[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]

 
 STATEMENT UNDER SECTION 27 OF THE CONCURRENT RESOLUTION ON THE BUDGET

  Mr. SASSER. Mr. President, on behalf of the Committee on the Budget, 
under section 27 of the concurrent resolution on the budget, House 
Concurrent Resolution 218, I hereby submit revised budget authority and 
outlay allocations to the Senate Committee on Finance and revised 
aggregates in connection with the Daschle amendment to the Mitchell 
substitute amendment (number 2560) to S. 2351, the Health Security Act.
  Section 27 of the budget resolution states, in relevant part:

     SEC. 27. DEFICIT-NEUTRAL RESERVE FUND IN THE SENATE.

       (a) * * *
       (2) Budget authority and outlay allocations and revenue 
     aggregates.--In the Senate, budget authority and outlays may 
     be allocated to a committee (or committees) and the revenue 
     aggregates may be reduced (as provided under subsection (c)) 
     for direct-spending or receipts legislation in furtherance of 
     any of the purposes described in subsection (b)(2) within 
     that committee's jurisdiction, if, to the extent that this 
     concurrent resolution on the budget does not include the 
     costs of that legislation, the enactment of that legislation 
     will not increase (by virtue of either contemporaneous or 
     previously passed deficit reduction) the deficit in this 
     resolution for--
       (A) fiscal year 1995; or
       (B) the period of fiscal years 1995 through 1999.

                           *   *   *   *   *

       (b) * * *
       (2) Purposes under subsection (a)(2).--Budget authority and 
     outlay allocations may be revised or the revenue floor 
     reduced under subsection (a)(2) for--

                           *   *   *   *   *

       (B) to make continuing improvements in ongoing health care 
     programs, to provide for comprehensive health care reform, to 
     control health care costs, or to accomplish other health care 
     reforms;

                           *   *   *   *   *

       (c) Revised Allocations and Aggregates.--
       (1) Upon reporting.--Upon the reporting of legislation 
     pursuant to subsection (a), and again upon the submission of 
     a conference report on that legislation (if a conference 
     report is submitted), the chairman of the Committee on the 
     Budget of the Senate may submit to the Senate appropriately 
     revised allocations under sections 302(a) and 602(a) of the 
     Congressional Budget Act of 1974 and revised aggregates to 
     carry out this section.
       (2) Adjustments for amendments.--If the chairman of the 
     Committee on the Budget submits an adjustment under this 
     section for legislation in furtherance of the purpose 
     described in subsection (b)(2)(B), upon the offering of an 
     amendment to that legislation that would necessitate such a 
     submission, the chairman shall submit to the Senate 
     appropriately revised allocations under sections 302(a) and 
     602(a) of the Congressional Budget Act of 1974 and revised 
     aggregates, if the enactment of that legislation (as proposed 
     to be amended) will not increase (by virtue of either 
     contemporaneous or previously passed deficit reduction) the 
     deficit in this resolution for--
       (A) fiscal year 1995; or
       (B) the period of fiscal years 1995 through 1999.
       (d) Effect of Revised Allocations and Aggregates.--Revised 
     allocations and aggregates submitted under subsection (c) 
     shall be considered for the purposes of the Congressional 
     Budget Act of 1974 as allocations and aggregates contained in 
     this concurrent resolution on the budget.

  On August 9, 1994, I submitted an adjustment under this section for 
S. 2351, the Health Security Act. Within the meaning of section 
27(c)(2) of the budget resolution, the Health Security Act constitutes 
``legislation in furtherance of the purpose described in subsection 
(b)(2)(B).''
  The Daschle amendment to the Health Security Act also meets the other 
requirement of section 27(c)(2) of the budget resolution that

     the enactment of that legislation (as proposed to be amended) 
     will not increase (by virtue of either contemporaneous or 
     previously passed deficit reduction) the deficit in this 
     resolution for--
       (A) fiscal year 1995; or
       (B) the period of fiscal years 1995 through 1999.
  As the Daschle amendment to the Health Security Act complies with the 
conditions set forth in the budget resolution, under the authority of 
section 27(c)(2) of the budget resolution, I hereby submit to the 
Senate appropriately revised budget authority and outlay allocations 
under sections 302(a) and 602(a) and revised aggregates to carry out 
this subsection.
  Note that, as this reserve fund submission accommodates an amendment, 
it covers the time that the amendment is either pending or adopted (if 
the amendment is adopted). If the Senate rejects the amendment, this 
reserve fund submission shall lapse, and the allocations and aggregates 
shall revert to the levels they would have in the absence of this 
reserve fund submission.
  There being no objection, the tables were ordered to be printed in 
the Record, as follows:

RESERVE FUND FILING PURSUANT TO SECTION 27 OF THE CONCURRENT RESOLUTION ON THE BUDGET FOR FY 1995--DASCHLE RURAL
                                                   AMENDMENTS                                                   
                        [Adjustments to aggregates and allocations; dollars in billions]                        
----------------------------------------------------------------------------------------------------------------
                     Aggregate totals                         1995       1996       1997       1998       1999  
----------------------------------------------------------------------------------------------------------------
Budget authority.........................................     $0.000     $0.125     $0.165     $0.180     $0.205
Outlays..................................................      0.000      0.060      0.130      0.168      0.190
Revenues.................................................      0.000      0.060      0.130      0.168      0.190
----------------------------------------------------------------------------------------------------------------


                                                                                                                
----------------------------------------------------------------------------------------------------------------
                                                                                   1995             1995-99     
----------------------------------------------------------------------------------------------------------------
Finance Committee allocations:                                                                                  
    Budget authority......................................................             $0.000             $0.675
    Outlays...............................................................              0.000              0.548
Revenue allocations.......................................................              0.000               0548
----------------------------------------------------------------------------------------------------------------


                                AMENDMENT NO. 3: DASCHLE RURAL AMENDMENTS (NO. )                                
                                            [In billions of dollars]                                            
----------------------------------------------------------------------------------------------------------------
                                                              1995     1996     1997     1998     1999   15-year
----------------------------------------------------------------------------------------------------------------
                     MANDATORY CHANGES                                                                          
                                                                                                                
Budget authority..........................................   $0.000    0.125    0.165    0.180    0.205    0.675
Outlays...................................................    0.000    0.060    0.130    0.168    0.190    0.548
Revenues..................................................    0.000    0.000    0.000    0.000    0.000    0.000
Deficit...................................................    0.000    0.060    0.130    0.168    0.190    0.548
                                                                                                                
                      SOCIAL SECURITY                                                                           
                                                                                                                
Revenues..................................................    0.000    0.000    0.000    0.000    0.000    0.000
Outlays...................................................    0.000    0.000    0.000    0.000    0.000    0.000
Deficit...................................................    0.000    0.000    0.000    0.000    0.000    0.000
                                                                                                                
                  RESERVE FUND ADJUSTMENT                                                                       
                                                                                                                
Finance:                                                                                                        
    Budget authority......................................    0.000    0.125    0.165    0.180    0.205    0.675
    Outlays...............................................    0.000    0.060    0.130    0.168    0.190    0.548
Revenues..................................................    0.000    0.060    0.130    0.168    0.190    0.548
----------------------------------------------------------------------------------------------------------------


                                AMENDMENT NO. 3: DASCHLE RURAL AMENDMENTS (NO. )                                
                                            [In billions of dollars]                                            
----------------------------------------------------------------------------------------------------------------
                                                            2000     2001     2002     2003     2004   6-10 year
----------------------------------------------------------------------------------------------------------------
                    MANDATORY CHANGES                                                                           
                                                                                                                
Budget authority........................................    0.249    0.015    0.000    0.000    0.000      0.264
Outlays.................................................    0.223    0.132    0.034    0.002    0.000      0.391
Revenues................................................    0.000    0.000    0.000    0.000    0.000      0.000
Deficit.................................................    0.223    0.132    0.034    0.002    0.000      0.391
                                                                                                                
