this bill has chosen to ignore the fact that millions of 
Americans, millions of Americans, most notably the younger and the 
healthier ones, may not want and possibly cannot even afford such a 
``standardized'' generous package. And those who need service not 
included in the standardized benefit package would have to buy the 
service out of their own pockets or buy supplemental coverage without 
any tax relief. Americans should be wary of a Congress or a commission 
to establish a comprehensive benefit system for all Americans 
especially in an era where medical technology is improving and making 
rapid advances. Senator Durenberger gave a very good statement on that 
point earlier in the debate.
  There is a heavy burden on States under the Mitchell bill. For 
instance, the Mitchell bill requires States to oversee and enforce the 
complicated rules governing health plans under the new system. It would 
also require them to operate a risk adjustment system designed to 
transfer billions from health plans primarily serving healthier 
families to an unusually higher proportion of sicker Americans. So 
States would also have to assemble vast amounts of insurance and health 
data, would be responsible for creating a network of health purchasing 
cooperatives.
  Here again we have essentially an unfunded mandate. Nobody really 
knows, nobody really knows how the Gephardt bill, the Mitchell bill or, 
for that matter, the Clinton bill, or the conference bill, how it is 
actually going to work. Some say pass Mitchell, pass Gephardt, 
whatever, get it to conference, and we will take care of it.
  Well, you saw what happened with the crime bill. We passed that out 
of here, and that went to conference and look what happened. It is now 
the subject of national debate. Many Members of Congress are getting 
dinner invitations to the White House now to be pressured to change 
their votes. This thing fell to pieces because what passed the Senate 
was not what turned out in conference. A tough crime bill became a weak 
crime bill, and now they are trying to put it together.
  What happens in conference, frankly, is a far cry from what the 
Founding Fathers thought about democracy. What happens in conference, 
my colleagues, is secret meetings, closed doors. We do not call them 
smoked-filled rooms anymore because not too many smoke cigarettes in 
the Senate. But they go into the conference and they close the door and 
nobody knows who put in these provisions. You cannot find out. You ask 
every conferee and nobody knows the answer. It just appears.
  With all these changes, we are not going to know what is going to 
come out of conference. So if you are going to vote for Mitchell to get 
it into conference, good luck. That is the bottom line.
  The more the American people found out what the Clinton bill did to 
their health care, the less they liked it. So my sense is that with the 
best of intentions, a bill moves into conference and then it is changed 
dramatically from what passed on the floor, and I would say 
dramatically changed for the worst.
  So the very fact that this debate has inertia of its own that runs 
counter to the feeling of the vast majority of Americans --I did not 
talk to every American. I did not talk to a majority of Americans, but 
I talked to a large number of citizens from New Hampshire, and I have 
talked to some from around the country who have called, and they say 
that anything resembling the Clinton bill, anything resembling it--and 
regardless of your feelings on the majority leader's bill, it certainly 
resembles the Clinton bill --they say would be disastrous for the 
country.
  Well, maybe they are wrong and maybe they are right. But they are the 
American people, and they are talking to us. They are talking with us. 
They are asking us to listen to them. It ought to at least give us a 
chance to pause, to step back and say, ``Hold on. Wait a minute. Maybe 
we are going too fast. Let us not be concerned about moving too 
quickly.''
  Remember, 85 percent of the American people are covered by insurance, 
15 percent are not. I saw Mrs. Clinton last night. As Senator Grassley 
talked about, those people need help, and we can help them. There is 
not a person in the Senate who does not want to help them, or in the 
country for that matter, as far as I know, who would not like to help 
those people. But why do we have to throw out the entire system to make 
unhappy 85 percent of the American people to help the 15? Would it not 
be better to reform gradually and help the 15 percent? Does that not 
make better sense? That is what the American people are asking us to 
do. That is all they are asking us to do--to go slowly, help the 15 and 
leave the 85 percent alone that are covered. That is what they are 
asking us to do.
  Now, given that fact, let me specifically discuss several things 
about the Clinton-Mitchell bill that I find particularly onerous and 
things that I cannot support and frankly I believe the majority of the 
American people do not support.
  No. 1 is the bureaucracy. And again this publication has been put 
together by Senator Coats and Senator Gregg. It is entitled ``Primer to 
the Clinton-Mitchell Bill, New Bureaucracies, New Mandates and New 
Federal Powers.'' It is something that has been shown here on the 
floor, and I am not going to read from it other than to simply say that 
just looking at the table of contents would give you some indication of 
what kind of a bureaucracy we are talking about here. We do not even 
have to read the book.
  But I have heard it said on the floor that this is not a Government 
bureaucracy. Here is the table of contents. There are 50 new 
bureaucracies within the bill, there are 33 responsibilities for the 
national health benefits board, there are 25 responsibilities for the 
national health care cost and coverage commission, there are 177 State 
responsibilities, 815 powers and duties of the Secretary of Health and 
Human Services, 83 powers and duties of the Secretary of Labor, and 6 
powers and duties of the Office of Personnel Management.
  That is just the table of contents. You can read all about it. There 
will be more discussion on that at the appropriate time. But with 175 
new mandates on States, this bill creates these 50 new bureaucracies. 
These bureaucracies range from the very trivial--I grant that some are 
very trivial and relatively meaningless and harmless-- and go to the 
very powerful. They run the whole gamut. Let me pick one.
  The National Health Care Cost and Coverage Commission; section 10002 
of the Clinton-Mitchell bill establishes that the commission shall be 
composed of seven members appointed by the President and confirmed by 
the Senate.
  That sounds relatively innocuous; another commission, seven people. 
Big deal. OK. Let us quote from the bill. The general duties of the 
commission are to--

        * * * monitor and respond to, one, trends in health care 
     coverage; and, two, changes in per capita premiums and other 
     indicators of health care inflation.

  Then, the commission will also have the responsibility to determine 
whether or not mandates will be necessary to meet the coverage goals of 
the Mitchell bill. Then the recommendations of the commission would 
have to be considered by Congress under fast-track rules, which means 
there will be no opportunity for amendment on the floor of the Senate, 
and there will be limited debate. It is the fast track.
  So my question is--I do not think anybody here can answer it--will 
seven people be able to do this all by themselves? What kind of people 
are they? Who are they? What is their stake in this? How much is this 
going to cost? Where will the commission be housed? Where are we going 
to put them? How many staffers does this commission need? How much 
research? How many dollars for research? What kind of research? How 
many computers? What do we need? Are we willing to invest such a huge 
amount of power to a bureaucratic entity not accountable to the 
taxpayers? We are going to create this commission. Who are they going 
to be accountable to? The President appoints them, we confirm them, and 
there they sit, a bureaucracy growing.
  That is one bureaucracy out of the ones that I have cited. That is 
only one. I only picked one just as an example.
  Are we willing to invest the power to the other 49, including a 
National Health Care Cost and Coverage Commission, a National Advisory 
Board on Health Care Work Force Development, a National Quality 
Council, and a Health Information Advisory Committee, and on and on?
  In short, and in fact, the Clinton-Mitchell bill will turn over the 
sensitive health care decisions of millions of Americans to 
bureaucrats, pure and simple. There is no other explanation for it. 
There is nothing else that you can say to deny it. It turns over the 
health care decisions of millions of Americans to bureaucrats. If those 
are efficient bureaucrats, if they do a good job, maybe it will not 
hurt you. Are you sure? Is there anybody out there who would want to 
take a chance when you watch some of the problems that we have seen in 
the Post Office, the IRS, the other agencies, and the EPA where there 
are problems which are constantly harassing towns and communities all 
over this country? Do you want those bureaucrats in between you and 
your doctor? Do you? If you like Uncle Sam, you will surely love Dr. 
Sam.
  In the process, there is the bad news. Americans will lose choice. 
They are going to lose quality, they are going to lose access. They are 
going to lose their personal freedom, and they are going to see their 
costs go up. Not everybody; there will be some on the receiving end 
whose costs will not go up because they do not have any costs because 
they are receiving some type of entitlement from the bill.
  But those who are working and carrying the load, it is going to 
happen. Those costs are going to go up. Clinton-Mitchell creates 17 new 
taxes. That is all I can find. There may be more. There is a 25 percent 
tax on plans to exceed the Government-set spending limit; 1.75 spending 
tax on all of the health plans. It is another tax. And there is a 45-
cents-a-pack increase on the cigarette tax.
  Then we have the Clinton-Mitchell community rating, which would raise 
rates on young Americans, which is, in effect, a hidden tax that forces 
the young to subsidize coverage for older Americans. It forces them to 
do it. They do not do it voluntarily here.
  I have heard it said on the floor that this bill is a voluntary bill. 
Come on. There is nothing voluntary about this. It forces the young to 
subsidize the coverage for older Americans. Community rating is going 
to force insurance companies to charge all of their customers, 
everybody, the same rate, regardless of their age. This means that 
older Americans will pay less for their coverage at the expense of 
younger Americans who lose care by comparison. It is not light. It is a 
bad plan. It does not work. It will not work.
  How are you going to enforce it? Are you going to fine some 25-year-
old young guy who says, ``I am going to buy a Porsche. I am going to 
have fun. I am not going to get insurance. I am going off and do my 
thing.'' What are you going to do, chase him down with another Porsche, 
and, say, ``You are going to pay some dollars in fines because you do 
not have health insurance''? Will you do that because he does not want 
to buy a plan that subsidizes somebody else who is 85 years old? Is 
that American? How are you going to do that? Are you going to have a 
bunch of bureaucrats chasing these people down?
  I cannot imagine what this America is going to be like under this 
thing. Neither can the American people, and that is why they are 
opposed to it.
  In addition, the issue of entitlements. Clinton-Mitchell creates, 
through new entitlement programs, subsidies covering those with incomes 
up to 300 percent of poverty, or $44,000-plus for a family of four. So, 
if you are a family of four making $44,000 roughly, you get a subsidy. 
That sounds great. Boy, that will pull in the votes, will it not? 
Because there are a lot of people out there in that category. So, if I 
can get something from the Government and I am making up to $44,000, I 
can vote for the plan. That is basically the rationale.
  The American people are smarter than that. They can see through that.
  There is prescription drug coverage for older Americans. It sounds 
great. Every drug is paid for. Who is going to pay for that? Who do you 
think is going to pay for that? Is it growing on trees? That is what we 
seem to think around here. We can pluck if off the trees like an apple. 
It is just Government money. Just send it down there, and everybody 
gets a free prescription. It does not cost anybody anything. Just ask 
them.
  That will cost the taxpayers, for long-term care, prescription drugs, 
and subsidies, about $172 billion. That is with a ``b.'' Add that onto 
your national debt, which is about $4.5 trillion now. Just keep adding 
it on.
  The Senator who is occupying the chair right now is working on an 
entitlement commission for entitlement reform. I have thousands of 
postcards about him. I am depending on him, I might say, to do the job 
and to make a recommendation.
  Here we are again with three new entitlements in this bill alone. At 
least 100 million people out of 260 million are going to receive some 
form of subsidy from the Government in this health care bill, the 
Mitchell bill, 40 percent. We are talking about entitlement reform 
because it is driving our country to economic ruin. And we are going to 
create this thing? Forty percent of Americans are going to have to deal 
directly with the Government when it is paying their health care. I 
hope they like it. I hope they like it. I hope they like their doctor. 
I hope they like wherever they are sent for that care. I hope they like 
the paperwork. I hope there is no objection to any of that, especially 
when you are sick, because you get what they give you. That is it. You 
cannot complain.
  At a time when we recognize again that entitlements--and we have to 
recognize it, we know it, and every Member knows--are sucking the 
country dry; 50-plus percent of the budget of America is entitlements, 
and 16 percent is interest on the national debt. There is not much left 
for anything else.
  What are we going to do about it?--adding three or four more 
entitlements, and adding billions of dollars, tens of billions, perhaps 
hundreds of billions of dollars more in Government spending in 
entitlements because it is all free. It is free. Just pick it off the 
trees, and send it down to somebody down there who will have their 
hands out eagerly waiting for some benefit.
  We hear a lot of talk about special interests around here. The only 
people that do not have a special interest around here are the 
taxpayers. There is no taxpayer that gets a chance to testify before 
committees around here. It is always some other special interest. It 
would be nice to just pull a taxpayer off the street, and say, ``Hey, 
Mr. Brown,, would you like to testify today since you pay all of these 
bills?'' That would be nice. That would be refreshing. But I have not 
seen it happen.
  The obligations of these entitlements are going to be borne by our 
children. That is who is going to pay for this, if they can. I doubt 
that they can. Who do you think is going to pay for all of this debt 
that we keep piling and piling on? Who is going to pay for it? It is so 
sad and so irresponsible and so un-American to pass our debt on to our 
children.
  As a father, I like to think that maybe, if I have anything left, 
when I die, if Uncle Sam has not gotten it all, I would like to say I 
would like to leave something of my assets to my children, not my 
debts. Not my debts, I would just as soon pay the mortgage off and 
leave my kids the house. They will fight over it, but I would rather 
leave it to them debt free.

