[Congressional Record Volume 140, Number 117 (Thursday, August 18, 1994)]
[Senate]
[Page S]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: August 18, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
                          HEALTH SECURITY ACT

  The Senate continued with the consideration of the bill.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BURNS. Mr. President, I want to rise today to thank the Senator.
  The PRESIDING OFFICER. The Chair needs to relate to the Senator from 
Montana that under the previous order the Senator from Texas was to be 
recognized for up to 5 minutes and then the Senator from South Dakota 
and then open debate.
  Mr. BURNS. I ask unanimous consent that I might be allowed 5 minutes 
to make my statement.
  Mr. BAUCUS. Mr. President, reserving the right to object.
  The PRESIDING OFFICER. Is there objection.
  Mr. BAUCUS. Mr. President, reserving the right to object.
  The PRESIDING OFFICER. The Senator objects.
  Mr. BAUCUS. Mr. President, I understand that my colleague, the 
Senator from Montana, would like to speak on this amendment. I, too, 
would like to speak on this amendment. I think it is a very important 
amendment. I understand there is a vote scheduled fairly soon.
  I am wondering if we could ask for an additional 10 minutes before 
the vote occurs so that my colleague and I can address this amendment.
  Mr. MOYNIHAN. I am sorry. I did not know anything about this.
  The PRESIDING OFFICER. The Senator from Montana asks for an 
additional 10 minutes.
  Is there objection?
  Without objection, it is so ordered.
  Mr. BURNS. Mr. President, I thank my colleague from Montana. As we 
move into this area, I just want to state, with these provisions in 
rural health, and, of course, our State of Montana which is entirely 
rural--in fact, it is considered one of the frontier States. We are not 
using wagons in the historical sense, but when it comes to delivering 
health care services, we might as well be.
  I displayed these maps the other night on the floor, but they are 
certainly worth showing again. Montana has nine counties with no 
physicians at all. These two counties down in the southeast, Carter and 
Powder River Counties, are as big as Massachusetts. Sure, they only 
have 3,600 people who live there, but they have to go a long way for 
their basic health care. In fact, if you consider the 39 counties in 
Montana without ob/gyn services--and this will give you an idea what 
that looks like--I would say I would have to worry about women's health 
care issues in the middle of Garfield County, which is over here. This 
red, by the way, in the central part of the State represents an area 
about the size of Indiana. So we have an access problem. It is not 
because of high-cost health care, Mr. President. It is because 
providers are not there. It would not matter how cheap health care was, 
these folks still would not have access.
  And we have to remember when we start talking about the Canadian 
system or the American system, the two differences are that in Canada 
you have universal coverage but you do not have universal access, and 
in this country we have universal access but we do not have universal 
coverage. It is just the other way around.
  Basically, we have a mix of the two in the State of Montana. So they 
have to travel many, many miles just for their basic health care needs.
  Have no doubt, I am all for some of these provisions that expand 
health care to rural areas. My colleagues here in the Senate, and the 
folks at home, know well the work I have done to promote telemedicine 
in the State of Montana. And I appreciate Mr. Harkin's hard work in 
this area. He knows the challenges of getting health care delivered to 
rural areas. And as encouraging as grant money for these projects may 
be, what is really needed is for the Government to get out of the way, 
let the private sector move forward, and eliminate the barriers that 
now exist. Namely, Medicare reimbursement. Telemedicine is 
ready to explode all across the country. The No. 1 barrier holding it 
back is not money--though that always helps--it is not doctor 
resistance, it is not lack of technology, it is the lack of 
reimbursement by HCFA that is slowing down progress.
  But, Mr. President, these amendments expanding access to rural areas 
would not benefit these underserved areas one bit if the rest of the 
Clinton-Mitchell bill is left intact. Let me explain.
  In rural areas there is a predominance of small businesses and self-
employed individuals. Montana is an agricultural State. The eastern 
part of my State is nearly all agriculture--farming, ranching, and the 
support that goes along with it. These folks will be so burdened by 
other provisions, that health care will be the least of their problems.
  The mandate, though not triggered for a few years, will no doubt have 
a profound effect on rural America, and most of Montana. Even if the 
business was exempt, having fewer than 25 employees, the mandate would 
fall on the employees. Requiring employees then to pay 100 percent is a 
hardship. This is an individual mandate on folks whose income doesn't 
have a lot of wiggle room.
  On top of that, the self-employed are not allowed to deduct 100 
percent of their health insurance costs. Big business can. We do not 
have a whole lot of big business in Montana. In fact, of 22,223 
businesses in Montana, 21,752 of those are considered small business--
that is 98 percent, Mr. President.
  The provision we struck last night would have had such an impact on 
those businesses who already provide comprehensive health care to their 
employees, I am not sure these small businesses could have survived. 
And I think that is just one justification for going through this bill 
with a fine tooth comb--although painstakingly slow, it is necessary, 
because Americans want to know. As my colleague from Oklahoma, Senator 
Nickles, reported last night, this provision would easily have turned 
for-profit companies into not-for-profit companies.
  The taxes on health plans, again, would cut into the operating 
expenses of small business. Adding a 1.75 percent tax on all health 
insurance premiums, most of which goes to fund Academic Health 
Centers--which we don't even have in Montana--simply adds to the cost 
of health care. This does nothing to make insurance more affordable. If 
anyone is under the impression that the Clinton-Mitchell plan would not 
grow Government, why do we need all these new taxes? History clearly 
shows more taxes grows Government.
  Here you are, encouraging and mandating--some now, some later--
employers to provide health care insurance. And then you tax them for 
doing so. I'm not saying the hardships will be felt only in rural 
areas. They will be felt all across the board. But in rural areas, 
there is not much room to maneuver. The options are limited. And if we 
tack on burden after burden, pretty soon, our ability to provide food 
and fiber for Americans is seriously impeded.
  And if we cut Medicare and Medicaid by hundreds of billions, funding 
that makes up the majority of the payments received by rural hospitals, 
those facilities will close. We have already experienced hospitals 
closing and whittling down services in Montana. The Medicare payments 
don't cover costs as it is. Cut those more and we'll have nowhere to 
deliver the services. Telemedicine won't even be an issue if there is 
no facility on the rural end.
  Mr. President, my point is this. We can do all sorts of things to 
expand access to these rural areas--and I think we should--but if we 
fail to keep these same areas in mind when crafting the rest of the 
package, then these provisions are useless. Rural America is already on 
the edge, let's not push them over.
  I look forward to working with both sides of the aisle on making sure 
health care is affordable and accessible in every sector of our fine 
country. And I am going to fight to make sure that this operation does 
not include a massive rural-ectomy.
  Mr. President, I yield to my colleague from Montana to make a 
statement on this issue, because I do not think there are two people in 
this body that better understand the challenge that rural health faces 
in order to serve the people of the State of Montana.
  I appreciate his work in this area. And I yield the floor.
  The PRESIDING OFFICER. Under the earlier previous order, the Senator 
from Texas has reserved 5 minutes.
  The Senator is recognized.
  Mrs. HUTCHISON. Mr. President, I will be happy to yield to the other 
Senator from Montana to continue this process, and then take up after 
he has finished.
  The PRESIDING OFFICER. The Senator from Montana is recognized.
  Mr. BAUCUS. I thank the Senator from Texas.
  It is fine with me if the Senator from Texas wishes to proceed.
  Mrs. HUTCHISON. I just felt that, since Senator Burns had started 
talking about Montana, that you would like to continue talking about 
the unique problems there, and then I will talk about the unique 
problems in Texas.
  Mr. BAUCUS. I thank the Senator.
  Mr. President, I rise in very strong support of the amendment offered 
by the Senator from South Dakota [Mr. Daschle], because it will improve 
the quality of health care in rural areas and give rural communities 
more access to the health care system.
  One in four Americans today lives in a rural area. Rural areas are 
going through a health care crisis in many ways even worse than the 
crisis everyone else faces. Rural areas suffer high rates of 
uninsurance and underinsurance. Rural counties have chronic and severe 
shortages of doctors, pharmacists, nurses, and other health 
professionals.
  Rural Americans get very little preventive care. And rural hospitals 
are closing. One in 10 shut down in the last decade.
  In Montana, the statistics are truly alarming. Over 20 percent of 
Montanans have no health insurance. That is one in every five. Three 
quarters of our State is a health professional shortage area. Almost 
half of our 56 counties have no doctor who can deliver a baby. And 
eight Montana counties have no doctor at all.
  As we consider national health reform, rural counties must get the 
help they need to provide high-quality health care to their people.
  The Mitchell bill already contains strong rural health provisions. 
This amendment has several rural health provisions which will 
strengthen the bill even further. I intend to speak this morning on 
just three.


                     national health service corps

  First, this amendment provides more money to the National Health 
Service Corps. Under this program, physicians and other health 
professionals agree to work in underserved areas in return for a 
scholarship or loan repayment.
  This program is the only way to get access to hundreds of rural 
counties. Most young doctors leave medical school hundreds of thousands 
of dollars in debt. Since salaries in rural areas are so much lower 
than in urban areas, they simply cannot afford to practice in rural 
counties.
  The National Health Service Corps now provides Montana with nine 
physicians and four physician assistants. Several Montana communities 
would have no primary care at all if not for this program.
  Take the example of our hospital in Culbertson. Culbertson is a 
little town, population 796, about 25 miles west of the North Dakota 
border. Thanks to the loan repayment program, Culbertson has a 
physician and a physician assistant. Without them, the hospital would 
close. That would make it impossible for all of Roosevelt County to get 
emergency room services and basic primary care.
  The National Health Service Corps is already making a difference in 
the lives of thousands of Montanans. With Senator Daschle's amendment, 
the corps can recruit about 40 more doctors to Montana counties that 
now have shortages. This means the men, women, and children in these 
counties will be healthier. And because they will get preventive care, 
Montana will save health care dollars down the line.