                     SOCIAL SECURITY                                                                            
                                                                                                                
Revenues................................................    0.000    0.000    0.000    0.000    0.000      0.000
Outlays.................................................    0.000    0.000    0.000    0.000    0.000      0.000
----------------------------------------------------------------------------------------------------------------

  Mr. REID addressed the Chair.
  The PRESIDING OFFICER. The Senator from Nevada.
  Mr. REID. Mr. President, the bill before this body that was 
introduced by the majority leader I believe provides a sound strategy 
for addressing many of the health care problems that face rural Nevada 
and rural America. Senator Mitchell's bill will guarantee a 
comprehensive set of standard benefits for all Americans. It will 
expand coverage--extremely important for rural America where there is a 
disproportionate number of underinsured people, and Medicare and 
Medicaid populations--and will channel resources to rural areas.
  The Mitchell bill also increases access to care by designating rural 
health clinics as essential community providers and in providing 
funding for enabling services like transportation, education, and 
outreach.
  The bill also provides funding for community health programs, 
increases funding for the National Health Service Corps, and encourages 
cooperative relationships among urban and rural providers.
  Mr. President, the amendments that are being offered today will build 
on the strong foundation laid by the majority leader's legislation. 
This amendment that is authored and sponsored by the Senator from North 
Dakota, and the junior Senator from West Virginia, the senior Senator 
from Montana, and the Senator from Nevada and, of course, Senator 
Harkin who just spoke so eloquently about a provision of the rural 
amendment that is certainly the wave of the future--that is, 
telemedicine, so that people in rural America can have access to the 
finest care available.