  That is not what we are doing here in the United States of America. 
We have run the debt now to $4.7 trillion, and it is rising. Every time 
we pass another entitlement, we raise it a little more. The 
entitlements and the interest are squeezing everything else down to 
this very thin little sliver of pie--about 30 percent it is now--and it 
is getting squeezed further and further every day. What is in that 
sliver of 30 percent? That is, you add the interest and entitlements 
and get approximately 70 percent. What is left in the 30 percent? What 
is it? Environment, education, national defense. And it is not getting 
any better. It is getting smaller and smaller.
  How far do you want to squeeze? Do you want to bring it down to 1 
percent? Do you want to increase interest to 90 percent? Where do you 
stop? If we do not stop, we are going to bring this country to its 
knees economically, and then nobody will get any health care--nobody--
because there will not be any money left for anybody for health care, 
for national defense, for environment, for education, or anything. We 
will be broke, and our creditors will be in here picking up the pieces.
  If that is what we want, that is what we are doing. We are creating a 
massive entitlement program, a massive new Government involvement in 
our lives. We are creating it here on the floor of the Senate if we 
vote for this bill. It will come back to haunt us for years and decades 
to come, I guarantee you.
  I am willing to let my word stand on the record right now and say 
that this will come back to haunt us. It will haunt us in less quality. 
It will haunt us in larger expenses. It will haunt us with more debt. 
It will haunt us with rationing, and on and on and on. It will. A lot 
of people in here know it.
  Samuelson, today, in the Washington Post had another very interesting 
article. But before going to that, I would like to read from a letter 
sent to me by a constituent regarding entitlements. I will not read the 
entire letter, but it is a sample of the hundreds of letters and phone 
calls I get. And I think the American people ought to be heard. I will 
not name the writers, but I think in concept they should be heard:

       Dear Senator Smith:
       I am writing to you to express my great fear that Congress 
     will pass a health reform law that will harm our children. 
     What I see at play in Washington is a desperate need by a 
     group of elected officials to pass a law that, good or bad, 
     they can claim shows they are so hard at work. The proposals 
     that are on the table ignore the fiduciary responsibility we 
     have as adults to the next generation. We will break our 
     children's backs with new obligations. We cannot even meet 
     our current obligations without borrowing from the rest of 
     the world. The Clinton plan, the Mitchell plan, and the 
     Gephardt plan are bonanzas to our industry.

  He is a hospital CEO.

       I suppose I could be crucified by my colleagues for writing 
     you this, but the reason we have given so much support to 
     health reform is partly because it will flood our coffers 
     with new money. The health cost controls the Government has 
     tried do not work. The market forces that business and 
     managed care are generating are working, however. For a real 
     change in costs under Government's direction, health care 
     must be nationalized, and we are not ready for that. I 
     implore you to do everything you can to slow this process 
     down.

  And on and on. That is the point, and that is what we are hearing. 
What does Robert Samuelson say today? He is somewhat critical of the 
press in the sense that the press seems to have missed the point as to 
what is exactly happening. He points out:

       In July, the bipartisan Committee for a Responsible Federal 
     Budget issued a report warning that all health plans could 
     involve huge spending increases. ``Common sense tells us,'' 
     the report said, ``that everyone cannot consume more health 
     care and pay less.''

  ``Common sense tells us that everyone cannot consume more health care 
and pay less.''

       The committee includes two former heads of the House Budget 
     Committee (both Democrats), five former heads of the Office 
     of Management and Budget (three Republicans and two 
     Democrats) and the ex-head of the Federal Reserve. The report 
     wasn't covered by The Washington Post, the New York Times, 
     the Wall Street Journal or any major TV network news 
     programs.

  It was not even covered.
  To go on a little more, Samuelson says:

       Unfortunately, the Times' coverage the following week 
     ignored health costs. In midweek, the CBO issued a report on 
     Senate Majority Leader Mitchell's health plan. Previously, 
     the CBO had estimated that health spending could increase to 
     one-fifth of the Nation's income (gross domestic product) by 
     2004, up from a seventh today. The Mitchell plan, the CBO 
     said, would increase it slightly more. The Times didn't 
     report that.

  Then he goes back to the CBO report:

       The CBO found that much of Mitchell's plan is probably 
     unworkable. States couldn't easily determine who would be 
     eligible for insurance subsidies. A tax on insurance would be 
     ``difficult to implement.'' It would not ``be feasible to 
     implement'' Mitchell's so-called ``mandate'' without causing 
     severe ``disruptions, complications, and inequities.''

  That is quoted out of the CBO report. Samuelson makes the point that 
he thinks that is ``news'' since this is the most significant piece of 
legislation to come before the Senate in 25 years, according to some. 
So he thought it should be covered.
  ``The New York Times ignored it,'' according to Samuelson, ``and The 
Washington Post brushed it off with a couple of paragraphs . . ..'' 
And, ``To their credit, the Wall Street Journal and Washington Times 
ran major stories; likewise, NBC `Nightly News' reported these 
findings.'' But, the major media treat this as a coherent plan without 
practical problems. So be it.
  So there is a paradox here. Samuelson says:

       Many reporters seem infatuated with ``reform'' even when, 
     by personal experience, they ought to know better. 
     Journalists are supposed to be seasoned skeptics, and most 
     Washington reporters are familiar with Government's defects. 
     We have covered agencies captured by ``special interests.'' 
     We know of many worthy but unkept promises. We know that 
     Congress evades difficult choices and, as a result, tends to 
     march off in five directions at once.

  I ask unanimous consent to have this article printed in the Record.
  There being no objection, the article was ordered to be printed in 
the Record, as follows:

                    Did the Press Flunk Health Care?