                              telemedicine

  The Daschle amendment would also help end the isolation of rural 
health care providers, and improve the quality of the care they provide 
by funding a Rural Telemedicine Grant Program.
  Telemedicine allows providers to use modern communications technology 
to consult with highly trained specialists in distant areas. It lets 
doctors transfer x rays or lab slides for analysis in top-quality 
laboratories. And it allows communities to develop innovative health 
education programs.
  This amendment provides for telemedicine critical for rural areas.
  This amendment also makes technical changes to the medical assistance 
facility program, a new hospital program contained in the underlying 
bill.
  The medical assistance facility program is a critical reform for 
rural areas. It allows small hospitals to operate under more flexible 
rules. For example, it lets nurse practitioners and physician 
assistants admit patients even when a doctor is not present. It also 
gives them higher reimbursement from Medicare.
  MAF's provide more than just inpatient care. They make it easier to 
provide other health services which the community otherwise would never 
have. An MAF is a base for 1-day-a-week dental service. It offers 
weekly physical therapy sessions, mobile mamography units, counseling 
services.
  At least six rural towns in the State of Montana would have no 
hospital services--none--if it were not for this innovative program. 
Jordan, Ekalaka, Circle, Terry and all the farms and ranches nearby 
would have no medical service were it not for this very specialized 
program which makes or breaks rural health care in those parts of the 
country.
  Mr. President, for all these reasons I strongly support the amendment 
and urge its adoption.
  The PRESIDING OFFICER. The Senator from Texas is recognized.
  Mrs. HUTCHISON. Mr. President, I rise to speak for the amendment. 
Texas is made up of 254 counties, 196 of those counties are considered 
rural.
  Let me tell you about the Dairy Queen test--On weekends I travel 
through Texas and walking in and out of coffee shops and Dairy Queens I 
listen to people in rural Texas. What I hear is that they do not want 
the bureaucrats in Washington ruining their health care. They ask me, 
as their Senator, to bring that message back to Washington: They know 
we have problems for rural health care in our system--but they are 
concerned about the solution being talked about here. They are 
concerned that the system has a cold and the solution prescribed is 
chemotherapy.
  The problems of health care delivery in rural America are real. The 
underlying health care bill encompasses many of the reforms that are 
necessary to improve the delivery system in rural America. However, 
there are a number of negative impacts on rural America that are 
evident throughout the bill. I support and agree with the Senator from 
South Dakota about his desire to improve the status quo in rural 
America. Many rural States are heavily dependent on the Federal 
Government for assistance in maintaining and enhancing rural health 
care resources. We must continue to be helpful--but we should also be 
focusing on ways of providing incentives as the Dole bill does and the 
development of infrastructure into rural America to yield to the States 
the flexibility to create viable programs.
  Every county in rural America is different. Just as I do not believe 
that the Federal Government should be dictating to every individual 
what benefits to buy, I do not believe that we, as legislators, have 
the right to dictate what every county, city, town in rural America 
needs, wants, and should have. I grew up in LaMarque, a town of 15,000 
outside of Galveston. I know our needs are a whole lot different from 
the needs of Sonora clear across the State. The point is that rural 
health care needs differ, rural Americans face unique health care 
situations and we should enable rural communities and States to play a 
strong role in designing and implementing solutions.
  I heard both of my friends from Iowa talking about amendments that 
can improve this bill and I would like to support their efforts to make 
health care more accessible to rural Americans.
  What are rural Americans concerned with? Rural Americans especially 
are concerned about the cost of insurance and mandates on employers. 
They would like to see health care coverage become more affordable and 
accessible; 100-percent tax deductibility should be available to 
individuals and the self-employed. This is achieved in the Dole bill, 
but not in the Mitchell plan. The American Farm Bureau Federation has 
estimated that for a typical family of four at a 15-percent tax level--
$36,900--a full tax deduction could generate over $1,200 in saving per 
year.
  That is an incentive for people to be able to go into the health care 
system. The self-employed deserve the same tax incentives that large 
corporations have. Medical savings accounts are another tool that rural 
Americans could benefit greatly from. Americans, rural, or otherwise, 
could save money for their health care needs without being penalized by 
the Tax Code. That option is not allowed in the underlying Mitchell 
bill. I am going to cosponsor an amendment to put it there. Small 
businesses in rural Texas oppose mandates. Farmers, ranchers, and small 
businesses across this country are already burdened with federal 
mandates. One more mandate is just another tax. I believe we can 
improve the rural health care delivery system without forcing many of 
these farmers and ranchers to cut employment or go out of business. 
Employer mandates will hit rural areas hard and have a devastating 
impact on fragile rural economies.


                                 taxes

  Taxes will hit rural Americans hard.
  The Dole proposal provides solutions to many of these concerns 
without imposing new taxes or mandates. It will provide incentives for 
primary care practitioners to go to rural areas, it will raise the tax 
deductibility for the self-insured, it will allow small businesses, 
farmers, and ranchers to pool together to buy more affordable health 
care coverage. These reforms are steps in the right direction.
  Mr. President, I want to conclude by expressing my support for what 
the Senator from South Dakota has proposed but also with my concerns 
that this one improvement, is one small step. We must go much further 
to address the needs of rural America as we address health care reform.
  Several Senators addressed the Chair.
  The PRESIDING OFFICER. The Senator from South Dakota.
  Mr. DASCHLE. Mr. President, under the unanimous-consent agreement, I 
have 5 minutes. I will yield that back to accommodate some Senators who 
must leave Washington.
  I have a couple of unanimous-consent requests to make. First, I ask 
unanimous consent to make some technical changes. They have been 
approved by the managers.
  I send the modification to the desk.
  The PRESIDING OFFICER. The amendment will be so modified.
  The amendment (No. 2564), as modified, is as follows:

       On page 112, line 6, insert ``including residents of rural 
     areas'' before the period.
       On page 215, line 10, strike ``(c)'' and insert ``(d)''.
       On page 215, between lines 9 and 10, insert the following 
     new subsection:
       (c) Transfer of Duties.--Effective January 1, 1996, the 
     functions, powers, duties, and authority that were carried 
     out in accordance with Federal law by the Office of Rural 
     Health Policy in the Department of Health and Human Services 
     are transferred to the Office of the Assistant Secretary for 
     Rural Health in the Department of Health and Human Services.
       On page 612, line 24, insert before the period the 
     following: ``, at least one of whom resides in a rural 
     area''.
       On page 613, line 9, insert before the period the 
     following: ``, at least one of whom resides in a rural 
     area''.
       On page 647, strike lines 25 and 26, and insert the 
     following:
       ``For purposes of carrying out section 3341, there are 
     authorized to be appropriated $15,000,000 for each of the 
     fiscal years 1997 through 2001.''.
       On page 644, line 10, strike ``or health professional 
     shortage areas'' and insert ``area, health professional 
     shortage area, or other rural underserved area (as designated 
     by the Governor)''.
       On page 651, between lines 9 and 10, add the following new 
     paragraph:
       (3) Subpart f.--For the purpose of providing funds under 
     subpart F, there are authorized to be appropriated 
     $10,000,000 for each of the fiscal years 1996 through 2000.
       On page 652, line 18, strike ``and''.
       On page 652, between lines 18 and 19, insert the following 
     new paragraph:
       ``(7) rural health clinics, except that for-profit rural 
     health clinics shall only be eligible for direct loans and 
     grants under subpart C; and''.
       On page 652, line 19, strike ``(7)'' and insert ``(8)''.
       On page 653, after line 23, add the following new 
     subsection:
       (f) Purposes and Conditions.--Grants shall be made under 
     this part for the purposes and subject to all of the 
     conditions under which eligible entities otherwise receive 
     funding to provide health services to medically underserved 
     populations under the Public Health Service Act. The 
     Secretary shall prescribe comparable purposes and conditions 
     for eligible entities not receiving funding under the Public 
     Health Service Act, including conditions with respect to the 
     availability of services in the area served (as provided for 
     in section 330(e)(3)(A) of such Act), and conformance of fee 
     and payment schedules with prevailing rates (as provided for 
     in section 330(e)(3)(F) of such Act). With respect to rural 
     health clinics, such comparable purposes and conditions shall 
     include conditions concerning sliding fee scales under 
     section 1128B(b)(3)(D) of the Social Security Act and waivers 
     of deductibles under section 1833(d) of such Act.
       On page 672, line 1, strike the subsection heading and 
     insert ``Federally qualified health centers and rural health 
     clinics''.
       On page 675, between lines 16 and 17, add the following new 
     subpart:

               Subpart F--Rural-Based Managed Care Grants

     SEC. 3467. RURAL-BASED MANAGED CARE GRANTS.

       (a) In General.--The Secretary shall award grants for the 
     development and operation of rural-based managed care 
     networks.
       (b) Eligible Entities.--To be eligible to receive a grant 
     under subsection (a), an applicant organization shall--
       (1) prepare and submit to the Secretary an application, at 
     such time, in such manner and containing such information as 
     the Secretary may require;
       (2) be based or provide services in rural or rural 
     underserved areas; and
       (3) be currently operating or in the process of 
     establishing a provider network serving the nonmedicare 
     population .
       (c) Use of Funds.--Funds provided under a grant under this 
     section may be used--
       (1) for the development and implementation of rural-based 
     managed care networks;
       (2) for data and information systems, including 
     telecommunications;
       (3) for meeting solvency requirements for a risk-bearing 
     entity under the medicare program under title XVIII of the 
     Social Security Act;
       (4) for the recruitment of health care providers; or
       (5) for enabling services, including transportation and 
     translation.
       (d) Priority.--In awarding grants under subsection (a), the 
     Secretary shall give priority to--
       (1) applicants that will use amounts received under the 
     grant to develop and operate rural-based managed care 
     networks that would serve at least one underserved rural 
     area; and
       (2) applicants that involve local residents and providers 
     in the planning and development of the rural-based managed 
     care network.
       (e) Definitions.--As used in this section
       (1) Rural area.--The term ``rural area'' means a rural area 
     as described in section 1886(d)(2)(D) of the Social Security 
     Act.
       (2) Underserved rural area.--The term ``underserved rural 
     area'' means a health professional shortage area under 
     section 332 of the Public Health Service Act (42 U.S.C. 254e) 
     or an area designated as underserved by the Governor of a 
     State taking into account--
       (A) financial and geographic access to health plans by 
     residents of such area; and
       (B) the availability, adequacy, and quality of qualified 
     providers and health care facilities in such area.
       (f) Study.--The Secretary shall study different risk-
     bearing approaches for rural managed care and payment 
     methodologies that differ from or modify the medicare average 
     area per capita cost payment methodology.
       Beginning on page 675, strike line 24 and all that follows 
     through line 4 on page 676, and insert the following: 
     ``priated $314,000,000 for fiscal year 1996, $285,000,000 for 
     fiscal year 1997, $365,000,000 for fiscal year 1998, 
     $382,000,000 for fiscal year 1999, $386,000,000 for fiscal 
     year 2000, $91,500,000 for fiscal year 2001, $53,350,000 for 
     fiscal year 2002, $38,100,000 for fiscal year 2003, and 
     $38,100,000 for fiscal year 2004, of which $2,000,000 shall 
     be made available in each of the fiscal years 1996 through 
     2000 to carry out section 338L of the Public Health Service 
     Act.''.
       On page 676, line 10, strike ``NURSES'' and insert 
     ``ADVANCED PRACTICE NURSES AND PHYSICIAN ASSISTANTS''.
       On page 676, line 20, strike ``nurse anesthetists'' and 
     insert ``nurse anesthetists or physician assistants''.
       On page 676, lines 21 and 22, strike ``nurse anesthetists'' 
     and insert ``nurse anesthetists or physician assistants''.
       On page 677, between lines 13 and 14, add the following new 
     parts:

       PART 4--ANTITRUST SAFE HARBORS FOR RURAL HEALTH PROVIDERS

     SEC. 3491. ANTITRUST SAFE HARBORS FOR RURAL HEALTH PROVIDERS.