  These amendments are necessary because the health care crisis facing 
this Nation is felt every day by the millions of people across this 
country who live in rural areas, where there are few, if any, primary 
care physicians. The lack of access to qualified primary care providers 
in rural areas is a critical symptom that our current system is badly 
broken.
  Unfortunately, Mr. President, for the rural population in the State 
of Nevada, health profession shortages are a daily fact of life. Nevada 
is much different than many of the other States in the Union. Even 
though it is the seventh largest State, including Alaska and Hawaii, in 
area, it is a small State in population. I think we are 36th or 37th in 
population. But unlike many of the other counties--I hear my colleagues 
here in the Senate talk about going back to their States and visiting 
dozens of counties on a weekend. Well, you cannot do that in Nevada. 
Nevada is about 80 million acres, consisting of only 17 counties. We 
have many counties larger than States. Thirteen of these seventeen 
counties are identified as health profession shortage areas. Eleven of 
our seventeen counties are classified as frontier. What does that mean? 
It means there are six persons or fewer per square mile, and more than 
45 miles between medical service sites.
  The loneliest road in the United States has been designated to be in 
Nevada. Four of the seventeen counties are classified as rural. So we 
have, Mr. President, 11 counties that are classified as frontier and 4 
counties that are classified as rural. So we have 15 of the 17 counties 
that are sparsely populated, and most of them are very large. The only 
two counties in the State of Nevada that have large cities in them are 
the counties of Clark and Washoe. Clark County is where Las Vegas is 
located. Washoe County is where Reno is located. The rest of our 
counties are--except for Storey--large in area and sparsely populated.
  In the State of Nevada, distances between major rural towns average 
100 miles, with distances of 180 to 200 miles in more isolated areas. 
There are some people within the sound of my voice who have driven from 
Las Vegas to Reno or vice versa, and that is a long, lonely drive. But 
as long and as lonely as that is, it is still not the loneliest road in 
Nevada. We have a number of roads that are longer and more isolated 
than that area.
  As an example, Pershing County, encompassing greater than 6,000 
square miles, has only one physician and no physician assistants to 
service this population of almost 5,000 people. Recruitment efforts 
have been complicated by intense competition for the limited number of 
primary care graduates. Esmeralda and Storey Counties have no resident 
physicians. Other health professionals are also scarce. Rural acute 
care hospitals have experienced nursing vacancy rates of 17 percent.
  I have given this illustration about rural health, Mr. President, and 
especially focused on Nevada, to indicate that we do have problems in 
Nevada and in our country with rural health. But no one should think 
that rural America is only the western part of the United States. There 
are many rural communities in a State like Massachusetts. There are 
rural communities in almost every State of the Union. So this 
legislation is not select legislation for the people of the State of 
Nevada or the State of Idaho, the State of West Virginia, the State of 
Montana, or the State of Iowa.
  Mr. President, because of the unique characteristic of rural areas 
and the geographical and resource limitations faced by rural providers, 
I believe it is imperative that rural providers, consumers, and patient 
advocacy groups are represented on all of our national advisory 
committees. One of the amendments in this package, submitted as the 
rural amendment, deals with that.
  Rural health care needs are much different than those of urban areas. 
A recent study done by the National Rural Electric Cooperative shows 
that although both urban and rural residents average 7 restricted-
activity days resulting from illness, rural residents miss more days 
from major activity than those in urban areas. Rural workers experience 
more health problems at work.
  As the Senator from Iowa stated, agriculture is a very dangerous 
occupation. But, also, in Nevada we know how dangerous mining is. It is 
not as dangerous as it used to be because there is limited underground 
mining in Nevada. In the State of South Dakota, though, there is a very 
deep underground mine, and that is very dangerous. Agriculture and 
mining are America's most dangerous occupations and, of course, they 
are done in rural areas. Rural residents are also more likely to lack 
health care coverage than their urban counterparts. These differences 
should be understood and taken into account when developing policy 
recommendations and implementing quality standards.
  Part of this package that was written by the Senator from Nevada 
deals with this. That is, when we develop health plan and policy 
recommendations and implement quality standards, there should be some 
input from rural America. That is what my part of the amendment deals 
with.
  This amendment would require at least two rural representatives, one 
representing rural physicians and health care providers, and one 
representing rural consumers and members of patient advocacy groups on 
the Advisory Committee on Medical Technology and the National Quality 
Council. The Advisory Committee on Medical Technology is made up of 
experts in medical technology assessment, health statistics, and 
economics, as well as representatives from the durable medical 
equipment industry, pharmaceutical industry, and the biotechnology 
industry. The advisory committee must also have representation from 
consumers, members of patient advocacy groups, and health 
professionals, two of which must be from rural areas. This committee 
will assist in preparing a study of the impact of medical technology 
and treating disease.
  Certainly rural America should be involved in this. The use of 
medical technology in treating disease and injury is especially 
important to rural areas. As an example, defibrillators are rarely used 
in urban areas. Why? Because they can get them to an acute care 
facility, emergency room, so quickly. But in rural America, our 
emergency medical technologists must know how to use defibrillators. 
Why? Because it takes them a long time to get the patient to an 
emergency room. So this is just one example of why we need input from 
rural America.
  Rural input on the advisory committee would ensure appropriate 
consideration of the accessibility, impact, and use of medical 
technology in rural areas. The National Quality Council, consisting of 
15 members, 2 of which must be from a rural area, will oversee a 
national program of quality management and improvement designed to 
enhance access and quality of care. The council is made up of 
individuals representing consumers, insurers, States, and health care 
providers. Many of the quality components in Senator Mitchell's health 
care proposal are private, nonprofit-based programs.
  Again, I repeat, the programs generally speaking, in Senator 
Mitchell's legislation, do not create Government bureaus, agencies, but 
rather they are, generally speaking, private, nonprofit, State-based 
programs, a design that will streamline quality measures, and because 
of its local nature, will benefit from rural input on quality issues 
facing rural America.
  This rural package of amendments will also place at least one rural 
representative on the 7-member National Health Care and Coverage 
Commission.
  Rural America must be actively involved in the delivery of health 
care services assessing the role of medical technology and ensuring 
health care and recommendations regarding coverage and health care 
costs. The perspective of rural America is necessary to guarantee 
quality and affordable care to rural residents.
  Let me say one more time the Mitchell bill does work to get rid of 
Government agencies and activities. I do not want to get into a debate 
at this time over comparing Mitchell's rural proposals and the Dole 
rural proposals. If anyone cares to enter into that debate, I will be 
happy to participate in that because clearly the Mitchell bill favors 
rural America as compared to the Dole bill.
  In addition to that, while we are talking about boards and 
commissions, if you compare, as I would be happy to do it at some 
subsequent time, if someone cares to do so, if you want to compare the 
commissions and boards established in the Mitchell proposal, you will 
find that he has done a great deal to eliminate bureaucratic red tape.
  But this is not the time to debate that. Perhaps one of the most 
important amendments in this package that I would comment on in 
addition to that that I talked about rural representation on boards and 
commissions is the one which provides full funding for the National 
Health Service Corps.
  As I stated, there are two Nevada counties with no resident 
physicians and one county with only one physician for its residents 
spanning 6,000 miles. Recruitment efforts have been extremely 
difficult. Currently Nevada has 11 National Health Service Corps 
participants providing health care services to rural residents. They 
are essential. They are very important. They are imperative.
  Fully funding the National Health Service Corps will greatly increase 
the availability of primary care health care providers to the 
underserved areas in my State and across this country.
  In closing, let me say that rural health care delivery in America is 
important. There are 7.7 million rural Americans who now lack basic 
health insurance. Fourteen percent of rural residents are without 
health insurance at some point during the year. Almost 27 percent of 
the rural uninsured are children. Thirty-two percent of the non-elderly 
rural uninsured have family incomes below the poverty level.
  We can make a case as to why we must reform our health care delivery 
system simply for rural Americans. If we came to this body and said we 
want to reform health care only for rural Americans, I think it would 
and should pass overwhelmingly. But we are coming with a package that 
not only takes care of rural Americans but urban Americans as well, and 
the amendment that we have submitted, Mr. President, will improve 
greatly the Mitchell bill as it relates to rural America.
  The PRESIDING OFFICER. The Senator from Iowa.
  Mr. GRASSLEY. Mr. President, I want to speak on the pending amendment 
and the subject of rural health care which relates to the entire issue 
of the Mitchell bill.
  Mr. President, on the subject of the pending amendment I have not had 
a chance to study it all in great detail, but large portions of it are 
provisions that have been worked on by the Rural Health Caucus over a 
long period of time and are in fact very necessary to make sure that 
rural areas are treated fairly. in any massive reorganization of health 
care reform that we could pass yet this year.
  However, I think we ought to consider why we have to give some 
special consideration to rural America in almost any bill that we pass. 
I do not care whether it is a Republican bill or a Democrat bill or a 
bipartisan bill, any massive reorganization of health care in America 
that is proposed by the most comprehensive bill, including President 
Clinton's own bill, ought to raise a red flag for people in rural 
America.
  The reason is, very simply, without change of the health care 
delivery system in America, there are problems of the quantity and 
quality of the delivery of health care in rural America. There is 
already a problem. OK, maybe you would think, well, if you are passing 
a comprehensive bill, you are going to solve these problems.
  There is too much in a comprehensive approach of health care reform 
that fits into the ``one size fits all'' pattern of things that we 
attempt to do in Washington, DC, I think, not only by some of the 
things we have done in past Congresses that have had a negative impact 
on the delivery of health care in rural America, and one of those is 
putting restrictions on Medicare reimbursement--that has had a very 
negative impact on rural America--but also if you look at national 
schemes in other countries, you find in these countries, as you have 
seen in some of the slight things we have done in rural America on 
Medicare and the impact on rural America, that rural areas of these 
countries come up short.
  And so, I think a long time ago, when we first started talking about 
comprehensive reforms, even in 1992, as we were working, some of us 
Republicans were meeting every other Thursday morning for breakfast to 
work on what eventually became the Chafee bill and what we were hoping 
to get President Bush interested in doing, we felt that we had to have 
some special considerations for rural America.
  Mr. REID. Will the Senator from Iowa yield for a question?
  Mr. GRASSLEY. Mr. President, I would be glad to yield for a question.
  Mr. REID. Mr. President, I say to my friend from Iowa, I have 
listened to the few minutes he has spoken. I think it is important 
that, on this issue alone we do not talk about the underlying bill, but 
on the issue of rural health care. It is something that those us of who 
represent States that have rural populations should recognize. During 
the last 10 years we have had 330 hospitals in rural America that have 
gone out of business.
  Is the Senator aware of those figures like that that are prevailing?
  Mr. GRASSLEY. Mr. President, I believe that the Senator from Nevada 
is making a case with statistics that I am prepared to agree with and 
make as well.
  As I was saying, it is it is a situation in rural areas of any 
country that have adopted national plans. I can show you a newspaper 
article I have here that, within the last 10 months, there was a major 
reorganization of health care in Saskatchewan because of the limit on 
funds that were available, that they just closed 52 hospitals in one 
move, one decision by the Health Minister of Saskatchewan.
  Mr. REID. Will the Senator yield for one further question?
  Mr. GRASSLEY. Yes.
  Mr. REID. I believe, as the Senator's statement indicated, one of the 
reasons we had 330 rural hospitals closing between 1980 and 1990 is how 
we have handled Medicare. The fact of the matter is that hospitals have 
not been reimbursed properly. They have gotten less for doing the same 
procedure in a rural hospital. They are given less money than if it 
were done in an urban hospital, and it should be just reversed.
  So I really very much appreciate the Senator's statement. I think, if 
the Senator looks closely at our amendments, that consists of this one 
amendment, he will find significant information in the amendment that 
came from the work that he and some of the others have done on the 
rural health care caucus.
  So, through the Chair, to the Senator from Iowa, I express my 
appreciation for the statement and the work that he has done in the 
years gone by in rural health, and I look forward to working with him 
on this issue. I think the importance of this issue to a lot of us is 
evident in the fact that this is one of the first amendments we brought 
up to make sure that rural health is taken care of if, in fact, we do 
major legislation dealing with health care.
  (Mr. CAMPBELL assumed the chair.)
  Mr. GRASSLEY. I do not disagree with anything the Senator from Nevada 
has stated. I think, for the most part, as we have read the outline--we 
have not studied the language of the amendment yet--that most of what 
is in there we would agree with.
  I was hoping to set the stage for the fact that when you have massive 
reorganization of health care, as is evidenced by this 1,400-page bill 
that we have before us, you do, in fact, have to commit yourself to 
taking very special care for rural America or, with that massive 
reorganization of health care, we are going to come up further short 
than rural America already is when it comes to the delivery of health 
care in rural America, both from a quantity and quality standpoint.
  I referred to the situation in Canada where, because of lack of money 
and reorganization, they found it necessary to close 52 rural 
hospitals. It is a situation you get into when you have a potential for 
limiting the amount of money that is going to be spent on health care 
in America.
  Even though there is not in this bill before us, as there was in 
President Clinton's bill, proposals for global budgeting and premium 
caps, there are some things in the bill, like the 25 percent assessment 
on high cost plans, which are going to eventually work like premium 
caps and which are eventually going to lead us to a point where there 
is going to be limits on what can be spent and plans are going to have 
to live within those limits.
  And those plans are going to lead to some rationing. And the impact 
of that rationing is going to be much more seriously impacted in rural 
America than in urban America. I think that is what we want to take 
into consideration.
  I have a letter that I want to refer to about the impact of some of 
these bills and the bill before us on rural America.
  And, the letter says:
       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-factor' Mandatory Alliance.
       But there are other rural concerns that required 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, base 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 areas.
       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.

  Mr. President, I am not going to read the 150-some organizations from 
rural America who have signed this letter. I ask unanimous consent to 
have the letter printed in the Record at this point.
  There being no objection, the letter was ordered to be printed in the 
Record, as follows:

                                                  August 12, 1994.
     Hon. Charles Grassley,
     U.S. Senate, Hart Senate Office Building, 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 areas.
       Cost-shifting. It cuts into projected Medicare 
     expenditures, which will hurt many rural hospitals, and 
     because it shifts billions in Medical 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 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 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 
     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 of 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; and the 
     National Council of Agricultural Employers.
       National Council of Farmer 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; and the 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; and the 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; and the 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 SweetPotato Commission; North Dakota Grain Growers 
     Association; North Dakota Stockmen; Ohio Contract Poultry 
     Growers Association; Oklahoma Contract Poultry Growers 
     Association; and the 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; and the 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; 
     and the 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; and the 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; and the Yakima Valley Growers-Shippers Association.