       As Congress debates health care, the press ought to be 
     asking itself whether it has blown this story just as it blew 
     the savings and loan scandal. The answer is yes, I think--
     though in different ways and for different reasons. We have 
     not ignored this story, as we initially ignored the S&L 
     crisis. But our vast reportage has not made health care any 
     more understandable. We have not clarified in our own minds 
     or the minds of our readers what the debate is ultimately 
     about or shown sufficient skepticism about whether ``reform'' 
     can work as intended.
       In some ways, our problem is that health care is too many 
     stories. It's about personal care, the economy, technology 
     (high-tech medicine), ethics (who deserves expensive care?), 
     styles of medicine (``fee for service'' vs. ``managed 
     care'')--and of course, politics and interest groups. We have 
     written thousands of column inches on all these subjects and 
     in the process have overwhelmed our readers and obscured some 
     of the larger issues.
       The most important of these is health spending. With good 
     reason, this is what the ``health crisis'' was once about. 
     Ever-higher spending is squeezing other government programs 
     and, through employer-paid insurance, take-home pay. For 
     example, Medicare and Medicaid now represent 17 percent of 
     federal spending, up from 5 percent in 1970. President 
     Clinton harped on high health costs in the 1992 campaign, and 
     his initial plan did--on paper at least--deal with them. But 
     the spending issue vanished as the Clintons focused on 
     ``universal coverage.''
       The press went along; the major media stopped listening to 
     concerns about spending. In July, the bipartisan Committee 
     for a Responsible Federal Budget issued a report warning that 
     all health plans could involve huge spending increases. 
     ``Common sense tells us,'' the report said, ``that everyone 
     cannot consume more health care and pay less.'' The committee 
     includes two former heads of the House Budget Committee (both 
     Democrats), five former heads of the Office of Management and 
     Budget (three Republicans and two Democrats) and the ex-head 
     of the Federal Reserve. The report wasn't covered by The 
     Washington Post, the New York Times, the Wall Street Journal 
     or any major TV network news programs.
       Sometimes editors and reporters don't even seem to read 
     their own papers. On Sunday, Aug. 7, Robert Pear of the New 
     York Times wrote a front-page piece saying that ``the goal of 
     cost control has been eclipsed by the furor over universal 
     coverage.'' A solid story. Unfortunately, the Times' coverage 
     the following week ignored health costs. At midweek, the CBO 
     issued a report on Senate Majority Leader George Mitchell's 
     health plan. Previously, the CBO had estimated that health 
     spending could increase to one-fifth of the nation's income 
     (gross domestic product) by 2004, up from a seventh today. 
     The Mitchell plan, the CBO said, would increase it slightly 
     more. The Times didn't report that.
       Now obviously, I have a point of view. I think health 
     spending matters and doubt that these ``reforms,'' if 
     enacted, would work as promised. But it is not necessary to 
     share my views to think that these are legitimate issues that 
     haven't been adequately aired in daily coverage. If a major 
     ``reform'' is adopted and doesn't operate as advertised, 
     people will ask: Where was the press?
       Good question. There have been warnings. Return to that CBO 
     report. The CBO found that much of Mitchell's plan is 
     probably unworkable. States couldn't easily determine who 
     would be eligible for insurance subsidies. A tax on insurance 
     would be ``difficult to implement.'' It would not ``be 
     feasible to implement'' Mitchell's so-called ``mandate'' 
     without causing severe ``disruptions, complications and 
     inequities.''
       This strikes me as ``news.'' The New York Times ignored it, 
     and The Washington Post brushed it off with a couple of 
     paragraphs in a small story. To their credit, the Wall Street 
     Journal and the Washington Times ran major stories; likewise, 
     NBC ``Nightly News'' reported these findings. But in general, 
     the major media tend to treat each of these health proposals 
     as a coherent plan without practical problems. This makes the 
     story a neat combat between ``reformers'' (implicitly good) 
     and opponents (implicitly bad).
       There is a paradox here. Many reporters seem infatuated 
     with ``reform'' even when, by personal experience, they ought 
     to know better. Journalists are supposed to be seasoned 
     skeptics, and most Washington reporters are familiar with 
     government's defects. We have covered agencies captured by 
     ``special interests.'' We know of many worthy but unkept 
     promises. We know that Congress evades difficult (a k a, 
     unpopular) choices and, as a result, tends to march off in 
     five directions at once. Yet the skepticism that this ought 
     to breed withers in the face of an appealing ``reform.''
       What also has been missed is the basic political nature of 
     this debate. Once government decrees what insurance must 
     cover (by creating a standard insurance ``benefits 
     package''), it has effectively nationalized insurance. The 
     obvious way of doing this would be a single-payer system that 
     taxes people and provides government insurance. But that 
     looks too much like a government takeover. The use of 
     ``mandates'' and regulation disguises this and seems to have 
     fooled many reporters. Hundreds of billions of dollars of 
     spending would still come under federal control.
       By now it's clear that the public is deeply puzzled by the 
     whole debate. The responsibility for this falls mainly on our 
     political leaders, President Clinton and his critics have not 
     been candid. They won't acknowledge that the goals that most 
     Americans share--better insurance coverage, personal freedom 
     in medical choices and cost control--are, to some extent, in 
     conflict with each other. In this sense, there can be no 
     ideal reform; somehow, incompatible goals will have to be 
     balanced.
       But the conflicts will not vanish just because Democrats 
     and Republicans refuse to discuss them. The press's job is to 
     bring candor and clarity to issues where political leaders 
     haven't shown much of either. We don't make society's 
     choices, but we can illuminate what those choices are. On 
     health care, we haven't.

  Mr. SMITH. In conclusion, Samuelson says:

       What also has been missed is the basic political nature of 
     this debate. Once Government decrees what insurance must 
     cover (by creating a standard insurance ``benefits 
     package''), it has effectively nationalized insurance.

  That is absolutely right. You can say it is not a Government-run 
system if you want to, but, in effect, you have nationalized the whole 
insurance situation when Government decrees what insurance must cover 
by creating a standard benefits package.

       The obvious way of doing this would be a single-payer 
     system that taxes people and provides government insurance. 
     But that looks too much like a government takeover.

  So we use the words ``mandate'' and ``regulation,'' and this seems to 
disguise, basically, the issue of Federal control or takeover.
  So it is clear that the public is deeply puzzled by the whole debate.
  The responsibility for this falls mainly on your political leaders. 
``President Clinton and his critics have not been candid,'' Samuelson 
said. ``They won't acknowledge that the goals that most Americans 
share--better insurance coverage, personal freedom in medical choices 
and cost control--are, to some extent, in conflict with each other. In 
this sense, there can be no ideal reform; somehow incompatible goals 
will have to be balanced.''
  Mr. Samuelson has gone right to the heart of the whole issue. He hit 
it right on the head, 100 percent accurate.
  I urge my colleagues to take a look at that article.
  Let us look at the benefits under Clinton-Mitchell. The Clinton-
Mitchell bill will create a one-size-fits-all standardized benefits 
package and make most existing plans totally illegal. The plan that you 
have will be illegal in most cases. If you have a plan out there now, 
you like it, you have good coverage, forget it. Hopefully, it will be 
as satisfactory as the Government plan because you are going to lose 
it. So if you like what you have, you may want to let your Senators 
know how you feel before the vote because this bill is going to 
radically, radically diminish consumer choice.
  We include in this so-called standard benefit package abortion 
coverage. I am not going to get into the abortion debate today. But a 
lot of the American people do not want abortion in the health care 
bill. It is stretching it a bit to call abortion health care.
  In June 1994 a Gallup poll found 59 percent of Americans are against 
including abortion in the Federal health care benefits package. Again, 
this goes to the heart of choice--freedom. Is that not what America is 
all about? Is that not what for 200 years people have died for?
  Think about this. A Catholic church cannot provide a health care plan 
for its parishes or its employees if it so chooses without having 
abortion in the package.
  That is exactly what is going to happen under this bill. That just is 
not right, pure and simple. It is wrong.
  You can bet that we will be down here in the future--we have already 
done it once--voting under fast-track rules to add more services. We 
just did it yesterday with the Dodd amendment, and tomorrow it will be 
the chiropractors or someone else. There is always going to be someone 
trying to get in here saying, ``I have been left out. I want to get in 
here.''
  So what we are doing is the same thing we did with Social Security, 
Medicare, Medicaid, and all of it. It is just like taking a balloon and 
blowing it up. It is going to get bigger and bigger and bigger until it 
bursts.
  It all sounds good. Get the kids covered. Get pregnant women covered. 
Get all these people covered, get everybody covered, because we cannot 
resist it. Congress could not resist yesterday. The Senate passed the 
Dodd amendment. So already we have found the first amendment mandating 
insurance companies cover specific services for pregnant women and 
children passes, whatever it was, 58 to 42, something like that.
  There will be more. They are going to be coming. Believe me. That is 
just the beginning, and the Senate will find it very difficult, as it 
did yesterday, to vote against them, because these are services for the 
people who need them. Of course, there are people who need. But is this 
best way to help those people by breaking the United States of America 
with a huge entitlement that has no end, that according to Samuelson, 
and many others, is going to go from one-seventh to one-fifth of the 
economy? Is that what we want?
  How can you vote against kids? I heard that yesterday. How can you 
vote against pregnant women? I heard that yesterday. How can you vote 
against immunizations?
  How can you bankrupt the future of our country for all the children 
in all the future, who are going to have to pay for all of this? How 
can you do that?
  I did not hear that stated by the supporters of that yesterday. We 
will be back here again and again and again and again, not just in this 
debate. We will be here for a while. Lord knows how long everybody has 
given up vacations? Anyway what difference does it make? We will be 
here as long as it takes until there is some blink and we decide to 
wrap it up and go home and come back. After that, after this thing 
passes, that is just the beginning. Wait until we try to implement this 
little guy. This is going to be really something. When we start 
implementing this thing and we find out what we have to do and how much 
it is going to cost, then we are going to be back here. We are going to 
be back here quite a few times, believe me.
  Let me tell you what is going to happen. Either premiums are going to 
go up or care is going to be rationed because we cannot promise the 
American people more care for less money. You cannot do it. You cannot 
bring everybody into the system, into the package, into the care, and 
do it for less money. It is impossible. Common sense will tell you 
that.
  If you do it, you are going to decrease quality, or you are going to 
ration it. Sure, you can put a cap on it. You can cap costs, and you 
can bring the quality down. You can cause rationing. And that is 
exactly what is going to happen. The American people better understand 
what this Senate and what this Congress is going to do to you and to 
your health care today and your children tomorrow if this thing passes.
  They are going to be forced to obtain benefits that they do not need 
in the standard plan, and they are going to be forced to take benefits 
that they do not want.
  Let us go to employer mandates. Millions of middle-class Americans, 
the very people that the President ran to help, millions of them are 
going to find their salaries cut, their benefits cut, and if they are 
not, most without a doubt in many cases will have their jobs lost. That 
is what is going to happen to middle-class America, because who do you 
think is going to pay for this? The poor do not pay for this. They are 
on the receiving end. They are not paying. The rich--do you think the 
rich are going to pay for it? Come on. Middle-class America is going to 
pay for it. That is who is going to pay for it. That is where all the 
dollars are. Only 1 percent of the people in America are rich. Look, 
the poor get the money. So who else is left? It is the middle class. 
That is who is going to pay for it. Do not be fooled by the debate how 
it is going to help the middle class. Come on.
  As to employer mandates, in my State alone in New Hampshire, 
according to estimates it is liable to cost anywhere between 4,800 and 
4,900 jobs. That is a lot of jobs in a State with a million people that 
has been hit hard in the past years. Over 100,000 New Hampshire workers 
face reduced wages or benefits if they did not lose the jobs. That is 
basically a decision the employer is going to have to make. Do I reduce 
the benefits, reduce the wages, or cut some jobs and leave the wages 
and benefits for the survivors as is.
  I have two letters I would like to read that would make that point. I 
think they make it better than I do.