       (a) In General.--The Attorney General, in consultation with 
     the Commissioner of the Federal Trade Commission, shall 
     clarify existing and future policy guidelines, with respect 
     to safe harbors, by providing additional illustrative 
     examples with respect to the conduct of activities relating 
     to the provision of health care services in rural areas.
       (b) Dissemination of Information.--The Attorney General, in 
     consultation with the Commissioner of the Federal Trade 
     Commission and the Assistant Secretary for Rural Health, 
     shall develop methods for the dissemination of the guidelines 
     established under subsection (a) to rural health care 
     providers.

                   PART 5--EMERGENCY MEDICAL SYSTEMS

     SEC. 3495. GRANTS TO STATES REGARDING AIRCRAFT FOR 
                   TRANSPORTING RURAL VICTIMS OF MEDICAL 
                   EMERGENCIES.

       Part E of title XII of the Public Health Service Act (42 
     U.S.C. 300d-51 et seq.) is amended by adding at the end 
     thereof the following new section:

     ``SEC. 1252. GRANTS FOR SYSTEMS TO TRANSPORT RURAL VICTIMS OF 
                   MEDICAL EMERGENCIES.

       ``(a) In General.--The Secretary shall make grants to 
     States to assist such States in the creation or enhancement 
     of air medical transport systems that provide victims of 
     medical emergencies in rural areas with access to treatments 
     for the injuries or other conditions resulting from such 
     emergencies.
       ``(b) Application and Plan.--
       ``(1) Application.--To be eligible to receive a grant under 
     subsection (a), a State shall prepare and submit to the 
     Secretary an application in such form, made in such manner, 
     and containing such agreements, assurances, and information, 
     including a State plan as required in paragraph (2), as the 
     Secretary determines to be necessary to carry out this 
     section.
       ``(2) State plan.--An application submitted under paragraph 
     (1) shall contain a State plan that shall--
       ``(A) describe the intended uses of the grant proceeds and 
     the geographic areas to be served;
       ``(B) demonstrate that the geographic areas to be served 
     are rural in nature;
       ``(C) demonstrate that there is a lack of facilities 
     available and equipped to deliver advanced levels of medical 
     care in the geographic areas to be served;
       ``(D) demonstrate that in utilizing the grant proceeds for 
     the establishment or enhancement of air medical services the 
     State would be making a cost-effective improvement to 
     existing ground-based or air emergency medical service 
     systems;
       ``(E) demonstrate that the State will not utilize the grant 
     proceeds to duplicate the capabilities of existing air 
     medical systems that are effectively meeting the emergency 
     medical needs of the populations they serve;
       ``(F) demonstrate that in utilizing the grant proceeds the 
     State is likely to achieve a reduction in the morbidity and 
     mortality rates of the areas to be served, as determined by 
     the Secretary;
       ``(G) demonstrate that the State, in utilizing the grant 
     proceeds, will--
       ``(i) maintain the expenditures of the State for air and 
     ground medical transport systems at a level equal to not less 
     than the level of such expenditures maintained by the State 
     for the fiscal year preceding the fiscal year for which the 
     grant is received; and
       ``(ii) ensure that recipients of direct financial 
     assistance from the State under such grant will maintain 
     expenditures of such recipients for such systems at a level 
     at least equal to the level of such expenditures maintained 
     by such recipients for the fiscal year preceding the fiscal 
     year for which the financial assistance is received;
       ``(H) demonstrate that persons experienced in the field of 
     air medical service delivery were consulted in the 
     preparation of the State plan; and
       ``(I) contain such other information as the Secretary may 
     determine appropriate.
       ``(c) Considerations in Awarding Grants.--In determining 
     whether to award a grant to a State under this section, the 
     Secretary shall--
       ``(1) consider the rural nature of the areas to be served 
     with the grant proceeds and the services to be provided with 
     such proceeds, as identified in the State plan submitted 
     under subsection (b); and
       ``(2) give preference to States with State plans that 
     demonstrate an effective integration of the proposed air 
     medical transport systems into a comprehensive network or 
     plan for regional or statewide emergency medical service 
     delivery.
       ``(d) State Administration and Use of Grant.--
       ``(1) In general.--The Secretary may not make a grant to a 
     State under subsection (a) unless the State agrees that such 
     grant will be administered by the State agency with principal 
     responsibility for carrying out programs regarding the 
     provision of medical services to victims of medical 
     emergencies or trauma.
       ``(2) Permitted uses.--A State may use amounts received 
     under a grant awarded under this section to award subgrants 
     to public and private entities operating within the State.
       ``(3) Opportunity for public comment.--The Secretary may 
     not make a grant to a State under subsection (a) unless that 
     State agrees that, in developing and carrying out the State 
     plan under subsection (b)(2), the State will provide public 
     notice with respect to the plan (including any revisions 
     thereto) and facilitate comments from interested persons.
       ``(e) Number of Grants.--The Secretary shall award grants 
     under this section to not less than 7 States.
       ``(f) Reports.--
       ``(1) Requirement.--A State that receives a grant under 
     this section shall annually (during each year in which the 
     grant proceeds are used) prepare and submit to the Secretary 
     a report that shall contain--
       ``(A) a description of the manner in which the grant 
     proceeds were utilized;
       ``(B) a description of the effectiveness of the air medical 
     transport programs assisted with grant proceeds; and
       ``(C) such other information as the Secretary may require.
       ``(2) Termination of fundings.--In reviewing reports 
     submitted under paragraph (1), if the Secretary determines 
     that a State is not using amounts provided under a grant 
     awarded under this section in accordance with the State plan 
     submitted by the State under subsection (b), the Secretary 
     may terminate the payment of amounts under such grant to the 
     State until such time as the Secretary determines that the 
     State comes into compliance with such plan.
       ``(g) Definition.--As used in this section, the term `rural 
     areas' means geographic areas that are located outside of 
     standard metropolitan statistical areas, as identified by the 
     Secretary.
       ``(h) Authorization of Appropriations.--There are 
     authorized to be appropriated to make grants under this 
     section, $15,000,000 for fiscal year 1995, and such sums as 
     may be necessary for each for fiscal years 1996 and 1997.''.
       Beginning on page 718, strike line 23 and all that follows 
     through line 5 on page 719, and insert the following new 
     paragraph:
       ``(8) with respect to the National Health Service Corps 
     program referred to in section 3471, $314,000,000 for fiscal 
     year 1996, $285,000,000 for fiscal year 1997, $365,000,000 
     for fiscal year 1998, $382,000,000 for fiscal year 1999, 
     $386,000,000 for fiscal year 2000, $91,500,000 for fiscal 
     year 2001, $53,350,000 for fiscal year 2002, $38,100,000 for 
     fiscal year 2003, and $38,100,000 for fiscal year 2004, of 
     which $2,000,000 shall be made available in each of the 
     fiscal years 1996 through 2000 to carry out section 338L of 
     the Public Health Service Act;''.
       On page 720, line 22, strike ``; and'' and insert a 
     semicolon.
       On page 720, between lines 22 and 23, insert the following 
     new paragraph:
       ``(14) with respect to the development of rural 
     telemedicine under section 3341, $15,000,000 for each of the 
     fiscal years 1997 through 2001; and''.
       On page 720, line 23, strike ``(14)'' and insert ``(15)''.
       On page 725, strike lines 7 through 11, and insert the 
     following:
       ``(6) in subsection (l), by striking paragraph (1) and 
     inserting the following new paragraph:
       ```(1) In general.--The Secretary shall use amounts made 
     available under section 3471 of the Health Security Act to 
     carry out this section in each of the fiscal years 1996 
     through 2000.'''.
       On page 777, line 18, strike ``and medical assistance 
     facilities''.
       On page 780, line 3, insert ``In the case of payment under 
     this subsection to medical assistance facilities, the lesser-
     of-cost-or charges provisions under subsection (j) are not 
     applicable.'' after ``services.''.
       Beginning on page 808, strike line 16 and all that follows 
     through page 809, line 4, and insert the following:
       (2) by inserting ``described in paragraph (2) and services 
     furnished by a physician assistant or nurse practitioner 
     described in such paragraph that would by physicians' 
     services if furnished by a physician'' after ``physicians' 
     services'',
       (3) by inserting ``physician assistant or nurse 
     practitioner,'' after ``physician'',
       (4) by striking ``10 percent'' and inserting ``the 
     applicable percent'', and
       (5) by adding at the end the following new paragraph:
       ``(2)(A) The applicable percent referred to in paragraph 
     (1) is--
       ``(i) in the case of primary care services furnished by a 
     physician, a percent determined by the Secretary that may not 
     be less than 10 percent and may not exceed 20 percent,
       ``(ii) in the case of primary care services furnished by a 
     physician assistant or nurse practitioner, as described in 
     section 1861(a)(2)(k), a percent to be determined by the 
     Secretary that is equal to the percent determined in clause 
     (i) and determined so that the total amount of such payments 
     under this clause and clause (i) is equal to the amount that 
     would have been paid under clause (i) if the applicable 
     percent for such clause was equal to 20 percent, and
       ``(iii) in the case of physicians' services other than 
     primary care services furnished by physicians in a health 
     professional shortage area located in a rural area (as 
     defined in section 1886(d)(2)(D)), 10 percent.
       On page 873, line 20, insert ``urban and rural'' after 
     ``representative of the''.
       On page 874, line 1, insert ``, at least one of whom 
     resides in a rural area'' before the first period.
       On page 874, line 4, insert ``, at least one of whom 
     resides in a rural area'' before the first period.
       On page 1390, line 22, insert ``and that at least one 
     member of the Commission is a resident of a rural area'' 
     before the period at the end.