  Mr. GRASSLEY. The letter was initiated by the Farm Bureau but signed 
by 150 organizations.
  I will yield the floor in just a minute. But the purpose of reading 
from that letter is, under a massive 1,400-page bill like this, making 
these changes, I am asking our colleagues to be cognizant that we 
already have problems in rural America under the status quo. If we make 
the massive changes like those in this 1,400-page bill we are going to 
have terrible consequences for the delivery of health care in rural 
America. The Daschle amendment legitimately is taking care of a lot of 
those problems. But the point I want to make is, and it is not the 
intention of Senator Mitchell or any of the people working closely with 
him, but it is just a fact of life--when you have a massive rewrite of 
legislation like this, some of the good you want to accomplish for the 
Nation as a whole has negative consequences in rural America. I do not 
think that the things that are in the Daschle amendment and other 
amendments that will be offered for rural America are going to make up 
the difference.
  We want to be prepared, to make sure that we take care of those. I 
hope we have, in the process, corrected some of those things that are 
in the original Mitchell bill, the underlying piece of legislation, so 
those negative impacts will not exist for rural America.
  Tomorrow on this side of the aisle we look forward to considerable 
discussion. Many of my colleagues want to speak on the impact of this 
legislation on rural America. I do not think too many of my colleagues 
will disagree with what Senator Daschle is trying to accomplish in his 
amendment. But we want to go through some provisions in the underlying 
legislation to point out where we feel that it has a very negative 
impact upon the delivery of health care in rural America.
  One of those would be what Senator Harkin has already mentioned. 
Self-employed people, farmers, et cetera, are not going to have equity 
under this legislation. We have to have 100 percent tax deductibility 
for the self-employed.
  The impact of Medicare cuts is further going to increase the number 
of rural hospitals going out business, above the 330 that Senator Reid 
just recently referred to. There are other things in this underlying 
legislation that is negative to rural America.
  So I yield the floor and look forward to the debate tomorrow.
  Mr. BINGAMAN. Mr. President, I rise in support of the amendment 
pending before the Senate. I worked with my distinguished colleagues 
from the Senate Finance Committee, Senators Daschle, Rockefeller, 
Baucus, and my distinguished colleague on the Labor and Human Resources 
Committee, Senator Harkin on this package, and I am pleased that we are 
discussing health care in rural America tonight.
  This package of amendments is straightforward, aimed at helping to 
develop a health care infrastructure and improve the health care 
delivery system in our five States--New Mexico, South Dakota, West 
Virginia, Montana, and Iowa--and throughout rural America. I urge my 
colleagues to support this package.
  Mr. President, there are many features of the majority leader's bill 
that would significantly improve the standard of health care for rural 
Americans. We have moved closer to really taking seriously the health 
needs of farmers, ranchers, small business owners, their families, and 
their employees. This is an important accomplishment.


                I. RURAL FEATURES OF HEALTH REFORM BILL

  The majority leaders's bill will, contrary to some assertions, make 
it easier for all small businesses to buy health insurance, whether 
those businesses are located in the inner city of Chicago or the rural 
towns of Mora County, NM.


                       A. INSURANCE REFORM RULES

  This is because the proposal limits the ability of insurance 
companies to discriminate against Americans with preexisting 
conditions. Many small businesses in rural areas would be protected 
from escalating costs and arbitrary charges.


                  B. WORK FORCE: MORE RURAL PROVIDERS

  The bill will increase the number of primary health care providers, 
which will significantly ease burdens on doctors, nurse practitioners 
and other health care providers in States like New Mexico. By 
increasing the number of health care providers nationally, the bill 
will make health care for rural Americans more accessible and more 
affordable.
  Last week, Senator Baucus told us that urban America has 2\1/2\ times 
as many doctors per 100,000 people as rural areas. By offering tax 
credits to doctors and other providers who practice in rural areas, we 
can ensure both continuing excellence in specialty care and improved 
access to primary care.


                            c. telemedicine

  The bill before us today also provides grants for telemedicine, or 
high-technology networks between rural health care providers and 
specialists. Many believe these cutting-edge programs are among the 
most efficient and promising developments in rural medicine.


                      d. community health advisers

  I am particularly pleased that the majority leader's bill contains a 
provision I authored in the Labor and Human Resources Committee health 
reform bill. This provision authorizes a new community health adviser 
program as part of the Public Health Service's priority National 
Initiatives on Health Promotion and Disease Prevention.
  Through this initiative, the Public Health Service will assist 
States, local governments, and nonprofit organizations in establishing 
and maintaining vital community health adviser programs.
  The advisers are specially trained local community residents who 
deliver preventive health information to their communities, in homes 
and larger groups. They help encourage access to critical primary and 
preventive care; in particular, this program would be aimed at helping 
to achieve the Healthy People 2000 goals. These programs can play an 
important role in reducing overall health care costs.
  Community health advisers and the provision in Senator Mitchell's 
bill are widely supported by public and women's health organizations, 
including the American Public Health Association; Children's Defense 
Fund; the National Breast Cancer Coalition; the New Mexico Public 
Health Association; the National Women's Health Network; and dozens of 
other national organizations.


                e. assistant secretary for rural health

  Finally, this bill takes a step toward acknowledging the health care 
needs of rural Americans by creating a permanent position of Assistant 
Secretary for Rural Health within the Department of Health and Human 
Services.


                           ii. two amendments

  Mr. President, the majority leader's bill is a beginning to improved 
rural health. But there are also some real opportunities to strengthen 
this legislation and make it even more responsive to the needs of rural 
Americans. I would like to briefly describe two of the provisions 
contained in the amendment pending before the Senate.


                      b. rural residents on boards

  First, we believe it is critical that rural residents be included on 
any board or commission authorized under this bill. Rural residents, 
rather than rural experts or rural representatives must be specifically 
included in all board membership lists to ensure that rural people 
assume a fair and proper role in all issues of governance.


                        c. rural frontier areas

  Second, we need to make sure that in the very definition of 
``rural,'' we do not exclude the people who most depend on us. A 
provision of title IV (section 4111(d)(2)(B)(i)) gives States the 
authority to designate medical assistance facilities in frontier areas.
  Under the current criteria of this section, States can only designate 
these special facilities if the entire county has fewer than six 
residents per square mile. This disadvantages Western States.
  Many of our counties are larger than some States in the east. In 
addition, they encompass both urban and very remote areas. As the bill 
stands, these counties would be disqualified even though many of their 
residents live in areas far more remote than eastern rural counties.
  We propose that an equivalent unit of local government or subcounty 
unit designated by the Governor or chief officer of the State be an 
acceptable criterion for designating the medical assistance facilities.
  Only by making this change can we actually conform to the true intent 
of the provision: To improve medical services in rural America.
  Mr. President, these are all vital provisions. They are essential to 
building the health care infrastructure and networks that are 
desperately needed in rural America. I urge my colleagues to support 
this package of amendments and to continue to work with us to improve 
the quality of life for all of our rural constituents.


                           health care reform

  Mr. HATCH. Mr. President, both yesterday and today, our colleague 
from North Dakota, Senator Dorgan, spoke in this Chamber about 
spiraling medical costs in the hospital and drug sectors. He pointed to 
specific drugs and compared the prices of those drugs in other 
countries with their prices here.
  He did not mention that all of those drugs have cheaper, generic 
counterparts. Nor did he mention that Congress specifically passed 
legislation--legislation that I sponsored--to accelerate the entry of 
generic drugs to the market as a cost-saving alternative to branded 
drugs.
  I think it would be useful for my colleagues to look at some relevant 
facts, starting with the latest figures from the Bureau of Labor 
Statistics [BLS].
  According to the BLS, drug prices, at the producer level, rose 2.8 
percent during the 12-month period that ended in July 1994. That 
increase can hardly be characterized as skyrocketing. If NASA's rockets 
rose at that rate, we would have never reached the Moon.
  In fact, this 2.8-percent increase is a new low, the lowest in 20 
years. That is a trend this Congress should encourage, not discourage.
  Drug prices have fallen steadily since 1989, when the rate of 
increase was 9.5 percent. I simply do not think this could be 
characterized as relentless inflation. On the contrary, I think it 
shows that drug inflation is under control.
  And this is a very important point. Because it is the result not of 
anything the Government has done, but because the market is working.
  In a June 1994 report, ``How Health Care Reform Affects 
Pharmaceutical Research and Development,'' the Congressional Budget 
Office stated:

       The market is changing. On the supply side, sales of 
     generic drugs are increasing. On the demand side, buyers 
     exercise more market power to reduce the profits of the 
     pharmaceutical companies. * * * in view of the increasing 
     competition within the pharmaceutical market, drug prices 
     could easily decrease regardless of the Administration's 
     proposal.