  Dear Senator Smith: I am writing at this time regarding the ongoing 
battle over health care reform. As a small business owner, I was 
appalled by the recent remarks made by Hillary Clinton with regard to 
free loading small businesses. While it is understood that neither Mrs. 
Clinton nor the President has ever had to run a business, it seems 
hypocritical of them to ignore the very real concerns of small business 
owners who have risked everything to build a business. Employer 
mandates will cripple many small businesses by adding a constantly 
escalating non-voluntary expense to operations. In addition, much time 
and expense will be lost to paperwork, regulatory compliance and 
administration. I fear the present administration has little regard for 
those of us who have already carried an excessive share of the tax 
burden.

  Another letter:

       Dear Senator Smith: Normally, I am not one who gets 
     involved in the political process. However, since you will 
     soon be voting on several different bills involving the 
     reform of the health care industry, I feel it is necessary 
     for my Representatives and Senators to know my opinion about 
     the likely impact on small business if some of these bills 
     passed. I am classified as small business. At present I 
     employ eight people in various roles from administrative to 
     technical design work. I am proud of the fact that I have 
     been in business since 1988, and I have always tried to keep 
     layoffs to a minimum even when it was not in the best 
     interest of the company. For 5 of the 6 years I have been in 
     the business, I provided company paid life insurance and made 
     health insurance available to my employees with the company 
     paying 50 percent of the premiums. I am currently in the 
     process of adding disability insurance in a benefits package. 
     You see health insurance and welfare of my employees is not 
     something I consider lightly. However, I am concerned about 
     the ramifications of instituting mandatory health insurance. 
     Small companies with under 25 employees should not be forced 
     to implement an insurance package for their employees. The 
     end result will be increased company expenses by way of 
     premiums and taxes which will yield an increase in layoffs, 
     business failures, and decreased wages which in turn result 
     in overall lower standard of living for all.

  New Hampshire under these mandates of this bill will lose 
approximately a half a billion dollars in personal income, almost 
$1,500 for a family of 4. The State of New Hampshire would lose over 
$60 million in much needed tax revenue. Clinton-Mitchell would ban 
self-insurance for companies with under 500 employees, and this will 
mean that 18 million middle-class Americans will suddenly find 
themselves without insurance and end arrangements that save some firms 
thousands of dollars in premiums.
  Is that really what it intended? Of course it did not. It is not the 
intent of the majority leader to have people without insurance. The 
intention is to have them covered by insurance. But what is going to 
happen is suddenly 18 million middle-class Americans--I emphasis 
middle-class Americans--will suddenly find themselves without 
insurance.
  There are 32,254 businesses, as best that I can count, in my State. 
Of these, 32,186, or 99 percent, have under 500 workers. Several of 
these are currently self-insured, with great success, I might add, that 
would no longer be able to do so.
  Again, a brief comment from a letter I received from a constituent:

       Our company provides insurance for its employees through a 
     self-insurance plan. We are concerned that self-funding may 
     no longer be an option for small businesses like ours if a 
     100-employee cap, or any cap, is imposed. By eliminating 
     self-funding and increasing cost of health care, it is 
     possible that many jobs will be lost. The same is likely if 
     employee caps are imposed, which would also raise costs and 
     jeopardize employee coverage.

  He basically goes on to say small employers should not be penalized.
  Mr. President, there are alternatives to this. We should not stand 
here on the floor and be totally critical of the majority leader's 
bill. He wrote the bill and brought it up in good faith, and we have to 
criticize it, if we are going to, in a responsible manner and have some 
alternatives.
  I think those of us on our side of the aisle and many on the other 
side of the aisle are united in their support for actions that would 
help millions of Americans right now, today. You can do it without 
throwing out the best health care system in the world. You can do it by 
prohibiting insurance companies from dropping individuals due to 
sickness. You can do it by dealing with preexisting conditions.
  If someone in my home area, the Lakes region of New Hampshire, in 
Wolfeboro, for example, has a daughter with cancer, that person should 
be able to get insurance at a reasonable rate. That insurance should 
not be canceled if that person moves to another job because his or her 
daughter or their daughter has cancer. We can stop that and that is 
what we should do. You do not have to throw out the entire health care 
system in America to do that.
  Portability. If a person in Nashua, NH, wants to switch their job and 
move someplace else, they take their policy with them, just like you 
take your auto policy or your life insurance policy. You can extend 
help to the working poor through vouchers, which both bills provide 
for.
  And perhaps, most importantly, and missing from the Mitchell bill--
and this is something I feel passionately about; it is so important, 
and it is totally ignored by the Mitchell bill--and that is the 
establishment of a medical IRA, an IRA account; or, another way to say 
it, a medical savings account. It is one of the best ideas that has 
been brought forth in any of the debate, and it is totally ignored in 
the Mitchell bill--not a word.
  The medical savings account would do more to help contain medical 
costs in our country than anything in the Clinton-Mitchell bill, 
anything at all, and would do so by relying on the market rather than 
Government bureaucracy.
  People with medical savings accounts could purchase high deductible 
coverage to guard against catastrophic costs and they would pay for 
those out-of-pocket costs in the account that they set up. Most health 
care expenses would, therefore, be paid by the individual who set up 
the account, rather than a third party.
  Let us get into that a little bit further. I believe that the main 
reason our current system fails to rein in runaway health spending is 
that it removes the consumer from the decisionmaking process.
  When the tab for health care is picked up by somebody else, not you, 
a third party, either employers or the Government, for the great 
majority of Americans, the consumer has no incentive, none whatsoever, 
to keep his or her own health costs in check.
  For most Americans, there is no financial reward for staying healthy. 
What is the reward? What is the reward for staying healthy? What is the 
reward for seeking preventive care? What is the reward for shopping 
around for the best available price? None. And under the Clinton-
Mitchell bill, absolutely none.
  To put this in perspective, let us compare health insurance just for 
the sake of debate--and we will probably hear some of my adversaries in 
the media say, ``Now, Smith says auto insurance and health insurance 
are the same thing.'' Lest there be some temptation to do that, I will 
say up front, they are not, and I recognize that health insurance is 
more important to our well-being than auto insurance.
  But I use the comparison for this reason. If I drive recklessly, get 
several speeding tickets, and cause an accident, my irresponsible 
behavior will be greeted with a higher premium. That is what is going 
to happen, and rightfully so. It is to my financial advantage to drive 
carefully, drive safely, avoid speeding, wear my seatbelt, whatever.
  But if somebody else were paying for my auto insurance, I might not 
have the same incentive. What is my incentive? My insurance is not 
going to go up. If somebody else pays, I could care less if it goes up. 
I am not paying for it.
  It is the same thing in health care. With another party bearing the 
responsibility for any costs, individuals have no incentive to keep 
themselves from incurring expensive health care bills. That is what 
medical savings accounts are all about. And they are totally ignored in 
this bill. Responsibility. Is that not what America is all about, 
responsibility?
  Think back to the Founding Fathers and what they did when they 
founded this great country, and the numbers of people who were wounded 
and died in 200 years of war. Responsibility. Why cannot we take on 
some responsibility for our own well-being if we have the capability to 
do it?
  And for those who say, ``Yeah, but there are those who do not,'' I am 
willing to help those 15 percent. I am talking about the 85 percent 
right now.
  It places the responsibility for health care costs where it should 
be--on you, on the consumer. With a medical savings account, the 
consumer, not a third party, will have to make decisions that will have 
a direct financial impact on themselves.
  If you want to drive a Porsche, you want to go out every night and 
drink, you want to spend your money, go ahead. If you want to buy a 
health premium, you want to buy an insurance policy, set yourself up a 
medical IRA and say, ``I'm going to assume responsibility for me. I'm 
responsible for me. Not the Government, not my neighbor, me. I'm 
responsible.''
  Exercise some responsibility. Set up the medical IRA account. And 
then lead a healthy lifestyle, and you will save money, big time. If 
you lead a healthy lifestyle and you seek routine preventive care, you 
will be rewarded with accruing balances in your medical IRA.
  Now, sure, something can happen. That is why you have an insurance 
policy. That is why you buy the policy, to protect yourself from injury 
or accident. However, you will accrue balances in that IRA if you take 
preventive care and you will have enough in there to pay for your 
insurance and still have money left over. Let it accrue, and this will 
defray future medical costs and even allow you to buy a catastrophic 
policy at some point when you are ready. You are holding down your 
personal health costs; individuals will help our country hold down our 
overall health costs. We will all do it as individuals.
  Not a word, not a mention of medical savings accounts in this plan. 
This is too American. I guess it makes too much sense. It is common 
sense. God forbid, we could do anything that makes sense around here in 
Washington inside the beltway.
  And, in addition, and in conclusion on medical IRA's, medical savings 
accounts will also unleash the market forces onto the health care 
delivery system; unleash, and that is exactly what we need to do, 
unleash the market forces on the health care system. Today's system 
encourages providers to bill for as many services as possible. With 
millions of individual consumers shopping around for quality care at 
low prices, providers are going to have to find ways to cut overhead 
costs and provide care in an efficient manner. That is the market.
  And these adjustments in the marketplace could be made today as we 
speak, and they would help millions of Americans to obtain less 
expensive health care insurance.
  In closing, we have heard many stories, many horror stories, about 
those who are not covered, about our current system and how tragic it 
is that 37 million Americans lack health insurance. And there are some 
horrible cases. There is not a person in the Senate or in the Congress 
that does not want to help those people, including this Senator. And we 
can.
  There is a right way and a wrong way to do that. It is wrong that 
people are suffering because they cannot get coverage. But who are 
these 37 million people? They are people, sometimes, who are between 
jobs. They lost their job, they move to another job, their insurance 
gets canceled so they need portable insurance. We do that. They are 
people who have a preexisting condition, either themselves or someone 
in their family has perhaps a terminal illness, something that involves 
a lot of medical costs, they lose their job and the next provider says, 
``I am sorry, that is a preexisting condition. It would cost us too 
much and we are not going to insure you.'' That is going to need to be 
changed. And we do that in our bill. That is a large group of that 37 
million.