  Mr. DASCHLE. I also ask unanimous consent Senator Paul Wellstone be 
added as a cosponsor.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. DASCHLE. Mr. President, as I explained briefly last night, the 
amendments we are proposing would help rural communities attract and 
retain doctors, nurse practitioners, and physicians assistants; clarify 
types of collaborative efforts and joint ventures that are permissible 
in rural areas; ensure that financial and other assistance is available 
to help rural facilities adjust to the changing health care 
environment, and assist rural providers in forming their own health 
care networks.
  I would like to take a bit more time today to explain what each 
provision in our amendment does.


                     national health service corps

  The centerpiece of this rural health package is increased funding of 
the National Health Service Corps--one of the most important, respected 
work force programs in the country.
  Why does the NHSC funding need to be increased? Most do not know that 
the National Health Service Corps Program was nearly eliminated in the 
1980's, despite the fact 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 few 
years, rural America still badly needs more of these doctors.
  In my home State of South Dakota there are only 14 National Health 
Service Corps [NHSC] physicians. However, South Dakota needs 43 
physicians in order to eliminate its rural underserved areas. We know 
that if the corps had better funding, many more physicians would be 
willing to serve in rural and other underserved areas.
  For example, over 4,000 scholarship applications were submitted to 
the NHSC Program last year, but only 406 awards were made.
  The Office of Rural Health in South Dakota tells me that if the NHSC 
funding was increased, our State would be better able to recruit these 
critical primary care providers.
  This amendment would simply restore funding for the National Health 
Service Corps [NHSC] to its pre-1980 levels so that those willing to 
work in rural underserved areas are not denied the opportunities they 
seek.


           antitrust safe harbors for rural health providers

  This amendment would clarify existing and subsequent antitrust ``safe 
harbors'' specifically for rural providers.
  A ``safe harbor'' is merely a statement by the Department of Justice 
and Federal Trade Commission that if you meet the criteria established 
in the safe harbor, you don't need to worry about antitrust prosecution 
by the DOJ, FTC, and private parties.
  For example, the DOJ and FTC safe harbor guidelines make it clear 
that these agencies will not challenge a merger between two hospitals 
if one of the hospitals has less than 100 beds and has an average 
caseload of 40 patients. This is an example of safe harbor. All our 
amendment would do is help rural providers to know how these safe 
harbors would apply to them.
  I know from speaking with rural providers that this type of 
clarification is badly needed. Rural doctors and hospitals tell me they 
are hesitant to collaborate, to share equipment, to form joint ventures 
or to create networks because they fear antitrust prosecution by the 
Government.
  Even though the DOJ and FTC rarely bring antitrust suits against 
rural providers, the perceived threat of prosecution is inhibiting 
collaborative ventures and networking among rural providers.
  These are exactly the kind of activities we want to be encouraging in 
rural areas--yet providers are reluctant because they don't have the 
type of legal counsel that can clarify for them the complicated 
antitrust guidelines. This provision would provide rural providers with 
clear, easily understood information about antitrust safe harbors.
  I also know that many rural providers are not even aware that these 
antitrust safe harbor guidelines exist. That is why this provision 
would have the DOJ, FTC, and the Department of Health and Human 
Services work together to develop a plan to disseminate this 
information.
  I would like to say one word about what this amendment does not do. 
The provision would not establish any additional safe harbors for rural 
providers nor would it give rural providers broad antitrust immunity. I 
believe as do others that the antitrust safe harbors established by the 
DOJ and FTC are simply not well understood. They need to be explained 
more clearly to rural providers.


                    medicare bonus payments for NPPs

  This provision would make nonphysician practitioners [NPP's] such as 
nurse practitioners and physicians assistants practicing in rural 
underserved areas eligible for the same Medicare bonus payments we 
already provide to doctors.
  As many of you may know, this provision is based on a recommendation 
from the respected Physician Payment Review Commission [PPRC], which 
advises Congress on Medicare part B and other issues.
  Why does the PPRC think we need bonus payments for NPP's? The answer 
is simple--we need to do whatever we can to attract primary care 
providers to rural underserved areas. That's why we already provide 
bonus payments for doctors providing services in rural areas.
  It is also important to remember that many of the same disincentives 
to relocating to rural underserved areas that exist for physicians 
exist for NP's and PA's. These include lack of professional peers, lack 
of health care facilities, and insufficient population base to sustain 
a practice. Providing stronger economic incentives to locate in rural 
areas is the one way to overcome these other disincentives.
  So, it makes sense to extend the bonus payments to other primary care 
providers like nurse practitioners and physicians assistants.
  Making bonus payments available to them will increase access to 
primary care services.
  Moreover, advanced practice nurses receive only 75 percent to 85 
percent of what physicians receive for the same service. These lower 
payments make it more difficult for NP's to set up independent 
practices. Extending the Medicare bonus payments to NP's would help to 
offset this lower payment rate and make it more feasible for them to 
open up practices in rural underserved areas.
  Finally, I want to point out that this provision is budget neutral 
relative to the Mitchell bill.
  The increase in bonus payments for physicians included in the 
Mitchell bill would be only slightly reduced, and the savings achieved 
would finance the NPP bonus payment. The NPP's and the physicians would 
receive the same percentage bonus payments. Our best estimates indicate 
that both physicians and NPP's would receive 17-percent bonus payments.


                   rural managed care demonstrations

  We all know that few managed care plans have entered rural areas.
  To encourage the creation of these plans in rural areas, this 
provision would establish a grant program for the development and 
operation of rural-based managed care networks.
  These grant funds could be used for the development of a rural-based 
managed care networks, for data and information systems including 
telecommunications, for meeting solvency requirements under Medicare, 
for the recruitment of health care providers and for enabling services 
such as transportation and translation services.
  The grant program would be authorized at $10 million annually for 
1996 through 2000.
  Special priority would be given to those plans that would serve rural 
underserved areas and those that involve rural residents and providers 
in the planning and development of the managed care network.


                      rural health clinic funding

  As Senator Rockefeller clearly explained last night, the Mitchell 
bill establishes three grant and loan programs to improve access to 
health care in urban and rural underserved areas.
  The first program provides grants for the development of health care 
networks, sites and services.
  The second program provides grants for and loans capital costs such 
as modernization, renovation, and construction.
  The third program provides grants for supplemental and enabling 
services such as transportation and translation services.
  Under the Mitchell bill, rural health clinics could only receive 
developmental, enabling, and supplemental services funds as part of a 
consortium of community based providers.
  I believe that RHC's, as important providers to the underserved in 
rural areas, must be given the same opportunities Senator Mitchell's 
bill gives other providers to enhance their ability to serve the rural 
communities that depend on them.
  This amendment would allow nonprofit and public rural health clinics 
to be eligible for the development, capital, supplemental and enabling 
funds provided under Senator Mitchell's bill.
  I understand the concern that some have raised regarding Federal 
grants to for-profit rural health clinics. That is why under this 
provision, for-profit RHCs would only be eligible to receive loans for 
capital costs.
  I cannot overemphasize the importance of rural health clinics in 
ensuring access to care in rural communities. These clinics serve a 
disproportionate number of patients that have traditionally lacked 
access to health care.
  A 1994 survey of RHC's revealed that nearly 28 percent of the 
patients in RHC's are on Medicaid, and 14 percent are uninsured. While 
63 percent of the U.S. population has private insurance, only 28 
percent of the patients cared for in an average RHC have private 
insurance.
  I would like to tell you about a rural health clinic that I visited 
in Wall, SD. Wall is a community of about 850 people. The clinic is run 
by Dave Custis who is a physician's assistant.
  Dave has been working in the clinic for the past 10 years. He is a PA 
practicing alone in the rural health clinic. The physician affiliated 
with his clinic is in Rapid City, and the physician comes to the clinic 
only half a day a week.
  The clinic was one of the first rural health clinics in the country, 
opening in the late 1970's. Prior to the clinic opening, no one 
provider consistently worked in the community.
  Physicians had practiced in Wall, but because of hospital closures 
and other factors, the town was not able to consistently keep a rural 
health care provider until the clinic opened.
  The clinic estimates that between 20 and 30 percent of the population 
it serves is uninsured. Without Dave and his clinic, these people 
probably would not receive any health care services, and certainly not 
preventive care.
  Seeking the providers in this and other rural health clinics in my 
State work tirelessly, often under adverse conditions, has convinced me 
we need to help these facilities in enhancing their ability to provide 
care.
  In closing, let me emphasize that these amendments build on the 
strong base Senator Mitchell's bill provides and they would simply 
enhance and supplement the rural provisions contained in his bill to 
ensure that health reform benefits rural and urban areas alike.
  I ask unanimous consent the USA Today article that featured Dave's 
clinic be printed in the Record.
  There being no objection, the article was ordered to be printed in 
the Record. as follows:

                    [From USA Today, Feb. 18, 1994]

In South Dakota, Problem Is Plain--Too Few Doctors--State Typifies the 
                Problems of medical Care in Rural Areas

                           (By Richard Wolf)

       Nestled between the Badlands and the Black Hills deep in 
     cattle country, health-care reform is a four-letter word: 
     Dave.
       Forget managed competition, employer mandates and a menu of 
     health plans. The ranchers and farmers out here--30 miles 
     from the nearest doctor and hospital--are dependent on 
     physician assistant Dave Custis for their care.
       ``I do all my own X-rays, I draw all the blood, I give all 
     the shots,'' Custis says, while juggling his Wall Clinic 
     caseload of colicky infants, frail Medicare patients and 
     occasional emergencies. ``We're out here on the front line of 
     medicine, and we don't have the technology to go with it.''
       The slice of rural America Hillary Rodham Clinton visits 
     today in Lennox, S.D., needs health-care help far more basic 
     than the complex prescriptions now under review in 
     Washington, to solve problems far more life-threatening:
       Manpower. Doctors are hard to find and keep, making 
     physician assistants, nurse-practitioners and county nurses a 
     godsend for people in small towns. The nation has one doctor 
     for every 400 people; in South Dakota, it's one for 600.
       Distances. When emergencies or illnesses are too much for 
     those front-line medics to handle, it's not unusual for 
     expectant mothers, accident victims or heart-attack patients 
     to travel an hour or two to the nearest hospital.
       In the 1940s, South Dakota had doctors in 165 places. Today 
     they're at just 69 locations.
       Money. Rising insurance premiums and medical bills take a 
     toll on a population dominated by the elderly, the self-
     employed and small businesses. Clinics and hospitals struggle 
     to balance books, with lower federal reimbursements.
       All those hardships come together in places like Wall, home 
     of Wall Drug Store. Billboards all along Interstate 90 tout 
     the store's 5-cent coffee and buffalo burgers.
       Custis sees 6,000 patients annually and sends some an hour 
     away to Rapid City. The clinic, which lost its lone doctor in 
     1991, turned a $985 profit last year--far short of the mark 
     needed to get Custis some help.
       ``If we didn't have `Doc,' we would be lost,'' says Betty 
     Dunker, 43, who visits Custis for anything from a bad cold to 
     treatment for multiple sclerosis. ``He'll make house calls.''
       That's the kind of care required in rural America:
       It's home to one-quarter of the U.S. population, but more 
     than one-half of all Americans living in areas officially 
     designated as short on doctors.
       More than 14 percent of rural residents go without 
     insurance for at least a year; 18 percent of farm families 
     lack insurance.
       The South Dakota story is like others. About 100,000 
     residents, one-seventh of the population, go ``bare''--
     without insurance. Two-thirds of the state has a shortage of 
     primary care.
       ``Health care is tentative. You can't count on it,'' says 
     Sen. Tom Daschle, D-S.D., as he pilots a plane to Wall to 
     meet with ranchers.
       At the Wall Clinic, mammograms are a road show from Rapid 
     City, a dentist stops by once a week, and orthodontia is 
     offered every six weeks.
       Thirty miles east in Philip, two doctors staff a clinic, 
     20-bed hospital and 30-bed nursing home for the area's 3,500 
     people. They're the only doctors between Pierre and Rapid 
     City, a distance of about 150 miles--and their stories 
     illustrate the manpower problem.
       George Mangulis, 71, is a Latvian-born doctor with a 
     medical degree from Germany who has hunkered down in western 
     South Dakota for four decades. Over the years, U.S.-educated 
     doctors recruited to help him have come and gone.
       ``We are like a transit station,'' Mangulis says. ``We are 
     struggling about how to make the ends meet.''
       Coenraad Klopper, 46 is a South African doctor recruited in 
     1991 from Saskatchewan after battles over residency and 
     certification. Unlike his predecessors, he has remained, but, 
     as Mangulis reduces his hours, Klopper is overworked.
       ``We do anything which comes along,'' he says. ``Out here, 
     you're it. You don't have any off time. You can't go 
     anywhere, you can't do anything.''
       To these and other rural Americans, health-care reform 
     holds both promise and peril.
       Among the promises are incentives aimed at boosting the 
     number of medical school graduates who enter primary care, 
     placing them in rural areas and expanding the roles of non-
     physician providers.
       Among the perils are additional cuts in Medicare, which 
     could further reduce already restrictive rural reimbursement 
     rates, and a system of mandatory consumer purchasing groups 
     that could prove difficult to implement in sparsely populated 
     states.
       Those new alliances--plus mandates that employers must 
     provide insurance, and price caps on insurance premiums--are 
     supposed to create President Clinton's vision of ``managed 
     competition.''
       But in Wall, where there's just one physician assistant and 
     few insurance plans, there's no competition to manage.
       Says Daschle, a defender of the Clinton plan: ``There is a 
     realization that you can't run South Dakota's health care 
     program like New York or Florida would run theirs.''