  This competition--which some of my colleagues seem to ignore--is also 
controlling the introductory prices of new drugs. The Boston Consulting 
Group looked at the prices of new drugs approved and launched during 
1991 and 1992 and found they were, on average, 14 percent lower than 
the market leader in their category.
  I recently saw a cartoon in the Wall Street Journal. It showed a 
receptionist telling a visitor: ``Can you come back tomorrow? Mr. 
Ferguson is in deep denial today.''
  I think some of my colleagues must be in deep denial, Mr. President.
  Marketplace reform is for real.
  The figures show it.
  The experts confirm it.
  Instead of denying this competition, as I have said, I think we ought 
to encourage it.
  Nor can we deny the fact that there are people, especially among the 
elderly, who are forced to make desperate choices between medicine and 
other necessities.
  There are the people we need to help, the elderly poor, not 
millionaires and billionaires who would be eligible for the new 
Medicare drug benefit in the Mitchell bill.
  No matter how much Congress tries to regulate drug prices, there will 
be some patients who cannot afford them. And the more we talk about 
artificially controlling prices, the more we hurt drug research. Seven 
out of 10 drugs lose money for the manufacturer.
  What we should be doing is targeting efforts on those who need 
assistance. Then, we can help those who need help the most, and we can 
do it without hurting drug research and without discouraging the market 
forces which are working.
  The PRESIDING OFFICER. The Senator from West Virginia [Mr. 
Rockefeller] is recognized.
  Mr. ROCKEFELLER. Mr. President, I want to echo the concerns of 
Senator Reid, the Senator from Nevada, about what the Senator from Iowa 
said. I have always thought of the Senator from Iowa as being sort of a 
quintessential westerner in the farm sense, and I have told him so. So 
that is not unnecessary flattery. He is very independent. It is my 
understanding that Senators from Iowa do not usually get reelected to 
second terms but this Senator has, Senator Grassley. I think it is 
because he has an independent streak. I think when he feels about 
something deeply, as he does about rural health care and rural matters, 
it comes through. I think it comes through partly because if you shake 
his hand it is usually pretty rough, because he owns a farm. His son 
runs it for him but he is there to help on weekends if it is needed.
  So this Senator, the junior Senator from West Virginia--very junior 
Senator from West Virginia--wanted to add his praise of the remarks the 
Senator from Iowa has made.
  Mr. DASCHLE. Will the Senator yield?
  Mr. ROCKEFELLER. Of course.
  Mr. DASCHLE. I appreciate very much the comments made by the 
distinguished Senator from Iowa. I have had the good fortune to work 
with him on both Agriculture and Finance. He and I had the opportunity 
to work with the distinguished Senator from West Virginia on rural 
health issues during the ongoing consideration of health in general 
over the last several months.
  As is always the case, he is an extraordinary student of the issues 
relating to rural health and is a tremendous partner. I associate 
myself with the remarks made by the distinguished Senator from West 
Virginia. He is absolutely correct, he has been someone that I hope we 
can continue to work with on many of these issues mutually.
  I thank the Senator for yielding.
  Mr. ROCKEFELLER. I thank my friend from South Dakota.
  Mr. President, I rise with a great deal of passion, interest, and 
fervor and good feeling because we are discussing something which I 
think is at the core of what we need to do, and that is to try to be 
helpful to rural America--which the distinguished Presiding Officer 
also represents--in any way we can in terms of health care. My 
colleague Senator Daschle, Senator Baucus, Senator Reid, and Senator 
Harkin and I have offered a number of amendments that I think are very 
important.
  It is late in the evening. Not many people are here, but that does 
not make any difference because our work here is significant.
  From this Senator's point of view, Mr. President, Senator Mitchell's 
bill already offers substantial hope for rural America. It contains 
important provisions to make very sure that the promise of health care 
is more than just an empty promise. That is very much on the minds of 
people who live in rural parts of this country.
  Nationally, 25 percent of all Americans live in a rural area. In West 
Virginia, that figure is 64 percent. We are 77 percent forest, so the 
fact we are 64 percent rural should not be surprising. In addition, all 
or part of 43 of our 55 counties in West Virginia are designated as 
``medically underserved''--a seriously bad designation.
  I should say, Mr. President, that my senior colleague, Senator Byrd, 
is not a fan of charts and neither is his junior colleague. In the 
nearly 10 years that this Senator has been in the Senate, I have never 
used a chart or a graphic entity on the floor of the Senate because I 
do not have a good feeling about them. But on this matter of rural 
health care in America, I feel strongly enough that I have broken my 
habit this one time, hopefully.
  One can see very easily, if I simply describe that all of the yellow 
that one sees on this map are areas that have enough doctors and all of 
the red, which is obviously the great majority of the map, are areas 
that do not have enough doctors. I will explain more of what I mean by 
enough doctors. These are basically underserved areas.
  Senator Mitchell comes from Maine. There is just a very small, little 
area here. Look at California. People think of California always as 
being--I do--as being urban with sort of rural intervals. Of course, 
that is not true and this proves it. Ninety percent of California is 
underserved.
  Look at Arizona, almost entirely, 95 percent underserved; New Mexico, 
98 percent underserved. My own State is right here. You can see there 
are just very few areas which are yellow which means that they are 
adequately served medically. Look down to Florida. I would have thought 
Florida would be substantially served for many reasons--its climate, 
its population, its way of life. But entirely to the contrary. It is 
hurting medically in terms of health care professionals and 
opportunities to get health care.
  Indeed, if you look at North Dakota, South Dakota, more toward the 
west than toward the east, but then look at Louisiana, it is really 
quite distressing; Mississippi; Hawaii, even with its universal health 
care plan, has substantial service problems. So they must be doing a 
remarkable job to overcome that.
  This map leads me to want to know more. I find this a distressing 
map. All the red--is not enough health care. It is the great majority 
of our country and it also describes, I think, that a lot of our 
country is rural. It certainly describes that my State of West Virginia 
is not alone.
  More than half a million Americans live in a county, Mr. President, 
that does not have a single doctor, and 34 million Americans live in 
areas with a thoroughly insufficient supply of physicians, or other 
health care providers. That all adds up to a situation that makes it 
extremely difficult for the rural areas, which the Presiding Officer, 
myself, the Senator from South Dakota, and others represent, to get 
health care in any form, much less when they need it and where they 
need it.
  Less access to primary and preventive care means more costly and 
serious illness that have to be treated later. I will give you an 
example in my own case.
  My wife and I and our four children have a farm right on the West 
Virginia border in the Allegheny Mountains in a beautiful county called 
Pocahontas County.
  And in the northern part of the county, we had, I can remember, a 
number of years ago when our children were still young a Dr. and Dr. 
Jones, a couple. They were two wonderful young physicians who graduated 
from West Virginia University and decided to come and live in that 
extremely rural area. The county where we live is one of the largest 
counties east of the Mississippi, Mr. President, and has only 6,000 
people, which, of course, my family and I love because of the solitude 
and the beauty of the West Virginia hills.
  But Dr. and Dr. Jones, husband and wife, came there with the full 
idealism, the full expectation of being able to make it. They both were 
family physicians. They both happened to love railroads, and we have 
some old logging railroads that still exist from earlier days. I 
suspect they do in the Presiding Officer's State also.
  They made the best of it for about 3 or 4 years, but then they just 
could not hang on, could not get the payments, could not meet their own 
bills, and they were forced to leave. So there we are with a building 
and with a doctor who visits from time to time and, basically, without 
health care in an enormous county, which in itself is a vast area of 
wilderness.
  Most of us realize that an insurance card is, in fact, meaningless 
unless there are doctors and hospitals and nurses and physician 
assistants who are actually available in an area to provide health care 
services. They have to be there or be close by. People understand that.
  In many parts of West Virginia, access to health care is simply 
wishful thinking. The problems of rural health residents in buying 
insurance are similar to the problems of small business owners, because 
so many of them are self-employed or employees of very small firms or, 
in many cases, not employed at all.
  Rural Americans generally have to pay insurance premiums that are 
higher than nonrural Americans because they are buying small-group or 
individual policies which are generally 35 to 40 percent more expensive 
than what larger companies can pay for the same product.
  It is not fair. It is part of what is wrong with our health insurance 
system. But it is a fact in rural America.
  Rural families are subject to the most abusive kinds of insurance 
underwriting practices because they are purchasers of small-group 
insurance policies.
  What I mean by that basically is that they are more or less helpless 
as they face the insurance company. Many rural residents are not 
familiar with terms like ``lifetime limits,'' ``preexisting 
condition.'' I would think that many rural residents, as many urban 
residents, would not know that if you are a young woman, get married 
and get pregnant and you do not have health insurance, you cannot buy 
health insurance. By the act of becoming pregnant, being pregnant, that 
itself constitutes a preexisting condition, and therefore you cannot 
get health insurance.
  Most people do not know that. Rural people are more likely to be 
subject to that kind of underwriting practice. They wind up having 
their policies canceled the minute that they or a family member has a 
serious medical condition. Most of them do not know that that is going 
to happen because they would tend to trust the insurance policy, 
because in America, if something is institutional, you tend to trust 
it.
  Well, sometimes that trust is not well placed. So a family member has 
a serious medical condition. No more health insurance. Or they might 
get to keep the health insurance but their premiums would rise very 
sharply in order for them to keep health insurance. Just because they 
are farmers. Just because they are loggers. Just because they are coal 
miners. Just because they are older, or just because they have 
something called a preexisting condition. And thus it is in rural 
America.
  Rural residents will gain significant health benefits under Majority 
Leader Mitchell's bill because they are so disadvantaged under the 
current system. Very stringent insurance reforms; the availability of 
purchasing cooperatives--something which is understood by farming 
families--the targeted subsidies to purchase private health insurance, 
all of these are ways that the majority leader's bill will 
substantially benefit rural Americans. I am very happy about that, and 
I am very excited about that. That is important and significant news.
  Before describing the exact provisions that I have worked on and 
authored in this amendment, I would like to just take a moment to 
emphasize that while an insurance card alone does not guarantee the 
actual delivery of health services, it is one of the single, most 
important things that we can do to try to encourage doctors and other 
health providers to move to a rural and underserved area, because if a 
physician or other provider understands that people have insurance, 
they are going to understand that they are going to be reimbursed, that 
life financially is going to be different.
  The proportion of people without insurance is higher in rural areas 
than in urban areas. Without a stable source of reimbursement that can 
only come with an insurance card, many doctors and nurse practitioners 
and physicians' assistants and others cannot sustain a viable practice 
in a rural area. My example of Dr. Jones and Dr. Jones that I talked 
about a moment ago applies here. If the vast majority of their patients 
are uninsured, a health practice is simply not sustainable--a fact of 
life, and a very painful one in rural America.
  Mr. President, the amendment we are offering, and that the 
distinguished Senator from South Dakota, Tom Daschle, is leading, 
offers several important provisions to make health care a reality for 
millions of Americans across this country. So I want to take a moment 
to describe a couple of these provisions.
  Especially important to me is the provision to provide improved 
funding for the National Health Services Corps. This is something about 
which I care deeply. VISTA, which is similar to the National Health 
Service Corps, changed my whole life. I did in social work what 
physicians and other providers will be doing in the National Health 
Service Corps. I know that if you get a young American in their mid 
twenties studying medicine, or in my case trying to learn more about 
their country and having the rudiments of social work in my head, when 
those folks get to the rural places or to the urban places, inner-city 
areas, they are going to be challenged. They will see things that they 
have never seen before. They are going to understand the importance of 
their presence to the people in that area.
  When I went to West Virginia as a VISTA volunteer, I had no intention 
of staying in West Virginia as a VISTA volunteer because all of my 
training had been in Japan and China and Asian affairs. I had worked in 
the Peace Corps and State Department and had lived in Japan for a 
number of years. VISTA just turned my life upside down because it put 
me in contact with real people in rural areas where there were real 
needs and where I thought I could make a real difference.
  If you are young and in your mid twenties or mid thirties and your 
life is before you, this is exciting. It is extremely exciting. So 
under this amendment, we will move towards restoring pre-1980 award 
levels in the National Health Service Corps. At that time 3,000 to 
7,000 scholarship awards were made on an annual basis. So imagine that, 
physicians, in return for payment of part of their medical school 
years, spreading out, 3,000 to 7,000, all across America in rural and 
inner-city areas.
  A very good friend of mine did that in eastern Kentucky, and it 
changed his life. It just totally changed his life. Eastern Kentucky is 
like southern West Virginia. He went there, practiced medicine there, 
fell in love with the place, with the opportunity, could not leave and 
has had a remarkable career--a fellow named Harvey Sloan.
  The amendment Senator Daschle and I have proposed would provide 
sufficient funding to place at least one doctor, nurse practitioner, or 
physician assistant in every single county in America that is currently 
designated a shortage area. In every one of those red areas, in every 
county in California, in every county in North Dakota, South Dakota, 
Montana, Wyoming, in every one of them, there would at least be one 
health care provider. That seems to me very reasonable, a very exciting 
prospect. And it can be done and is done under the amendment that 
Senator Daschle, myself, and others are offering.
  Now, last year, Mr. President, there were 2,492 primary care shortage 
areas.
  That is a big chunk of this country. A health professional shortage 
area is an area that does not have at least 1 primary care provider for 
every 3,500 residents. That is what is reflected on this map; there is 
not 1 physician or nurse practitioner or physician's assistant or other 
health provider for every 3,500 residents. That is pretty slim 
coverage.
  If we want to do the ideal--which, of course, I would--but we cannot 
because of the finances, the ideal percentage is 1 doctor for every 
2,000 people. That is what it ought to be. That is what this country 
ought to have. We do not. It is a mystery that we do not. We continue 
not to. But, nevertheless, that is the fact.
  The National Health Service Corps Program has been extremely 
successful in providing essential services in remote areas, which are 
very familiar to the Presiding Officer, and rural areas, and, again let 
me repeat, in inner cities.
  I am a member of the board of the Children's Health Fund. It was 
started actually in New York City by a wonderful pediatrician, a 
physician by the name of Dr. Irwin Redliner. The Children's Health 
Fund's purpose is to put pediatricians in areas of the country where 
they are not.
  So in New York City, which is surrounded within 10 blocks by doctors 
of every variety, there is an enormous shortage of physicians, a 
shortage in New York City, not to speak of upstate New York.
  The National Health Service Corps would place health care providers 
in rural areas and in the inner-city areas. It is so popular as a 
concept, and well thought of, in fact, that Senator Dole and Senator 
Packwood in their summary also list a provision to fully fund the 
National Health Service Corps Program. That is what we intend to do. 
That is what they said they intend to do.
  A total, Mr. President, of 43.5 million people in America live in 
medically underserved areas. Last year, the National Health Service 
Corps had only 1,200 providers in the field providing care to only 
about 1.2 million of those 43.5 million people who need their help. So 
you can see the disparity between availability and need.
  The corps received over 4,000 applications last year, Mr. President, 
to fill awards for 406 slots. So do not tell me that medical students 
are not ready to do that, that idealism is dead in America.
  This demonstrates the tremendous interest by medical students, by 
nursing students, by physician's assistants to have their training paid 
for in return for making a commitment to practice in an underserved 
area, urban or rural, after completing their training. I cannot think 
of a better deal for those young students, and for America.
  For many students, especially minority students, and low-income 
students, this is the only way that they can afford to go to medical 
school or to go to nursing school--a major factor to bear in mind.
  I constantly get calls from West Virginia clinics and hospitals who 
are desperate to find a physician or other health care provider. In 
1986, Mr. President, 26 corps doctors were placed in West Virginia. 
That was 8 years ago. In 1987, 28 came to West Virginia. In 1988, 5 
came to West Virginia. Since then, between one and three physicians or 
other providers have been placed in West Virginia on an annual basis. I 
am appalled. I am appalled at our willingness to so ignore underserved 
areas of America. Needless to say, the need for these folks has not 
declined.
  Funding in our amendment will give all underserved areas, rural and 
urban, a tremendous boost. In fact, I want to note that of the 43.5 
million people that live in designated medically underserved areas, 50 
percent are urban residents. The funding for the corps in this 
amendment will help millions of people from Appalachia, Montana, 
Colorado, South Dakota, Massachusetts, Chicago, and Los Angeles.
  Mr. President, a lifeline in many, many rural counties in West 
Virginia and rural areas across the country are something called local 
health centers, rural health centers. Some of them are designated 
federally qualified health centers. Some are rural health clinics. Some 
are just primary care clinics. While the names and the designations may 
vary, their missions are all exactly the same, and their importance is 
all exactly equal.
  I have probably visited all, certainly most, of our clinics in West 
Virginia. I am always not just impressed but in many ways overcome by 
their dedication, by their commitment--the doctors, the nurses, the 
administrators, the physician's assistants who staff these clinics. 
They are not big hospitals. They are small places. One place I am 
thinking of in a small county in West Virginia is in a grocery store 
that closed down in a shopping center. But it is comfortable. People 
are familiar with it. There it is. I am so proud of what they do. I 
cannot say that strongly enough. They are performing miracles every day 
with very meager resources and without notice from the rest of the 
world.
  The majority leader's proposal establishes several special accounts 
to help rural providers improve, expand, and reorganize themselves, to 
deliver services efficiently and to deliver them effectively.
  One account provides funding for network development and expansion 
into shortage areas, including recruitment and training, upgrading 
equipment purchasing, and as Senator Harkin mentioned, telemedicine 
systems.
  A second account provides grants and loans for capital needs. And a 
third account provides funding for supplemental or enabling services, 
such as transportation services, home visiting, case management, and 
outreach.
  Our amendment would expand the list of providers eligible to apply 
for funding from these accounts to include rural health clinics. That 
is my point.
  Under the majority leader's proposal, federally qualified health 
centers, or FQHC's, are automatically eligible for funding 
opportunities. But rural health clinics with the same mission, same 
miracles, the same people, and the same need, are not eligible, except 
if they are part of something called a consortium.
  Mr. President, I support the notion of various rural providers 
banding together to promote integration and coordination of services. 
But I do not think the participation of rural health clinics should be 
restricted.
  Under this amendment, rural health clinics would be able to qualify 
and compete for funds in each of the separate accounts, without being a 
part of a larger consortium. For profit, rural health clinics would be 
eligible to apply only for capital funding for loans. Nonprofit rural 
health clinics could compete for funding under all three separate 
accounts.
  In my own State of West Virginia, the majority of clinics and centers 
are already designated federally qualified health centers. West 
Virginia has about 38 of them, and about 14 rural health clinics. My 
point is that the rural health clinics do the same work, serve the same 
people, and have the same needs, and provide the same miracles as the 
federally qualified health centers.
  Of those 14 rural health clinics, a few are in the process of 
qualifying as a federally qualified health center. But a few are not. 
And they cannot. The reasons they are not designated federally 
qualified health clinics has nothing to do with the quality of the 
service they provide or the qualifications of the people providing 
those services. A few clinics cannot qualify because they do not meet 
the very specific criteria required of a Federal qualified health 
clinic. I am not quarreling with the criteria, but I do want to make 
sure that all essential rural providers in West Virginia have equal 
access to all of the available funding sources in Senator Mitchell's 
bill.
  For example, the Belington Community Medical Services Association, in 
Belington, WV, a very small community, often flooded, cannot qualify 
for FQHC status because one full-time physician is not a permanent 
staff member. That is part of the FQHC criteria. The Belington clinic 
is run by a physician assistant named Tom Harward, and physician 
coverage is provided on a rotating basis. That is the best they can do, 
Mr. President. And they do it well. But they do not have a permanent 
physician on staff and, therefore, the Belington clinic cannot nor will 
they ever receive FQHC status. I think you understand that is not fair.
  I do not think that fact alone should disqualify the Belington 
clinic, along with other rural health clinics across this country who 
are in a similar situation, who cannot meet the criteria for reasons 
which they cannot overcome, from applying for all available funding to 
help clinics in underserved areas.
  Tom Harward, who runs the Belington clinic, was honored several years 
ago by his professional association as the Outstanding Physician 
Assistant of the Year. At that time, Tom described his typical week. 
This is what his week is.
  He sees 20 to 30 patients a day and makes house calls 2 days a week. 
That still happens in places like West Virginia, and I expect South 
Dakota and Colorado. I, frankly, do not know when he would find the 
time to even fill out an application for new rural health funding. But 
if he can find the time, I want to make sure that he is not 
automatically disqualified because his clinic is something called a 
rural health clinic as opposed to a federally qualified health clinic.
  Another example is the Children's Health Care Clinic in Pineville, 
WV, in the southern part of the State. They cannot qualify for 
federally qualified status because they only serve children. They only 
serve children. Yes. Therefore, they do not qualify. One of the 
criteria for federally qualified status is that they must provide a 
full range of services to people of all ages, not just pediatric 
services.
  Again, we are not talking about a quality problem but rather a 
criteria issue. Children's Health Care Clinic in Pineville, WV, should 
also be able to compete for any and all funds made available under the 
majority leader's bill. I intend to fight to make sure that it happens.
  A final provision would clarify that the current set-aside for nurse 
practitioners for National Health Service Corps funding includes 
physician assistants--the same Tom Harward I have just been talking 
about. I think it was a drafting oversight. I think it was nothing more 
than that. The current National Health Service Corps program already 
includes a 10 percent set-aside for nurse practitioners, nurse 
midwives, and physician assistants. The majority leader's bill 
increases the set-aside to 20 percent, and my provision merely 
clarifies that physician assistants are included in the corps set-
aside, as they are under current law.
  So, Mr. President, Senator Mitchell's bill would go a long way to 
assure financial and physical access to health services for rural 
residents that are on my mind very much, as I speak. I see faces and I 
see families, as I speak. Our amendment--mine, Senator Daschle's, and 
others'--builds on some very important improvements that the majority 
leader already proposed. Taken altogether, I believe rural residents 
will gain real health security from health care reform. There will 
still be challenges. There will still be bumps in the road. There 
always are in places like West Virginia. But I believe that, on the 
whole, I can tell the majority of my constituents that the legislation 
we are considering will make a real difference in their lives. I have 
no other reason for being here. That is what I am hired on to do by my 
people of West Virginia--to try to make a difference in their lives. I 
believe this bill and this amendment will do that. For rural doctors 
and rural hospitals, this bill, frankly, is a long-awaited relief 
package that will provide them with additional resources and stable 
financing.
  Mr. President, I look forward to the adoption of this amendment by my 
colleagues.
  I thank my patient colleague from South Dakota and the distinguished 
Presiding Officer, and I yield the floor.
  The PRESIDING OFFICER. The Chair recognizes the Senator from South 
Dakota [Mr. Daschle].
  Mr. DASCHLE. Mr. President, let me commend the distinguished Senator 
from West Virginia for an extraordinarily complete explanation of our 
amendment.
  I think it is appropriate that as we begin this debate we have a 
better understanding of why it is necessary to introduce this 
amendment, and how it addresses the critical shortage of rural health 
providers that the Senator from West Virginia so ably depicted on his 
chart.
  I commend him. He has been an extraordinary partner in this whole 
effort and, as a cosponsor, has been a real leader over the years in 
rural health care reform. It has been my privilege to work side by side 
with him for virtually as long as I have been here, and I cannot think 
of a greater privilege I have had in the Senate.
  I commend him for his statement and appreciate very much his 
contribution to this effort.
  Mr. President, I ask unanimous consent that Senators Wofford and 
Leahy be added to the list of cosponsors, which includes Senators 
Baucus, Harkin, Rockefeller, and Reid.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. DASCHLE. Mr. President, the Senator from West Virginia, as I 
indicated, has described our amendment very well. He, too, publicly 
commended our majority leader for including in his bill a substantial 
set of rural health provisions.
  Senator Mitchell has listened to the concerns that many of us have 
expressed about how rural areas would be affected by changes being 
proposed in our health care system. The bill he introduced, as the 
Senator from West Virginia has indicated, truly reflects his commitment 
to ensuring that rural health reform does not pass by rural 
communities.
  The amendments that we are proposing tonight build upon the solid 
base that the majority leader's bill establishes for rural America.
  From the very beginning of this debate, many of us have insisted that 
we would not vote for a bill that did not include substantial 
recognition of the need for improvements to rural health care access. I 
do not think anyone who has cosponsored this amendment is prepared to 
back off that determination. We are not going to abandon that principle 
now.