  We can take care of these cases through providing insurance market 
reforms and providing assistance to the working poor. But for some 
reason--I do not know what the reason is; I am not going to make any 
allegations about political reasons--but for some reason we are 
concentrating on disrupting the entire health care system which 85 
percent of the American people are happy about for the sake of 15 
percent. Why not just help the 15 percent when you can do it without 
disrupting the other 85 percent? It is going to be a grave mistake if 
we do this. We are going to regret the decision made in 1994 on the 
floor of the U.S. Senate, because we have the finest health care 
delivery system in the world. We know it because people come from all 
over the world to receive it. Doctors come from all over the world to 
learn medicine, to practice medicine. Everybody knows it. If you are 
sick, if you have a problem, where do you want to go? Guatemala? 
Mexico? Russia? Canada? Or the United States of America?
  Let us take advantage of the quality and the innovation and the 
creativity of the best physicians and health care providers in the 
world. Let us take advantage of it. Let us not throw it out.
  So now we stand, as I speak, at a fork in the road--and it is a fork 
in the road. We can go to the left, as the Senate considers a massive 
restructuring of one-seventh of the economy, which will probably make 
it one-fifth Government involved. We can take that path toward a health 
care system controlled by an inefficient, uncompassionate, expensive 
government bureaucracy. We can take that path. That is one choice we 
have. Or we can go this way, to the right, which will lead us to a more 
efficient marketplace that can meet the needs of all Americans. The 
left fork gives us bureaucracy, more taxes, job-killing mandates, 
rationed care, diminished quality. The right fork will help those who 
are truly needy while preserving the world's best health care for 
everyone. Access, low cost, personal freedom, quality, choice. That is 
what we get when we go to the right. Bureaucracy, mandates, less 
personal freedom, more controls, less quality, less choice--to the 
left.
  What is the decision?
  Let me read just a couple of lines from two more letters.

       Dear Senator Smith, I am writing to you to advise in my 
     opinion that health care as presently espoused by Washington 
     will not work. We all would cherish an umbrella of universal 
     care, but at a reasonable cost and especially at a cost which 
     is no greater than we presently pay. This means no additional 
     taxes. Unfortunately, the record suggests programs managed by 
     the Government are many times barely effective or efficient.

  Then he cites a couple of examples and goes on to say:

       The warmth and general concern for our well-being are not 
     well known as priority attributes in our Federal employees, 
     IRS, FBI, et cetera. To have a government manage anything as 
     important as health care is ludicrous. And to be bullied into 
     this legislation is akin to lemmings heading with a blind eye 
     for the cliff.
       The first step, it seems to me, would be to analyze the 
     problem of health care. The major problem is not the quality 
     of health care. We have the best in the world. The problem is 
     associated costs which are and have been out of control.

  The last letter:

       Senator Smith, I am writing about my concern on the current 
     health care proposal now in Congress. Improvements in health 
     care are needed and desirable but I feel many of the plans 
     include restrictions and mandates that are contrary to a good 
     health care system and a free enterprise system that has made 
     our country so successful and great.

  I take the time to read these letters because these are the American 
people who are going to be impacted and affected by the decision that 
we make, sitting here inside the beltway, without talking with them, 
without having the opportunity to go out and speak with them. We are 
here making this decision that impacts them. They ought to be heard on 
the floor of the Senate. That is why I am taking the time.

       Restrictions that would prevent you from choosing your 
     choice of doctors is a horrible thought. Before I go to a 
     doctor I check his dossier and I talk to people that know 
     him. Let's face it, all doctors are not equal. Some are 
     better than others. Not all ailments or illnesses fit into a 
     standard mold. A doctor has to have a keen analytical or 
     diagnostic ability to accurately identify, in a timely way, 
     what is ailing a patient and what medication or treatment is 
     best for that patient. It is not uncommon to change doctors 
     when his or her prognosis does not render relief, or to get a 
     second opinion before a serious medical or surgery procedure. 
     Some doctors are more skilled than others and you want the 
     doctor with the best track record and the one you can get 
     along with.