  Mr. DURENBERGER. Mr. President, there is no single issue that unites 
the concern of rural Americans more than access to quality health care. 
It is one of the crucial components of rural quality of life, which 
keeps and attracts people to small towns. A major obstacle is the 
financial squeeze faced by many rural hospitals and physicians because 
the reimbursements from Medicaid and Medicare are often much less than 
the cost of the specific medical procedures. These inequities are what 
I have been working to resolve during my years in the Senate.
  Approximately 27 percent of the Nation's population lives in rural 
America. However, the rural population is disproportionately poor, 
experiences significantly higher rates of chronic illness and 
disability, and is aging at a faster rate than the Nation as a whole. 
In rural areas, the elderly accounted for 13.8 percent of the 
population, but 22.5 percent of all physicians visits.
  The Medicare payment has had a negative effect on many rural 
hospitals. A CBO report concluded that payments to rural hospitals have 
been much lower, relative to their costs, than payment to urban 
hospitals. And there is a constant threat of closure of rural 
hospitals, clinics, and other rural health care providers. Since 1986, 
14 rural hospitals have closed in Minnesota and another 8 are 
identified as high financial risk institutions.
  The goal of this amendment is laudable. I believe my colleagues look 
at this as a means to improve access to quality health care in rural 
America. But it falls far short of addressing the inequities in current 
law and perpetuated in the Mitchell bill.


                            rural physicians

  If we want to help rural physicians, we should not burden them with 
more Medicare cuts and then on top of it mandate that they accept the 
Medicare rate as payment in full. The Mitchell bill gives physicians 
two choices: Either accept Medicare payment in full or do not treat 
Medicare patients at all. It eliminates their ability to help meet 
their costs by billing those patients who can afford to pay more. 
Current law, allows physician to balance bill up to 110 percent of the 
Medicare allowable charge.
  The Physician Payment Review Commission [PPRC] reported to Congress 
that Medicare is now paying physicians only 59 percent of what private 
insurers pay. And health reform takes another chunk out of Medicare 
payment rates. What impact will this have on beneficiary access to 
physicians--especially in rural areas? To date, we have seen a number 
of physicians already refuse to accept new Medicaid patients because 
payment rates markedly fell.


                            rural hospitals

  If we want to help rural hospitals we should eliminate the need to 
shift costs to make up for Medicare's underpayment. In rural areas and 
the poorer areas of our cities, this is a recipe for disaster because 
they lack a large base of private payers to make up the loss.
  My colleagues from States with rural areas will want to take a look 
at this chart. For United Hospital, which serves a largely middle-class 
population in St. Paul, we see that 42 percent of the patients are on 
Medicare or Medicaid. The loss that the hospital suffers on those 
patients can be passed on to the larger population of patients, nearly 
58 percent, who pay themselves or have private insurance.
  Fairview Ridges Hospital in Burnsville, which serves a suburban, 
upper-middle-class population, has a much easier time absorbing 
Medicare's underpayment since it only accounts for 14.4 percent of 
patients and private insurance account for nearly 80 percent.
  But look at what Medicare cuts do to a rural county hospital in 
northern Minnesota. The Tri-County Hospital in Wadena has 70 percent of 
their patients paid for through Medicare and Medicaid. How is this 
hospital going to make it? They have a mere 27 percent of their 
patients in private plans and another 3 percent who self pay. Where can 
Tri-County shift its losses from the Government-run program? Twenty-two 
percent of the population is below the poverty level.
  This rural hospital is not going to make it unless Congress does 
something about the Medicare Program. Universal coverage will do 
nothing for them. Reforming the Medicare Program, on the other hand, 
will give them the chance they need to survive and continue to serve 
that area.