  Thankfully, efforts to enhance access to rural health care have 
always had strong bipartisan support, as the statement from the Senator 
from Iowa indicated this evening.
  Earlier this year I cochaired a bipartisan working group that 
recommended a series of rural provisions that should be included in 
health reform. I am very pleased that many of the suggestions we 
recommended were included in the Senate Finance Committee bill and now 
in the legislation Senator Mitchell has presented to us.
  Our efforts have been for a good cause. Indeed, both Republican and 
Democratic health reform bills frankly have included similar strong 
rural provisions. It gives me hope that the majority of Senators on 
both sides of the aisle share our insistence that health reform benefit 
rural and urban areas alike.
  We have come together on this issue in the past, and I am hopeful 
that we can be united again on this debate. Let the same bipartisan 
spirit of cooperation prevail as we consider this set of amendments.
  We all want to make health care reform a guaranteed winner for rural 
people.
  The amendments that we are proposing tonight would encourage doctors, 
nurse practitioners, and physician assistants to practice in rural 
underserved areas, to ensure that financial and other assistance is 
available to help rural facilities adjust to the changing health care 
environment, and to assist rural providers in forming their own health 
care networks.
  Among the provisions we are proposing, including some the Senator 
from West Virginia described so ably tonight, is a proposal to increase 
funding for the National Health Service Corps, one of the most 
important, respected workforce programs in the country today.
  This program was nearly eliminated in the 1980's despite the fact 
that many rural communities are completely dependent upon corps doctors 
as their only source of physician care. While the program has been 
slowly built back up over the last couple of years, rural America badly 
needs more of these providers.
  Another amendment we are proposing would provide Medicare bonus 
payments to nurse practitioners and physician assistants who practice 
in rural areas. This incentive money will help rural America attract 
and retain these important practitioners.