  These people are concerned. They are concerned. Let me put it even 
stronger--they are scared. They fear.
  I am going to close with a quote from a gentleman who came to one of 
my 10 county meetings. We talked about health care, and he said to me, 
``Senator, I have known you more than 20 years. But let me tell you 
what bothers me. I am afraid of my Government. I am afraid of my 
Government. I don't want to be afraid of my Government. I want the 
Government to be afraid of me.''
  I yield the floor.
  The PRESIDING OFFICER (Mrs. Boxer). The majority leader.
  Mr. MITCHELL. Madam President, I want to address two subjects that 
were raised by the distinguished Senator from New Hampshire and several 
of our Republican colleagues with respect to the pending health care 
legislation. One involves the question of choice in health care. The 
other involves the role of Government in health care and the reaction 
of our colleagues to that.
  The statement of the Senator from New Hampshire was filled with 
references to less Government involvement, no Government control, and 
fear of Government by Americans. That has, of course, become the 
dominant theme of the statements made by our Republican colleagues 
seeking to capitalize on a public sentiment of disillusionment with 
Government and even hostility to Government.
  I would like to make two points with respect to that argument as it 
relates to this debate. First, it does not describe my bill. The 
statements are not correct as they relate to the bill which is pending 
before us. My bill does not provide for a Government-run health 
insurance system. It provides for a voluntary system of private health 
insurance. Indeed, in a significant respect, my bill is the opposite of 
what our colleagues are trying to portray it as. A large Government 
program is Medicaid, a Government program which provides health 
insurance to those Americans whose incomes are below the poverty line. 
Under my bill, that program would be virtually abolished and 25 million 
Americans who are now in one of the largest Government programs would 
be out of that Government program and would purchase their health 
insurance on the private market as do most other Americans.
  It is simply inaccurate to characterize legislation which would 
virtually abolish one of the largest Government programs in existence 
and encourage and assist the people now in that program to purchase 
private health insurance, it is simply inaccurate to describe that as a 
Government-run program. It is not.
  I recognize that our colleagues are having some success in this false 
portrayal. It is a pattern we have seen before. But success does not 
mean accuracy. We went through it just a year ago when we debated the 
President's economic plan, when the very same Senators now saying that 
this bill is a Government-run health insurance system said to the 
American people that the President's economic plan would raise 
everyone's taxes and was a tax on small businesses. They said it over 
and over again, it was reported by the press and, as a result, the 
American people believed it. Polls showed overwhelming majorities of 
Americans believed that their income tax rates would go up as a result 
of the President's tax plan, even though those statements were untrue 
and the beliefs were unfounded. It was an aggressive effort at 
misinformation which regrettably did succeed and, therefore, creates 
incentives for a similar campaign of misinformation now.
  But I want to state clearly, so there can be no misunderstanding, the 
characterization is incorrect. My bill creates a voluntary system 
building on the current system of voluntary private insurance. It 
virtually abolishes one of the largest Government programs and takes 25 
million Americans now in such a program and has them enter the private 
insurance market. So that is my first point. It is not a Government-run 
health insurance system.
  But now my second point deals with the attitude of our colleagues 
toward Government insurance and Government health care and the vast gap 
between their rhetoric about it and what they do about it when it 
affects them and their families.
  First, they say they are against Government health insurance and 
Government health care. Well, the largest Government health care system 
in the country, indeed the largest health care delivery system in the 
country, is the Veterans' Administration health care system. If they 
truly believed what they are saying here about Government health care 
systems, they would abolish the Veterans' Administration system. But, 
of course, they do not say that and they will not say that.
  In fact, with respect to that Government health care system, their 
actions directly contradict their words. The very same Senators, our 
Republican colleagues who stand here and say, ``We are against 
Government health care systems,'' when they go back to their home 
States, they go seek out the veterans and they run television ads 
promising the veterans that they will protect the veterans health care 
system, even though it is a Government-run health care system and it is 
the largest health care delivery system in the country. Their actions 
contradict their words.
  The same is true with respect to Medicare. Medicare is a Government-
run health insurance system, and nearly 40 million Americans, most of 
them elderly, participate in that system. And the Republican Senators 
who stand here and say they are against Government-run health insurance 
all support the Medicare system. They go back home and they seek out 
elderly citizens. They go visit senior citizens' centers and fall all 
over themselves in promising to their senior citizens that they will 
protect Medicare, and they run television ads seeking reelection, 
promising their senior citizens that they will protect Medicare, even 
though it is a Government-run insurance system. Their actions 
contradict their words.
  The same is true with respect to Social Security, the largest of all 
Government programs, a Government-run system which includes health care 
by virtue of incorporating Medicare part A. Our Republican colleagues 
go back home and also seek out senior citizens and also run television 
ads promising to protect Social Security, which is a Government-run 
program.
  So I hope the American people will not be fooled by the rhetoric they 
are hearing here today. And I hope the American people will also think 
about the irony of these Republican Senators getting up here day after 
day after day and denouncing Government health insurance and Government 
health care as bad for their constituents, even as they benefit from it 
themselves as individuals and their families. Every Member of this 
Senate participates in the Government-run health insurance system that 
is available to all Federal employees, and the Government pays 72 
percent of the cost of that health insurance for these Republican 
Senators who are standing here telling their constituents that it is 
bad for the constituents even as they participate in it for themselves 
and their families.
  You, American taxpayers, are paying through the Government 72 percent 
of the cost of health insurance in a Government-organized health 
insurance system for the very Republican Senators who are now telling 
you that you should not want Government-run health insurance. And you 
are entitled to ask yourselves: If it is so bad for you, why is it so 
good for them and their families?
  Has one of them stood up and said, ``My constituents, Government 
health insurance is bad for you, and to prove how much I believe that 
statement, I'm going to voluntarily drop out of the Government 
insurance system, and I'm going to put my family in the same place 
where your family is"? Have you heard one say that yet? No, and you are 
not likely to.
  I urge you to listen to the debate, and as these Republican Senators 
stand up and tell you, Mr. and Mrs. America, that Government health 
insurance is bad for you, ask yourself, ``If it is so bad for me, how 
come it is so good for them and their families? And if they really 
believe it is bad for me, if that is what their conscience and 
conviction tells them, why do they not drop out of it for them and 
their families and put themselves in the same position I am, an average 
American who doesn't have access to that?''
  That is just the insurance. Now let us talk about direct care. If one 
of these Republican Senators does not feel well, if he gets a headache, 
or stomach ache, he walks a few feet down the Capitol and he goes to 
the Office of the Capitol Physician, a Government employee. He is 
greeted by a clerk who is a Government employee, checked by a nurse who 
is a Government employee and then goes in to see the doctor who is a 
Government employee.
  If Government health care is so bad, why do these Republican Senators 
insist on having it for themselves? And then if they get sick, if the 
doctor says, ``You've got to go to the hospital,'' they go to the 
Bethesda Naval Hospital or the Walter Reed Army Hospital--Government 
hospitals.
  Well, my gosh, ask yourself, Mr. and Mrs. America, if these 
Government facilities are so bad, why do these Republican Senators want 
to go there themselves? And it is not just Senators. President Reagan 
and President Bush were, in their capacities as President, the most 
powerful men in the world. They were independently wealthy, and they 
could have gone anywhere in the world when they got sick. And where did 
they go? Why, they went to these Government hospitals. And who can 
forget the photographs taken of them waving out the window to the 
public and the press in those Government hospitals. Why are you telling 
us that it is good enough for Presidents but it is not good enough for 
ordinary Americans?
  Mr. and Mrs. America, leave aside politics. Leave aside health care. 
When a fellow walks up to you and says, ``I've got something, and its 
good for me and my family, but you really don't want it for your 
family,'' you ask yourself: Who is he thinking about? You or him?
  This debate has not been about health care reform. This debate has 
been about slogans. When the first Republican Senator stands up and 
says I believe so much in my conviction that Government health 
insurance is bad that I am going to withdraw myself and my family from 
the Government-organized health insurance system and I believe so much 
that Government health care is so bad that I am going to promise if I 
get sick never to talk to a Government doctor and, if I have to go to 
the hospital, never to go to a Government facility, when that happens, 
pay attention to what they say thereafter.
  But until that happens, you can take what is being said as slogans, 
separated from the reality of daily lives. If they want it for their 
kids, if they insist on having it for their kids, if they will keep it 
for their kids, then why is it so bad for your kids?
  I want to repeat what I said at the outset. My bill is not a 
Government health insurance system. It is not a Government health care 
system. It is the opposite. It is a private system, voluntary, in which 
people are encouraged to purchase private health insurance. And I have 
mentioned this debate about individuals and health insurance here only 
to make the point of the inconsistency of the arguments being made by 
our colleagues.
  To summarize, they are all for the Veterans Administration, which is 
a Government health care system. They are all for Medicare, which is 
Government health insurance. They are all for Social Security, which is 
the largest Government program. Therefore, their statements here 
against Government participation simply do not ring true because they 
will not stand up and say they oppose those programs, they want to 
abolish them. And then their actions in placing themselves and their 
families in a Government-organized health insurance system and getting 
direct Government health care for themselves, even as they say to their 
constituents, ``That is not good for you,'' I say be aware, on guard, 
listen carefully.
  Now, just the other day one of our colleagues came out here and said, 
well, the insurance program we are under is not a Government program 
because although it is organized by the Federal Government and 72 
percent of the cost is paid by the Federal Government, it is really a 
mechanism where private insurance plans can be made available to 
Federal employees.