                           rural managed care

  Mr. President, this amendment seems to recognize that need on the 
surface. It provides grants to develop managed care networks in rural 
areas if they incorporate the Medicare population. But if we want to 
help rural managed care develop--first, we must address the payment 
problems. This amendment tells the Secretary to study the payment 
problems--without even requiring a timetable to report back. It's the 
long-term instability of payment that is a problem for rural areas.
  What good will grants do if we fail to address the way we pay private 
health plans for accepting Medicare beneficiaries? Even if we help 
networks develop, why will they want to seek to enroll Medicare 
beneficiaries? The payment is now tied to the historical cost of fee-
for-service care county by county.
  Rural areas are plagued by access problems. Yesterday, my colleague 
from Nevada, Mr. Reid told us that some counties in his State do not 
even have a physician or have only one. Obviously, we can expect some 
low historical patterns of utilization in these counties. For example, 
Medicare will pay plans serving residents of White Pine County, NV, 
$251.10 per month. Yet the national average per capita cost is $378.13 
per month. And, the payment rates vary more than 300 percent 
nationally. This does not leave much question regarding why plans may 
not be attracted to serve Medicare beneficiaries in this area of 
Nevada. Providing grant money alone to set up in the area wouldn't do 
it either. More importantly, paying plans based on the fee-for-service 
cost of a rural area with little access to quality care will not 
support the formation of managed care networks.
  Today's Medicare managed care plans flock to high-cost areas where 
they are doing very well--because we pay them based solely on fee-for-
service cost--not based on their cost in a more efficient system.
  The only way to help rural America is to support rural America. To 
pay the cost of care--not to discount it and expect rural providers to 
make it up elsewhere. Inherent cost-shifting will not attract efficient 
care delivery. The answer is to give every American the opportunity to 
purchase a private health plan. In the underlying amendment, the 
Mitchell bill does it for the Medicaid population. But why is Congress 
choosing to deny seniors and the disabled the very same opportunities 
as the rest of America? The problems of rural America will be better 
addressed when all individuals are insured through the private system.
  We can do so much more. Both this bill and this amendment fail to 
send a strong message to rural America. It fails to say ``Washington 
cares about your problems and wants to help ensure access to quality 
health care.''
  Only a commitment to reforming all parts of the health care system, 
the publicly paid and the private, can we give rural America a fair 
opportunity.
  Mr. DORGAN. Mr. President, I rise in strong support of the Daschle 
amendment on rural health care. America's rural communities have unique 
health care needs that we must address if we ever hope to achieve truly 
national health care reforms. The rural health amendments offered by my 
good friend and colleague Tom Daschle will significantly improve health 
care in rural America.
  First, we must make sure our rural communities have the medical 
professionals necessary to provide high-quality care: 85 percent of 
North Dakota's counties do not have enough health care providers to 
provide adequate care for the county's residents; 13 North Dakota 
counties had no physician residing in them in 1992; and 2 counties had 
neither a hospital or a clinic.
  By increasing funding for the National Health Service Corps [NHSC], 
this amendment will encourage individuals to join health care 
professions and work in areas with shortages of health care providers. 
This amendment will provide scholarships and student-loan repayment 
programs for more than 14,000 physicians, nurses, and physicians 
assistants over the next 10 years.
  North Dakota's small communities are spread far apart. People 
rightfully worry how they are going to get health care in an emergency. 
So, second, this amendment will establish grant programs to allow 
States to develop rural emergency medical systems. I have cosponsored 
similar legislation in the Senate and I am encouraged that States will 
have these grants available to create or enhance air medical transport 
systems that effectively will bring rural residents closer to critical 
lifesaving treatment.
  Third, this amendment will provide grants for telemedicine programs 
to bring sophisticated medicine to small-town health care providers. A 
physician in Bismarck, or even across the country, literally could read 
the x ray or analyze the heartbeat of a patient at a clinic 100 miles 
away. These grants will bring telemedicine hookups to more North Dakota 
communities.
  Fourth, health care reform must expand the role of nonphysician 
practitioners and I am glad this amendment will help tear down the 
barriers that advanced practice nurses and physician assistants face 
when they try to set up practice in rural areas. In some North Dakota 
communities, these medical professionals provide the only health care 
available, and we ought to help them.
  North Dakota has one of the few successful rural health maintenance 
organizations [HMO] in the Nation, the Heart of America Health Plan. 
This health care plan has been extremely successful in delivering high-
quality care to the residents of Rugby, ND, in a very cost-effective 
manner. A fifth provision of this amendment will fund development of 
more rural managed-care organizations like Heart of America.
  Sixth, antitrust provisions in this amendment will encourage 
partnerships between urban and rural providers to expand medical 
services available to rural communities. Many collaborative ventures 
and mergers already have expanded access to health care services in 
North Dakota. This provision will help clear the way for other projects 
that expand access in rural communities.
  Health care reform must address the needs of rural America. This 
amendment will go a long way to ensure that rural Americans receive the 
High-quality health care we all expect. Mr. President, I urge my 
colleagues to support the amendment.
  Mr. CAMPBELL. Mr. President, it is with great pleasure that I 
cosponsor the rural health amendments offered by Senator Daschle. The 
majority leader's bill includes a substantial set of rural health 
provisions, and he should be commended for trying to ensure that rural 
communities are included in health care reform. The Daschle amendments 
build on the base set in the Mitchell bill to expand much-needed health 
care services in rural communities.
  Rural health care issues are especially important to me and my State. 
More than 17 percent of Colorado residents live in rural communities. 
Rural residents, whether they have health insurance coverage or not, 
are at a particular disadvantage when it comes to receiving health 
care. The problem for rural residents is primarily one of access.
  These amendments would increase access by offering incentives for 
health care providers to locate in rural areas or expand current 
services. Managed care programs would be offered developmental and 
operational grants to encourage rural-based managed care networks. The 
bonus payments now available to doctors would be extended to advanced 
practice nurses and physicians assistants, vital providers of health 
care in rural areas.
  The National Health Service Corps scholarship and loan repayment 
programs would be expanded to encourage more medical students to become 
primary care physicians. This program carries an obligation to provide 
1 year of medical services for each year of educational assistance. 
Although the National Health Service Corps is an important source of 
primary health care professionals in underserved areas, this program 
has been drastically cut back in recent years. The proposed amendments 
would increase funding for this valuable program and boost the number 
of much-needed health professionals serving rural areas.
  More providers and more clinics mean greater access to care. By 
providing greater access to health care services to rural residents, we 
can encourage preventive health care. The resident who has to drive 50 
miles to see a doctor most likely will not do so until he or she is 
very sick.
  If a doctor is only 10 to 20 miles away, a mother is more likely to 
take her child in for a measles shot, a diabetic is more likely to get 
treatment before going into a diabetic coma. Preventive care saves 
money by treating a condition before it exists or before it advances to 
a more serious stage that is more costly to treat.
  And so, Mr. President, it is with great pride that I add my support 
to the Daschle rural health amendments. Rural areas need different 
things from health care reform than urban and suburban areas. Health 
care reform presents an opportunity to improve health care in rural 
areas. These provisions seek to supply greater access to care in 
underserved rural communities. Americans deserve to have the same 
access to health care as their Representatives in Congress do, 
regardless of where they live.
  Mr. SIMPSON. Mr. President, rural health care is experiencing a 
renaissance of interest in Congress. In fact, even frontier health 
care--a term several of us coined for what we have in Wyoming and other 
similarly situated States--is even gaining the attention of 
policymakers. I want to join Senator Stevens for acknowledging earlier 
today that the States of Alaska, Montana, and Wyoming have unique 
needs. Our States have much in common regarding the delivery of health 
care to our constituent populations. I want Senator Stevens to know 
that I will most gladly join his Frontier Health Caucus.
  The last few years have witnessed an alarming number of hospital 
closures in rural areas, the loss of physicians to more sophisticated 
and profitable urban settings, and a shrinking pool of allied health 
and community service professionals in virtually every field. At the 
same time, the population of rural America is growing older and more 
frail--requiring more and higher levels of service.
  Clearly, we in Congress have reason to be seriously concerned about 
issues of access to health and supportive services in rural and 
frontier regions. Our challenge is to craft a public policy response 
that is appropriate to all rural regions, including--and particularly 
from my perspective--frontier Wyoming.
  I am pleased to see the inclusion of many provisions pertaining to 
rural health care in this bill. As Senator Grassley noted last evening, 
many of these provisions were recommended previously by the bipartisan 
rural health care task force. This is one area of health care that has 
always been bipartisan, and it is important for all of us to work 
together in furthering our main objective--bringing the highest quality 
health care to rural and frontier America.
  However, I did notice that ``frontier'' is not mentioned anywhere in 
Senator Mitchell's 1,400 page document. All of us from rural and 
frontier areas--including both Senators from Alaska--worked very hard 
in the Republican health care task force to get our message across that 
rural and frontier States have unique needs. Finally they heard us. 
Everyone on the task force finally understood that rural health care 
must be addressed within the context of the health care debate--and, I 
was very pleased to see that ``frontier'' health care was given a 
distinct status and definition in both the Chafee and Dole bills.
  Rural America, as we have heard today is quite diverse and complex. 
Although close in population, Vermont and Wyoming are vastly different 
in terms of heritage, resources, economic base, and geography. In fact 
the entire State of Vermont could fit into two of Wyoming's 
southwestern counties. Iowa, with its urban centers and small towns 
sprinkled every 10 or 20 miles in between is considered by Washington, 
DC regulators to be the very epitome of a rural state. Wyoming clearly 
does not fit that model. No indeed. Not in the land of high altitude 
and low multitude--where our major towns are far apart and the people 
are scarce in between. Yet my colleagues here in Washington seem to 
believe that if a program or a rule or regulation will work in Iowa, 
then it will work anywhere rural, including Wyoming. We have been 
hearing a lot about rural health care today so I wanted to come to the 
floor and talk about what kind of health care we have in Wyoming.
  In Wyoming, we are talking about nearly 98,000 square miles with an 
average population density of less than five people per square mile. 
Twenty percent of the population is in either Cheyenne or Casper which 
each have about 50,000 people. The remainder of the State has a density 
of less than four persons per square mile.
  Wyoming has 26 acute care hospitals or one hospital for every 3,600 
square miles--or one hospital for every 18,000 people. The population 
per hospital is why so many of them are on the ropes financially. The 
area covered is why they are medically essential.
  We need basic providers in Wyoming. With only 26 hospitals, no 
federally qualified community health centers, and only 5 rural health 
clinics, we are in desperate need of just basic providers. For example, 
at the present time, the Basin-Greybull area in northwest Wyoming has 
been reeling over the past year from the effects of a hospital closing 
between those two towns. The county hospital district in this area has 
established a rural clinic located at the closed hospital and has just 
applied for rural health clinic designation for the clinic. This 
designation would allow the clinic to receive cost-based reimbursement 
for each of the Medicare-Medicaid patients seen there.
  This rural clinic designation is much easier to obtain than the 
federally qualified health center designation. Still we only have five 
rural clinics, but hopefully more of them coming in the future. This 
type of clinic would go a long way for us in treating people in the 
basin area and in most areas of Wyoming, especially for emergency 
services, which are always so desperately needed in rural areas.
  What primarily concerns me about the rural provisions contained in 
the finance bill, and the Mitchell bill is that they do not contain 
enough flexibility for frontier States. My colleagues here in Congress 
seem to have this know best approach to rural health which has limited 
flexibility. This lack of flexibility saps the vitality, creativity, 
and resourcefulness from the very programs that have been developed to 
help rural areas, and may drain funds from other areas that local 
policymakers have identified as more pressing priorities. In a State 
like Wyoming, with so few resources at its own disposal and so many 
urgent needs, this lack of flexibility can be devastating. When we look 
at these bills, we are looking for greater flexibility in obtaining 
needed Federal grants and loans. For example in the Mitchell bill, 
under Subtitle E, Health Services for Medically Underserved 
Populations, there are much needed grants available for the planning 
and development of networks of providers and plans. These grants can be 
used for the expansion, development, and ongoing operation of health 
delivery sites. Direct loans and grants are also available for capital 
costs including the modernization, conversion, and expansion of 
facilities. There is a list of entities that are eligible to receive 
these grants and loans--and lo and behold, most of the eligible 
entities are located in urban underserved areas. By limiting 
eligibility, this section has the perverse effect of excluding the very 
communities that are most in need of capital and infrastructure funds. 
We need a flexible definition of eligible entities included in this 
section, if this bill is going to accomplish assisting all underserved 
areas--not just urban underserved areas.
  Finally, I want to briefly discuss telemedicine and the promise it 
holds for rural and frontier areas. I was particularly heartened to see 
that demonstration projects for telemedicine are included under the 
Mitchell bill as they are under the Dole bill. Physicians and 
nonphysicians in Wyoming could benefit greatly from the use of 
telemedicine. They could be connected through interactive video for 
consultations with hospital and medical school staff from across the 
country. A solo practitioner would not feel as isolated while 
practicing in a rural area if he or she knew he or she could consult 
with other physicians on a particular case. In addition, physicians in 
rural areas would not have to travel to educational seminars and 
conferences if they could receive continuing education training through 
computer video. I believe telemedicine is the future for rural areas 
and that we should do everything we can to promote its use. Rural areas 
need start-up moneys and capital for planning telemedicine systems and 
for the purchase of computer hardware, software, and interactive video 
equipment. The moneys included in both the Mitchell and Dole bills 
would go toward these types of worthwhile projects.
  I wholeheartedly support all of our bipartisan efforts in Congress to 
implement rural health care policies that are responsive to the very 
special needs and circumstances of all of the rural, including frontier 
States, which we represent.
  Mr. WELLSTONE. Mr. President, I am delighted to support the amendment 
of my colleague from South Dakota.
  Nearly half the population of Minnesota and nearly half the people in 
the Nation live outside our major metropolitan areas. Often when we 
discuss health care reform we focus on urban communities because that 
is where the high-technology subspecialty care is found. But health 
care in rural American is an essential link in our health care system. 
We need a strong rural health care system to have a health care system 
that works for all Americans.
  When we discuss universal care we must remember that access to a 
health care provider is a necessary component of that universality. In 
a growing number of rural areas there is shrinking choice of provider 
and it is increasingly difficult to find a doctor or other health care 
provider in many rural areas. People in rural Minnesota tell me they 
really want to keep their doctor in town.
  The revival of the National Health Service Corps that this amendment 
calls for is an important emergency measure while we rebuild the 
primary care system in rural America.
  We must also support the work of health care providers in our rural 
communities who are working to organize a revitalization of rural 
health care. There are many rural physicians and health care 
professionals in Minnesota who are leading the way.
  These are real people who have committed their lives to this effort. 
I think of Dr. Ray Christensen, who lives and practices in the town of 
Moose Lake, MN. Dr. Christensen is a life long rural resident and a 
leader in rural health care in Minnesota. And I think of Terry Hill, 
executive director of the Northern Lakes Health Care Consortium in 
Duluth, MN. They are both working on recruitment of primary care 
physicians to rural communities and have had some important successes.
  Two important examples of success achieved by the rural health 
community are Grand Marais, MN, where a few years ago the hospital was 
in danger of closing and with a lot of work has been turned around. It 
is now a growing concern. And Silver Bay, MN, where a rural clinic was 
near closing and has been kept open. Both of these victories for rural 
health have been enabled by the ongoing support from their local 
communities and health care providers in the region.
  We must also support the work of those medical schools that have 
taken on the challenge of training rural physicians. Dr. Ron Franks, 
dean of the Medical School at the University of Minnesota, Duluth has 
done tremendous work in this area. At UMD they understand the 
importance of recruiting medical students from rural communities. 
During their medical education they get these students into rural 
clinics to see what rural practice is like. And they help the students 
develop contacts in the rural health community to support them in their 
rural practices.
  This amendment also gives needed support for nurse practitioners and 
physician assistants with more adequate reimbursement, by allowing some 
of them to receive Medicare bonus payments at the same rate as 
physicians providing primary care in underserved areas.
  Another issue that is addressed by this amendment is the important 
concern of rural residents that they do not want the rural health care 
system taken over by urban based insurance companies. In Minnesota, 
there is growing concern that urban based insurance companies are not 
sensitive to the real needs of the rural population. We have to make 
sure these rural voices are heard.
  In this amendment, steps are taken in this direction by increasing 
the rural representation on boards created in the Mitchell legislation. 
We must listen to rural physicians, nurses, physician assistants and 
nurse practitioners, and rural consumers. They are in the trenches 
every day making our rural health care system work and they have a lot 
to teach us.
  This amendment does not solve all the health care problems facing 
rural America but it makes a start. I hope we will all pledge that as 
we continue our efforts to reform the health care system we will set 
the same standards for rural health care that we do for ourselves here 
in the Senate--all rural Americans should be covered with a decent 
benefits package, all should be ensured accessibility of care not just 
insurance, people should be guaranteed that needed care is affordable 
and they should have a choice of health care provider.
  I urge my colleagues to support the Daschle amendment.
  Mr. MOYNIHAN. Mr. President, I believe the time has come to vote.