  Another series of provisions included in this amendment would ensure 
that clinics in rural areas are eligible for loans and grants that can 
help them upgrade their services, form networks with other providers, 
and help better serve rural areas.
  Finally, to help rural communities determine how to develop their own 
health care plans, we have established 10 demonstrations projects for 
the development of rural-based managed care.
  Simply put, rural America's most significant problem is that we do 
not have enough providers. We see that in rural Colorado. We see it in 
rural Idaho. We see it in rural South Dakota. We have attempted to 
address that problem through a number of different provisions in our 
amendment.
  Why do we need these provisions, some may ask. Does not universal 
coverage solve the problems facing rural America? It is true that if we 
move closer to universal coverage we could enhance access to care in 
rural America.
  The problem we have is that guaranteed health insurance in rural 
America is defined differently than it is in urban America. In my home 
State of South Dakota, 145,000 residents had no health insurance at 
some point in 1993.
  We must ensure rural residents have the same opportunities as urban 
dwellers to buy the range of insurance plans that will be required 
under the Mitchell bill.
  Because we know that, compared to their urban counterparts, rural 
residents are less likely to be insured and tend to be older, sicker, 
and poorer with higher rates of uneconomic and chronic ailments and 
disability. This will remain so in spite of the fact that rural 
Americans may have improved coverage under the Mitchell bill.
  Universal coverage is the most important building block to ensuring 
health security in rural America. But providing health coverage is not 
and cannot be the whole solution for what ails rural America today.
  In far too many rural areas a health insurance card does little good 
because there are simply no providers to care for patients. Increasing 
the supply of primary care practitioners and attracting them to rural 
communities is by far the biggest challenge facing us today.
  This is a serious issue in South Dakota and in many States throughout 
the Midwest and West. South Dakota currently ranks 47th in the country 
in terms of physician-to-population ratio with 1 primary care doctor 
for about every 1,500 people. In fact, 16 counties in my State have no 
hospital at all. Equally important is increasing the number of 
nonphysician providers practicing in these rural areas and enhancing 
their ability to practice independently.