  Mr. President, the denial negates the original claim, because that is 
essentially what my plan would do. It would create a mechanism whereby 
employers would offer to their employees a minimum of three different 
types of private insurance plans, and employees would choose among 
them. There would be no requirement on the employer to pay for any part 
of the cost unless we did not reach 95 percent coverage by the year 
2000, as I believe we will.
  And so it is ironic that the explanation about the Government 
insurance plan effectively negates the original allegation about my 
plan being Government insurance in the first place. So our colleagues 
cannot have it both ways. If my plan is not Government health 
insurance, then their original argument falls. On the other hand, if 
the Government-organized, Federal employees program is Government 
health insurance, they are all participating in it, willingly, taking 
it for them and their families while they tell their constituents it is 
bad for them.
  Madam President, I will have more to say on that subject. I now want 
to mention just briefly the subject of choice. The Senator from New 
Hampshire said if our plan is adopted, ``Americans will lose their 
choice.''
  That statement is untrue, categorically untrue. There are two types 
of choice in health care. The first is in choice of health care plans. 
How much choice does the individual American have in selecting a health 
insurance plan? Right now, almost none. Most Americans are insured 
through employment. The employer negotiates a plan with the insurance 
company and presents it to the employee, and the only choice the 
employee has is to accept or reject that plan, to either participate in 
it or not to participate in it.
  Under my plan, the individual employee will be offered a minimum of 
three different plans. They will have the same standard benefits 
package, but they will deliver care in three different ways: either in 
the form of traditional fee-for-service, or a health maintenance 
organization, or in some other form. So in the first dimension of 
choice, that of health plans, my bill will dramatically expand choice 
for almost all Americans. For the first time, individual Americans will 
be able to choose from more than one health plan.
  Second, the element of choice in physician or other providers. It is 
simply not true that choice will be denied under my plan. Since 
everyone will be offered at least three types of plans, one of which 
must be traditional fee-for-service, every American will have the 
opportunity to continue to have the fullest freedom of choice with 
respect to physicians. No one will be denied that opportunity.
  Interestingly enough, the current trend in the country is in the 
other direction. As costs of health care rise, employers are 
increasingly turning to managed plans, HMO-type plans in which the 
individual's choice is limited. So if we do not adopt health care 
reform, more and more Americans will be denied choice in provider. So 
you have a reduction of choice in the one area where it now exists and 
continuing lack of choice with respect to health plans.
  So I think it is important that Americans understand that my bill 
will do the opposite of what our colleagues have alleged. It will 
greatly increase choice in health plans and it will preserve fully 
choice of providers. Anyone will still be able to see any doctor they 
want, choose anyone they want to see in nurses or any other form of 
provider.
  I hope that we all understand that.
  Finally, the statement was made, ``Don't throw out the entire 
system,'' thereby creating the implication, since the remarks were on 
my bill, that my bill does throw out the entire system. Madam 
President, it does not. It builds on the current system. It says that 
most Americans now receive their insurance through employment, and we 
should continue that. We should encourage those who do not have 
insurance to get it. And what we ought to do is to try to increase the 
number of Americans who have health insurance through a voluntary 
system of guaranteed private health insurance.
  Now, what my bill does do is to provide health security for the 85 
percent of Americans who now have health insurance but do not have 
health security.
  Right now many of them face the incredible situation where their 
health insurance could be canceled if they become sick. Think about 
that. A person buys health insurance to protect himself in case he 
becomes sick, and then when he becomes sick the policy is cancelled. My 
bill will prevent that from occurring. It will prohibit that from 
occurring.
  Second, right now, a person can be denied health insurance on the 
basis of a preexisting condition, something that affects millions of 
Americans. My bill will prohibit denying on the basis of preexisting 
condition. By contrast, the Republican bill would permit that to 
continue on an ongoing basis. My bill will phase out the preexisting 
condition exclusion completely by a time certain in sharp contrast to 
the Republican bill which permits the denial for preexisting condition 
to continue.
  My bill will make it possible for a person to change jobs without the 
fear of losing his or her insurance. That is a real problem today. My 
bill will make it possible for people who are between jobs, temporarily 
unemployed, to continue with insurance. The insurance will be private, 
it will be guaranteed, it will be renewable, and it will not be able to 
be canceled. I think that is what Americans want who have health 
insurance. Yes. They are happy to have health insurance. But many of 
them are concerned about their lack of security, the fact that they do 
not know for sure whether it is going to be canceled tomorrow, whether 
the premiums are going to be doubled, or whether it will cover what 
they want when they become sick.
  So, Madam President, I emphasize that my plan will increase choice. 
It will prohibit current insurance practices which leave Americans who 
have insurance insecure, and it will encourage those who do not have 
insurance to get it. It will abolish one of the largest Government 
programs that have those people enter the private insurance market. It 
is a voluntary system. And I ask Americans to keep that mind as they 
listen to the debate.
  Madam President, I yield the floor.
  Mr. HATFIELD addressed the Chair.
  The PRESIDING OFFICER. The Senator from Oregon.
  Mr. HATFIELD. Madam President, I would like to comment briefly on the 
majority leader's remarks, at least a few of them.
  I think that it is the duty of the leader, as the majority leader or 
as the minority leader, to represent a party position or a political 
perspective. I admire both Senator Mitchell and Senator Dole for their 
able and professional way of carrying out those duties.
  But I also think that the American people are alert enough and wise 
enough to know that the leadership of the U.S. Senate on either side of 
the aisle cannot easily categorize, as the majority leader has today, 
the Republicans all in one position and the Democrats all in another 
position. That is just an inaccurate portrayal of this issue, and the 
things that divide us on this issue.
  I happen to be participating with what we call the mainstream 
coalition. These are at least nine Democrats who are not happy with the 
Mitchell bill. These are at least 9 or 10 Republicans who are not happy 
with the Dole-Packwood bill. But nevertheless, they are trying to seek 
to join together in a bipartisan effort to create a piece of 
legislation to lead us to wise, effective, economical health reform.
  So I just want to clarify the record on that point, that my leader, 
Senator Dole, as much as Senator Mitchell's contingent of Democrats, 
are not easily divided as has been portrayed this afternoon.
  Second, I would like to indicate just for clarification that somehow 
we have a coverage that is a Government operation, our own medical 
coverage. I would like to clarify that record to say that Blue Cross-
Blue Shield is one of the many contractors with the Federal Government. 
I gain my health care from Blue Cross-Blue Shield where the Federal 
Government is in contract the plan, and like many private industries, 
pays a portion of our health care premiums. Portraying that somehow the 
Members of the Congress, in particular Republican Members, are getting 
this great benefit out of the Government operation, as we have heard 
today, is just not accurate. So I want to clarify the record on that 
point.
  I might also say we have thresholds, or we have deductibles. We have 
copayments. And yes we may go to see the Capitol physician but we pay a 
premium. I pay a fee for that kind of service. So this is not some 
broad-based freebie as that is being portrayed here today.
  Madam President, the Senate has embarked on a very historic debate, 
and health care is probably one of the most important social issues 
that I think we will probably debate this entire century. During the 
last several months, we have heard a lot about the need for health 
security, that health care is a right that can never be taken away. I 
subscribe to that. And we have all heard the tragic stories of those 
who have fallen between the cracks in our health care system and have 
faced huge financial losses when faced with a health crisis. We have 
heard about the uninsured, and the cost shifting that occurs as between 
those of us who are insured to those who are uninsured who seek their 
health care services in hospital emergency rooms.
  There is no doubt that our current health care system is not meeting 
the needs of a large segment of our country. We all share a commitment 
to achieve the finest health care delivery system possible in the 
United States to be extended to all in the United States. That is the 
purpose of this debate.
  I would like to take the perspective as an appropriator. Let me use 
the old jingle that is often used, that authorizations--and that is 
what both the Mitchell bill and the Dole-Packwood bills represent, 
authorizations--are but a hunting license for an appropriation. We on 
the appropriations committees have found that there has been much 
action to authorize many programs in this century by the U.S. Congress, 
and then somehow it ends up in our lap to try to find the money for it. 
It is awfully easy to make promises. It is awfully easy to paint great 
broad brushes of new credits or new entitlements or new subsidies or 
new coverage. But someone at some point has to provide the money.
  Let me say also that having been involved in Government for a few 
years, I am not willing to put my entire expectation and hope and trust 
on some kind of prospective savings. We have been through many of these 
experiences in the past. Under President Franklin Roosevelt, we had the 
Browley Commission; under President Truman we had the Hoover Commission 
I; and, under President Eisenhower, Hoover Commission II, studying the 
reorganization of the executive branch of Government and projecting the 
savings that could be achieved out of those reorganization proposals.
  The first year out we found there were some savings that could be 
directly attributed to those reorganization efforts. But as time went 
on in the outyears, those savings disappeared pretty quickly.
  So to undertake a program that is so heavily dependent upon 
prospective savings of changes and so forth, I am a little bit dubious. 
I am not saying we have not achieved some, of course, but to say that 
we are going to fund a portion of this health care program under the 
Mitchell bill out of those savings I think is a little risky business. 
And I know what will happen. If those proposed or prospective savings 
do not occur, it will be back on the Appropriations Committee to come 
up with the money to fund the commitments that have been made.
  So I would like to focus a few comments on two key areas: The cost 
analysis of health care reform; and second, the nonmonetary issue as 
the legacy we are leaving for our children and our 
grandchildren. ``Legacy'' might be translated, also, into the word 
``indebtedness.'' We began this debate more than 4 years ago when it 
became apparent that health care costs were rising at a rapid rate and 
would endanger the financial stability of our country. We are now at a 
point where national health care expenditures make up more than 14 
percent of our gross national product and near $1 trillion.