                vote on amendment no. 2564, as modified

  The PRESIDING OFFICER. Under the previous order, the question is on 
amendment No. 2564, as modified, by the Senator from South Dakota [Mr. 
Daschle].
  Mr. MOYNIHAN. Mr. President, have the yeas and nays been ordered?
  The PRESIDING OFFICER. The yeas and nays have been ordered.
  The clerk will call the roll.
  The assistant legislative clerk called the roll.
  Mr. FORD. I announce that the Senator from Maryland [Ms. Mikulski] is 
necessarily absent.
  Mr. SIMPSON. I announce that the Senator from Maine [Mr. Cohen] is 
necessarily absent.
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
who desire to vote?
  The result was announced--yeas 94, nays 4, as follows:

                      [Rollcall Vote No. 290 Leg.]

                                YEAS--94

     Akaka
     Baucus
     Bennett
     Biden
     Bingaman
     Bond
     Boren
     Boxer
     Bradley
     Breaux
     Brown
     Bryan
     Bumpers
     Burns
     Byrd
     Campbell
     Chafee
     Coats
     Cochran
     Conrad
     Coverdell
     Craig
     D'Amato
     Daschle
     DeConcini
     Dodd
     Dole
     Domenici
     Dorgan
     Exon
     Faircloth
     Feingold
     Feinstein
     Ford
     Glenn
     Gorton
     Graham
     Gramm
     Grassley
     Harkin
     Hatch
     Hatfield
     Heflin
     Helms
     Hollings
     Hutchison
     Inouye
     Jeffords
     Johnston
     Kassebaum
     Kempthorne
     Kennedy
     Kerrey
     Kerry
     Kohl
     Lautenberg
     Leahy
     Levin
     Lieberman
     Lott
     Lugar
     Mack
     Mathews
     McCain
     McConnell
     Metzenbaum
     Mitchell
     Moseley-Braun
     Moynihan
     Murkowski
     Murray
     Nickles
     Nunn
     Packwood
     Pell
     Pressler
     Pryor
     Reid
     Riegle
     Robb
     Rockefeller
     Sarbanes
     Sasser
     Shelby
     Simon
     Simpson
     Smith
     Specter
     Stevens
     Thurmond
     Wallop
     Warner
     Wellstone
     Wofford

                                NAYS--4

     Danforth
     Durenberger
     Gregg
     Roth

                             NOT VOTING--2

     Cohen
     Mikulski
       
  So the amendment (No. 2564), as modified, was agreed to.
  Mr. MOYNIHAN. Mr. President, I move to reconsider the vote.
  Mrs. BOXER. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.
  Mr. DOLE addressed the Chair.
  The PRESIDING OFFICER. The Republican leader.
  Mr. DOLE. As I understand now, the Republicans will offer an 
amendment.
  Mr. MOYNIHAN. Yes.
  Mr. DOLE. Mr. President, I just wanted to clarify, it is my 
understanding under our sort of loose arrangement here the Democrats 
offered the rural amendment. Some of us may still want to speak on that 
amendment, because we tried to accommodate a couple of colleagues who 
had to catch a plane, so there may be some speeches after the fact. I 
think Senators Mack and Coats are prepared to offer their amendment. I 
wonder, if they wanted to lay their amendment down, if I might be 
permitted to speak for 5 minutes on the amendment we just passed.


                           Amendment No. 2568

  (Purpose: To assure that decisions critical to the health and well-
being of all Americans be made with public knowledge and not in secret)

  Mr. MACK addressed the Chair.
  The PRESIDING OFFICER (Mr. Dorgan). The Chair recognizes the Senator 
from Florida.
  Mr. MACK. I have an amendment to send to the desk.
  The PRESIDING OFFICER. The clerk will report the amendment.
  The legislative clerk read as follows:

       The Senator from Florida [Mr. Mack] for himself and Mr. 
     Coats, proposes an amendment numbered 2568.

  Mr. MACK. Mr. President, I ask unanimous consent that reading of the 
amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

       On page 129, strike line 13 and all that follows through 
     line 16.
       On page 263, insert between lines 15 and 16 the following 
     new section:

     SEC. 1604. APPLICATION OF THE FEDERAL ADVISORY COMMITTEE ACT 
                   AND THE PROVISIONS OF TITLE 5, UNITED STATES 
                   CODE.

       (a) Federal Advisory Committee Act.--
       (1) In general.--Subject to paragraph (2) of this 
     subsection, the provisions of the Federal Advisory Committee 
     Act (5 U.S.C. App.) shall apply to any entity that--
       (A) is established by or pursuant to this Act or is 
     established or required to be established by an entity 
     created under this Act; and
       (B) is an advisory committee as defined under section 3(2) 
     of the Federal Advisory Committee Act.
       (2) Exception.--A provision of the Federal Advisory 
     Committee Act shall not apply to an entity described under 
     paragraph (1) only if a provision of this Act expressly 
     provides that such specified provision (or all provisions) of 
     the Federal Advisory Committee Act shall not apply to such 
     entity.
       (b) Title 5, United States Code.--
       (1) In general.--Subject to paragraph (2) of this 
     subsection, the provisions of title 5, United States Code, 
     shall apply to any board or other similar entity that--
       (A) is established by or pursuant to this Act; and
       (B) is not an advisory committee as defined under section 
     3(2) of the Federal Advisory Committee Act.
       (2) Exception.--A provision of title 5, United States Code, 
     shall not apply to an entity described under paragraph (1) 
     only if a provision of this Act expressly provides that such 
     provision (or all provisions) of title 5, United States Code, 
     shall not apply to such entity.
       On page 605, strike line 3 and all that follows through 
     line 13.
       On page 1409, strike line 1 and all that follows through 
     line 3.

  Mr. MACK. Mr. President, I know that there will be quite a discussion 
on this amendment which really has to do with the issue of secrecy and 
the number of commissions. The Mitchell proposal, in fact, exempted 
certain of the commissions from public scrutiny. This amendment goes to 
the heart of that issue, and will strike that exemption.
  I yield the floor.
  Mr. MOYNIHAN. Mr. President, may I just say briefly to my friend from 
Florida that I am sure he will find a good deal of support on this side 
of the aisle for his amendment, and look forward to the debate.
  Mr. DOLE. Mr. President, we have just adopted, I guess by an 
overwhelming vote, an amendment dealing with rural health care. Some of 
us did not have an opportunity to speak because we were accommodating a 
couple of our colleagues who had to catch a 12 o'clock plane.
  Mr. President, I commend my colleague, Senator Daschle from South 
Dakota, for bringing the issue before the Senate because health care 
for rural Americans is a very important issue.
  Mr. President, on January 21, 1993, I was in this Chamber and I laid 
out the initiatives that I hoped Congress would accomplish in the 103d 
Congress. On that day I said I was going to introduce a comprehensive 
health care reform proposal because of my strong belief that 
responsible health care reform was going to have to be drafted on a 
bipartisan basis with the support of at least 80 or 90 percent of the 
Senate. I have not given up on that effort either. However, I did say 
January 21 that there was one area I was concerned about that I would 
be working on that we could not afford to delay, and that was health 
care reform for rural America.
  So I on that day, Mr. President, I introduced the rural health care 
bill to improve access to health care in rural America, and that bill 
received broad bipartisan support.
  The point I would make is that I am happy to see that we have the 
groundswell for support for rural health care. Rural Americans make up 
about 20 percent of the population. Contrary to what some may believe, 
rural Americans are as much of a diverse group of Americans as any 
living in other parts of the country. That is why, when proposing 
health care reforms, rural Americans are no more likely to adopt a one-
size-fits-all model than are Americans living in any other part of the 
country.
  Many of these provisions we have now put in the Mitchell bill, if 
adopted, are in the so-called Dole-Packwood bill which was sponsored by 
38 Republicans along with myself and Senator Packwood.
  Again, I say it is not a partisan bill. It is called The American 
Option. We still have to attract colleagues on the other side of the 
aisle to this bill. Many of these provisions are quite technical, but I 
think they follow along. In fact, probably the amendment that we just 
passed would supplement some of the things we have done in our bill.
  So, while we do have our fair share of disagreements in this Chamber 
on the issue of health care reform, I am happy to see the groundswell 
of support to make rural health care better and more accessible.
  Rural Americans make up about 20 percent of the population. And, 
contrary to what some may believe, rural Americans are as diverse a 
group as Americans living in any other part of the country. That's why 
when proposing health care reforms, rural Americans are no more likely 
to adapt to a one-size-fits-all model than are Americans living in any 
other part of the country.
  Mr. President, Senator Packwood and I, along with 38 of our 
colleagues have incorporated many of these provisions in the American 
option plan that we introduced on August 9. In that bill, we give 
special consideration to rural Americans.
  Mr. President, as rural Americans know all too well, access to health 
care providers can be just as much of a challenge in rural America as 
is cost. That is why in our bill we have special provisions to improve 
access to health care in rural America.
  Many of these provisions are quite technical, but let me just 
summarize what they would accomplish.
  More primary care: The way Medicare reimburses medical education 
would be changed so that young physicians can be trained in places like 
community health centers, or other out-patient settings, where more 
primary care providers are likely to be trained.
  Improved reimbursement for nurse practitioners and other nonphysician 
providers to encourage more of these providers to practice in rural 
areas.
  Better access to rural hospital by extending payments for Medicare 
dependent hospitals through 1998. The Dole-Packwood proposal recognizes 
that these payments may make the difference between keeping a 
hospital's doors open or not.
  Establishment of telecommunication grants in rural areas, so that 
providers practicing in these areas have better information and the 
ability to communicate with providers in distant areas.