  More recently, we have seen a new problem. The increased competition 
for primary care physicians and nonphysician providers from urban-
managed care plans is complicating life in rural America today. Rural 
areas are seeing a drain of primary care physicians from rural to urban 
areas, where employment packages offered by HMO's provide a shorter, 
more predictable work schedule and a much higher guaranteed income.
  In other words we exacerbate the problem of a shortage of 
practitioners by encouraging doctors to leave underserved areas to go 
to those areas where there is no shortage.
  We try to address that problem, Mr. President, with a number of the 
provisions to encourage providers, both doctors and other health care 
practitioners, to move to rural areas, and stay there, once they are 
there.
  Coordinating care in rural areas is another major challenge. While 
urban residents can join a number of health care plans and have 
available to them a network of primary care doctors, specialists, 
nursing homes, and home health care providers, we have very limited 
access to integrated networks that can help patients manage their care.
  These arrangements rarely exist in our part of the country. Managed 
care plans have been hesitant to enter rural health care markets and 
few rural providers have formed no networks at all.
  So we need to do everything we can to encourage providers to 
cooperate and form integrated service delivery networks.
  We should not wait for an urban-based HMO to set up shop in rural 
America. We can form our own community health plans and networks. All 
the providers need are the proper incentives.
  In sum, this package of amendments makes the statement that rural 
America should no longer be asked to settle for less health care than 
their urban counterparts. What better message can we send as we debate 
health reform?
  I certainly hope that, as we debate this amendment over the next day, 
Mr. President, we appreciate fully the unique set of circumstances that 
we have in rural America today; that we understand, we also have a 
unique responsibility to be sensitive to those circumstances. We simply 
cannot allow health reform to pass rural America by.

  This amendment is a concerted effort on the part of a number of 
Senators from different States, all with the same appreciation of the 
need to respond more effectively to rural health care needs, 
recognizing very well how much the majority leader has already done in 
his bill to address many of the concerns we have expressed to him.
  So I am hopeful, Mr. President, that before the end of the day 
tomorrow, perhaps, we can have a good debate and a good discussion 
about these needs and about ways to respond more effectively to these 
needs. This is our best effort to do so in a concerted and very sincere 
way.
  I also ask unanimous consent, Mr. President, that the junior Senator 
from Colorado, Senator Ben Nighthorse Campbell, be added as a cosponsor 
to this amendment.
  The PRESIDING OFFICER (Mr. Akaka). Without objection, it is so 
ordered.
  Mr. DASCHLE. Mr. President, the distinguished Senator from Idaho has 
shown remarkable patience tonight. So while I have a much longer 
statement and full explanation of what our amendment would do, I would 
like to elaborate more tomorrow on each of the provisions. We got a 
good start tonight from the Senator from West Virginia, so there is no 
need to further delay this evening.
  I am aware that a number of housekeeping chores are required, and I 
will do that and then yield the floor to the distinguished Senator from 
Idaho.

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