  By the year 2000, national health expenditures, at this continuing 
rate, are expected to reach more than $1.6 trillion; and by 2004, they 
will exceed $2 trillion. According to the estimates released on Tuesday 
of this week by the Congressional Budget Office--the legislative arm of 
the Congress--the legislation proposed by the majority leader, Senator 
Mitchell, will exceed these estimates. I can only draw a conclusion 
that this does not represent cost containment.
  Yes, we need health care reform, but we cannot forget the impact new 
Federal spending and new entitlement programs will have on our children 
and our grandchildren, who will be faced with paying the bills 
associated with these increases of today.
  We have a bipartisan commission on entitlements and tax reform that 
recently released findings which showed that even if increases in 
health care costs were held to the growth of the economy by 1999, due 
to the aging and changing demographics of the aging population, Federal 
outlays for Medicare and Medicaid will still double as a percentage of 
the economy by the year 2030. In fact, they will increase from 3.3 
percent of the economy today to 11 percent of the economy. Mark you, 
these findings and projections do not include the effect of the new 
health care entitlements envisioned by the Mitchell bill.
  Let me stop here a moment and say, as I indicated in the very 
beginning, no leader in this body can speak for all the Members on his 
respective side. You have heard a lot of talk about Republicans saying 
``no new taxes.'' Well, this is one Republican who will vote for new 
taxes if it is to fund the high priority that I place on health care 
reform. I am not talking about depending it on the cigarette tax or the 
sin taxes; I am talking a basic tax increase, because I want to remind 
ourselves today that when we went through the throes of getting 
catastrophic illness and everybody wanted catastrophic illness, led by 
the AARP, when the people of this country found it was going to cost 
them $3 to $4 more a month in premiums, there was almost a stampede 
into the well of this Chamber to see who could be down there with the 
first bill to repeal the act passed by the previous Congress, in order 
to respond to the American public's outcry that they were not willing 
to pay a $3 to $4 increase for coverage of catastrophic health care. I 
am one Republican--and I am sure there are others--who will say that we 
put such a high priority upon covering all Americans with decent health 
care access that we are willing to stand and vote the tax to support it 
and to guarantee it and not make promises that cannot be guaranteed by 
saying prospective changes or prospective reforms are going to provide 
us with the money.
  Let me also say that under the Mitchell bill, many are going to find 
themselves paying more for their health care. By the year 2002, all 
Oregonians will be paying the same rate for premiums regardless of age. 
According to a recent editorial in the Washington Post written by Neil 
Howe and Bill Strauss, this so-called pure community rate will increase 
costs for young people by 100 percent. Essentially, this means that we 
will be taking at least $40 billion yearly out of the pockets of young 
adults--those under the age of 35--and putting it into the pockets of 
adults over the age of 45. It is a cost shift.
  While there is no doubt that reform needs to be made in the insurance 
industry--for example, to make insurance portable so you can take it 
with you when you change jobs and available to you regardless of your 
health status. In fact, I was recently chatting with a gentleman in my 
office who is now among the ranks of the uninsured. He changed jobs and 
became self-employed. Due to the change, he lost his employer-provided 
health insurance, and in the meantime he learned that he had diabetes 
and now cannot find health insurance because nobody will insure him 
with this preexisting condition. These are the kinds of problems we 
must address in our current insurance system. Yet, we must do so in a 
way that does not bankrupt our children and grandchildren. This is the 
challenge that makes this debate so difficult, because there is no easy 
answer. Again, what is the legacy we want to leave to the future 
generations?
  As many of my colleagues know, the State of Oregon has taken 
substantial steps to enact health care reform which controls health 
care costs and achieves universal coverage. The Mitchell bill could 
negate the innovative Oregon health plan. Although Oregon's Medicaid 
waiver appears to be grandfathered, none of the other reforms Oregon 
enacted into law receive such protection against Federal preemption or 
Federal prescription.
  For example, Oregon has developed a standard benefits package under 
the Oregon health plan. This unique benefits package explicitly 
recognizes that we cannot afford to provide every service to every 
person.
  Madam President, there is not a plan out here that has taken the 
tough position to say we cannot provide every service to every person. 
What we are trying to do in Oregon is to provide everybody with 
standard primary health care. We are not going to separate every 
Siamese twin born in Oregon. We are not going to guarantee, in a sense, 
that everybody has a right to any medical procedure--over 9,000 of them 
under Medicare alone. We have prioritized them. People say, oh, that is 
rationing health care. Well, we are rationing health care, yes, but we 
are doing that today based on economics, which is certainly 
discriminatory, far more than saying to a person who is 80 years old, 
if you have a life expectancy added to your life by 1 year, are we 
going to engage in a very costly medical procedure as against covering 
100 women with prenatal care? No, we cannot afford to do it. That gets 
down to where the real rubber hits the road in terms of having to make 
the tough decisions that somehow we are going to offer everyone any 
medical procedure or access to any medical procedure. That is the 
implication, because we have not addressed those thousands of medical 
procedures, and we have the attitude that any one of them--it is very 
clear--would be open to anybody.
  Oregon focuses on the position of preventive health care services and 
provides an access to primary health care before serious health 
problems develop. It looks at the effectiveness of treatment and draws 
lines to exclude payments of services that are noneffective or add to 
the individual's quality of life.
  I think we have to face this reality in the national picture as well. 
It was difficult for Oregon. It was complicated. But they gathered the 
best brains and representation of the people, theologians, 
philosophers, doctors, lawyers, humanists, people from all walks of 
life, people from all incomes, and they sat down and worked out this 
dialog.
  Under the Mitchell bill, will Oregon be permitted to continue to 
offer this unique benefit package to all Oregonians? Oregon has also 
taken steps in the private insurance market which have completely 
changed the nature of health care in the State, and has contributed to 
a significant lowering of health care costs in Oregon compared to the 
national average. Oregonians are familiar with managed care, where they 
join a network of providers through whom they can access health care 
services.
  These networks include primary care physicians, hospitals, 
specialists, and other health care providers. In fact, more than 60 
percent of the 1.1 million Oregonians who have coverage through Blue 
Cross/Blue Shield of Oregon are enrolled in managed health care plans. 
And in addition to that, Kaiser Permanente has more than 400,000 
subscribers in Oregon out of a total population of 2.9 million.
  However, there is a provision in the Mitchell bill that threatens the 
ability to health plans, such as those that are covering the majority 
of Oregonians, to manage health care costs by limiting ineffective 
treatment and care. Under the claims dispute mechanism which would be 
established if the Mitchell bill is passed in its current form, health 
plans will have no incentive to manage cost because every decision, 
every claim--and there are millions every year in this country--could 
be reviewed through an administrative process, or in Federal or State 
court where damage awards available would be ``any appropriate 
relief''--underscored--``any appropriate relief'' possible, a true 
lawyer's paradise. This could be called in a sense a lawyer's economic 
development act.
  Let us be clear about this. The disputes we are talking about here 
are contractual disputes over service coverage in health plans. These 
are not malpractice claims, not malpractice claims. They are not 
disputes that arise over negligent medical care. The implications of 
this provision for our ability to control costs through managed care 
are erroneous and they become also more enormous. It will completely 
undermine cost containment efforts.
  I have long advocated that we give States more flexibility to develop 
a database to assist us in formulating a Federal role in health care 
reform. Certainly, I agree that there need to be certain Federal 
standards that assist us in achieving the goal of universal coverage. 
However, I do not believe the Federal Government should be dictating a 
regulatory and prescriptive process to the States and that each State 
then must follow to reach these Federal standards.
  This approach penalizes States such as Oregon that are progressive. 
Many States have been working on these issues for many years, and I 
believe it is wrong for the Federal Government to come in and undo the 
reforms that we have already established and are experiencing.
  For example, the Mitchell bill includes a provision that will preempt 
all State laws in the area of medical liability reform that are 
different from the new Federal laws established if the Mitchell bill is 
passed. In Oregon, that would mean that our medical liability law which 
includes a cap on noneconomic damages and has contributed to a 
significant lowering of costs would be preempted because the Mitchell 
bill does not include a similar provision of a cap. The Federal 
Government should not be paternalistic in this realm. Some States, like 
mine, are years ahead in their reform efforts.
  So you ask, what about the States that are not as progressive as 
Oregon? How do we get them to do the right thing?
  I believe we must set minimum Federal standards and then provide 
those States with guidance--not mandates--about how to reach those 
standards. We should provide incentives and credits for innovation, not 
more regulation. In all areas, our Federal system penalizes States that 
are more progressive and reduces them to the standards of the lowest 
common denominator. Our citizens expect better, they deserve better, 
and Oregonians certainly demand it.
  Madam President, I want to make it clear that I am committed to 
reforming our health care system. The concerns I have raised must be 
addressed before we pass comprehensive health care reform. This is not 
a stalling tactic. This is asking for the data and information. Let me 
digress for just a moment. I happen to have been Governor when Kerr-
Mills was first established as a precursor to the Medicare Program. 
Under Kerr-Mills, the Federal Government indicated the States should 
develop a database upon which to designate, to define, and to analyze 
the health care needs of the elderly citizens. Oregon, I am proud to 
say, was the first State out there to start the process of developing 
this database to know what the Federal role legitimately and rightfully 
should be. There were those who wanted to rush through a Medicare bill 
which came to be known as the King-Anderson bill superseding the 
progress that was established under Kerr-Mills, and they pronounced as 
the ultimate statement of costs in 25 years it would not cost more than 
$10 billion under King-Anderson.
  Madam President, in 25 years it was $65 billion, and it is going sky 
high. It is going to eat up our whole budget if we do not do something 
about cost containment.
  My point is simply this, that we can prove at the State level and if 
we had the time to develop the base I am sure we would have a finer and 
a better, more efficient Medicare system than what we are now 
experiencing. Concerns I want raised must be addressed. We cannot 
legislate in the dark, afraid to face the reality that we may not be 
able to afford unlimited health care for everyone in this country. 
However, we must assure that everyone has access to preventive and 
primary health care.
  As a Member of the Appropriations Committee, I have directly 
experienced the struggle we face to allocate funds for our complex 
array of domestic programs. This discretionary funding funds the 
operation of those all three branches of the Government. It pays for 
the roads and the bridges of our transportation infrastructure, the 
loans that go to provide public housing, student loan assistance and 
small business startup, our national parks, and many more purposes 
which have nearly universal support. These funds have been drastically 
diminishing over the years as the entitlement programs have grown. The 
programs authorized under health care reform will put further pressure 
on the Appropriations Committee to make funding decisions.
  And do not forget that the budget caps we are now under require us to 
cut discretionary spending next year by $5 billion. And as entitlement 
programs continue to grow, less and less will be available to 
discretionary programs. We are literally facing choices between running 
the Government and paying for our biggest entitlement programs--Social 
Security, Medicare, and now a new health care bill.
  I return to the premise with which I began--what kind of a legacy are 
we leaving for future generations? Because I have this in common and 
have this with many of my colleagues and I share their concern. I made 
a commitment to work with this bipartisan mainstream coalition, which 
includes Democrats and Republicans, to try to improve upon the reforms 
in the Mitchell bill.
  We are not rejected either bill. We are just saying we cannot accept 
either bill in its current form.
  I want to repeat again that I am one Senator who is willing to pay 
the bill to improve our health care system. But let us face the 
responsibility for paying for it now rather than later. We have an 
obligation to future generations to approach this issue of cost up 
front. We have all seen the illusory nature of projected savings over 
the years. This time we cannot afford to saddle future generations with 
mistaken cost estimates and glossed-over realities of the fiscal 
tradeoffs.
  We must be conscious of the costs of such a system and make a 
commitment to control these costs. If we are up here getting ready to 
adopt a new health care plan and engaging in all sorts of rhetoric, 
political and otherwise, I think we have to understand that we have an 
obligation to tell the American public precisely how it is going to be 
funded. To only dodge that issue to me represents more a fraudulent 
approach than an honest approach.
  We must make a commitment also in this or any other bill we adopt to 
funding medical research. We must assure that we make sufficient 
provisions to address the needs of our rural and underserved areas.
  It is very interesting to note that rural America was left out of the 
original proposals that were called upon to be adopted in the Congress. 
It was only after pressures from within the Congress that rural America 
was seen as having a very special problem of rural health care because 
of the gravitation of medical resources to the urban centers.
  We must enact meaningful malpractice reform. We must pass a bill that 
is less prescriptive and regulatory on State Government. And finally, 
we must encourage innovative and creative approaches to health care 
that are occurring in our States and private health care markets now. 
We are not going to write a bill in concrete. We cannot do so because 
of those changes that are occurring now, even before legislation is 
adopted. Meaningful reform is possible if we keep these goals in mind.
  I look forward to working with my colleagues to fashion a bipartisan 
solution that addresses these goals.
  We cannot afford to pass a health care bill that has 51 votes from 
one side of the aisle or 50 plus 1.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from North Dakota.
  Mr. DORGAN. Madam President, I would like to speak today about an 
amendment I intend to offer, or a couple of amendments, to the health 
care reform bill.
  I will not go on at great length. I know that others wish to speak.
  The PRESIDING OFFICER. The Chair would note that the Senator from 
North Dakota stood on his feet and his voice was heard and he was 
recognized. He was on his feet first and that is the reason the Chair 
recognized him.
  (Mr. WELLSTONE assumed the chair.)
  Mr. DORGAN. Mr. President, I would observe that I have been here 
since 12 o'clock, with the exception of about 10 minutes when I left 
the floor, and I believe I watched for about an hour and a half or an 
hour and 45 minutes on the other side and about 15 minutes on our side.
  But, nonetheless, I will be very brief.
  I want to talk about an amendment that I intend to offer with my 
colleagues--in fact, two amendments.

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