  Mr. President, take for example a case involving a doctor in Hays, 
KS. He was stumped by a young boy experiencing paralysis of the right 
side. Unlike stroke victims, the paralysis was sporadic and difficult 
to diagnose. During one such episode, the doctor and patient used a new 
telemedicine link-up site. Two hours later, a specialist 266 miles away 
in Kansas City diagnosed the condition and prescribed the proper 
medication. The boy is now back on his feet again, all without leaving 
his hometown.
  No doubt about it, two-way interactive video, through telemedicine 
provisions in this amendment, as well as in the Dole-Packwood bill, 
improves health care and can save lives.
  Mr. President, I support this amendment because of provisions such as 
this. The Dole-Packwood bill would also help rural Americans through 
many of its insurance market reforms.
  For example, rural Americans are more likely to be self-employed or 
work for a small business that does not provide health insurance. In 
fact, over 90 percent of the businesses in my home State of Kansas have 
fewer than 10 employees.
  Under current law, individuals who purchase their own insurance are 
not able to deduct the cost of that insurance. The Dole-Packwood bill 
would phase in full deductibility of health insurance so that those who 
are self-employed or who buy their own insurance are treated the same 
as those employed by large businesses.
  I would note that the bill introduced by the majority leader would 
only allow for a 50-percent deductibility of insurance premiums by the 
self-employed. For those buying their own insurance, the difference 
between 50 percent deductibility and 100 percent deductibility may 
greatly influence the decision to purchase insurance or not.
  Mr. President, I ask unanimous consent that a list of provisions in 
the Dole-Packwood bill that specifically target rural areas be printed 
in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

  Provisions in Dole-Packwood Proposal Specifically Targeted to Rural 
                                 Areas

       1. Extend Essential Access Community Hospital program and 
     Rural Primary Care Hospital program (E.A.C.H./R.P.C.H.) to 
     all states. Currently only 7 seven states have these grants 
     available to them. The purpose is to enable these smaller 
     hospitals to continue in their mission to provide primary 
     care services to the residents of rural areas.
       2. Better access to rural hospitals by extending payments 
     for Medicare dependent hospitals through 1998. The Dole-
     Packwood proposal recognizes that these payments may make the 
     difference between a hospital keeping its doors open or not.
       3. Expand the Medical Assistance Program to all states. 
     Currently, this program is limited only to the state of 
     Montana--a state which has had a lot of success assisting 
     small rural communities to establish medical facilities.
       4. Non-refundable tax credits for health care personnel who 
     establish practices in medically underserved communities.
       5. Improved reimbursement for nurse practitioners and other 
     non-physician providers to encourage more of these providers 
     to practice in rural areas.
       6. Federal funds available for the development of health 
     care networks in underserved rural communities. Grants and 
     low interest loans would assist with resources needed to 
     develop rural health care facilities.
       7. States may designate medically underserved areas which 
     will then receive special considerations, including service 
     from health plans in adjoining geographic areas, increased 
     compensation for health services, and federal assistance for 
     development of health care services.
       8. Establishment of telecommunication grants in rural 
     areas, so that providers practicing in these areas have 
     better information and the ability to communicate with 
     providers in distant areas.
       9. Provides resources for medical transportation for rural 
     and frontier areas.
       10. Upgrades the federal office of rural health to increase 
     the attention to rural health care needs in the federal 
     establishment.
       11. More primary care: the way Medicare reimburses medical 
     education would be changed so that residents can learn in 
     places like community health centers, or other out-patient 
     settings, where more primary care providers are likely to be 
     trained.
       12. Increased federal support for primary care services for 
     groups most likely to be uninsured or high risk: childhood 
     immunization, maternal and child health, breast and cervical 
     cancer prevention, HIV early detection, tuberculosis 
     prevention, and health care for the homeless.
       13. Increase support for public health service programs, 
     including community health centers, migrant health centers, 
     and federally qualified health centers.
       14. Prospective payment assessment commission (PROPAC) will 
     conduct studies and make recommendations on ways to improve 
     access to health care for vulnerable populations in rural 
     areas.

  Mr. DOLE. I thank my colleague from Florida, Senator Mack, for 
letting me intervene during his debate.
  The PRESIDING OFFICER. Who seeks recognition?
  Mr. GREGG addressed the Chair.
  The PRESIDING OFFICER. The Chair recognizes Senator Gregg.
  Mr. GREGG. Thank you, Mr. President.
  Mr. President, I wanted to address the Senate generally on the issue 
of health care reform. We heard a tremendous amount of discussion about 
the issue of health care reform over the last few days. I think it has 
been extremely informative and worthwhile as we have tried to digest 
and understand this incredibly complex document called the Clinton-
Mitchell bill.
  The implications of that bill for not only health care delivery in 
this country, but actually for the country itself as it moves into the 
next century, are overwhelming and very pervasive.
  I want to talk a little bit about the philosophy of the health care 
reform effort as represented by the Clinton-Mitchell bill, and by the 
attempts put forward by Senator Dole, and Congressman Rowland, and then 
talk a little bit about the specifics of what this bill does in the 
area of impacting States' rights and State's obligations because it is 
overwhelming in its effect on States and how they are going to function 
as we go into this next decade, should it be passed.
  We started out here as a Congress and as a people with the leadership 
of the President and the First Lady, which I certainly commend, in the 
area of saying to the American public that the health care system of 
this country needs some repair.
  There was set out a series of goals, and amongst those goals I think 
there was general agreement; an agreement that we should extend 
coverage, an agreement that we should increase quality, and an 
agreement that we should control costs. I think we also understood that 
in trying to reach those goals, they were inherently in conflict to 
some degree.
  It is difficult, for example, to control costs while expanding 
coverage and to control costs while increasing quality. But still, 
these were very substantive, very appropriate goals for our Nation to 
pursue, and for this Congress to try to address as we look at the 
health care delivery system.
  The President and his people sat down, the First Lady leading the 
exercise, and it was sort of an exercise. And 500 or so people met in 
secret for an extended period of time. They came forward with this 
large opus called ``The Clinton health care bill.'' It was a bill which 
put forward a certain philosophy, not only of how health care should be 
delivered in this country, but actually how Government should function 
in this country.
  When you look at this health care debate, you have to recognize that 
it goes beyond the issue of health because when you are dealing with 14 
percent of the American economy, you are talking about impacting not 
only everybody's life as they pursue it, as to whether or not it is a 
healthy lifestyle or a non-health lifestyle or how they are cared for; 
but we are talking about a large percentage of Americans' financial 
well-being, and the manner in which the economy of the country reacts 
to that financial well-being, especially the relationship of the 
Government to the financial well-being of individuals, and the size of 
the Government specifically as it relates to the individuals, as it 
relates to the Nation as a whole and its percentage of absorption of 
the gross national product.
  So we had in this whole debate from the beginning, not only a desire 
to reach these goals of coverage, quality, and cost control, but we had 
an underlying philosophical debate in trying to reach these goals which 
involved the question of how we govern ourselves as a society.
  There is no question in my mind but that in the President's proposal, 
which has basically borne these additional proposals which we see today 
in the area of the Clinton-Mitchell plan or in the Gephardt proposal, 
but in these proposals we see a philosophy of government which 
subscribes to one set of values. Whereas, in proposals set forth by 
Senator Dole, we see here, having been presented in this House with 39 
sponsors, Senator Nickles or Senator Gramm, we have a different 
philosophy, and a different approach.
  I think it is important to analyze or talk at least a little bit 
about these philosophies before we make a decision on this bill, 
because which philosophy we decide to ascribe to is going to clearly 
impact not only the delivery of health care and the quality of health 
care in America for the foreseeable future and for generations to 
come, but it is going to dominate the quality of lifestyle in the area 
of the relationship of individuals to Government, in the area of tax 
policy, in the area of the size of Government, and in the area of 
employment and who employs who, for decades to come.

  Obviously, the philosophy put forth by the administration, by 
President Clinton and by Mrs. Clinton, is one that basically arises 
from the belief that Government knows best and that Government can be a 
dominant force in our life and should be the dominant force in our 
lives in determining public policy and how public policy is pursued.
  That has been a philosophy that has been, obviously, not only strong 
but, to a significant degree, successful in our country for an extended 
period of time. I remember sitting on the floor of the House one time 
and expressing some frustration about a very important piece of 
legislation coming through, and the size of the legislation, and the 
effect it was going to have on the capacity of us to remain a 
productive society, because it was going to take so much in the way of 
Government activity to take over the private sector by such a large 
degree. At the time, a very thoughtful and knowledgeable Member of 
Congress, who had served many more years than I, came up to me, and he 
knew of my frustration, and he said to me, Judd, just remember this: 
All government moves to the left.'' There is certainly no question 
about that, all government does move to the left. It is the question of 
how fast and how far it goes to the left.
  In this case, what the Clinton administration has proposed and what 
the Mitchell bill carries forward is a giant leap forward to the left, 
a giant expansion in our Government activity as it intrudes into the 
private sector, as it intrudes into individual lifestyles and into, 
specifically, the health care delivery of the American people. And this 
is not something that is unique to this time. This is a continuum of 
events that has occurred. If you look at it in a historical 
perspective, in my opinion, it is a logical continuum of events, and it 
really represents one of the key strains between different philosophies 
and within different cultures, especially democratic cultures, 
throughout this century and the prior century.
  If you trace it back, I suppose you would go back to the French 
Revolution and our own Revolution being the two defining events which 
set the course of action where you had basically the philosophy of the 
politics of the state versus the politics of the individual.
  You had Marxism being the ultimate expression of the politics of the 
state, which arose in the 19th century, and in the 20th century was 
totally discredited. But as the concept of the politics of the state 
evolved from decade to decade--or devolved, as the case was, certainly 
in the area of Marxist philosophy--you ended up in the late 20th 
century coming to something in democracies which is basically the 
politics of dependency. Essentially, the politics of dependency says 
that you structure a government around a philosophy that says you can 
get elected to a position if you create enough people that are 
dependent on the Government so that they are inclined to vote for you 
because their dependence is tied to getting their support through the 
government, either direct or indirect.
  That got sort of coupled with a politics of Populism, as we went 
through this century--Populism being defined in a lot of different 
manners, but essentially it says you can get a free lunch. That is 
essentially what Populist politics is about. It says that somebody else 
will pay for a benefit, do not worry about it; we will promise you the 
benefit. Somebody else will pay for it, and that is usually someone who 
represents an easy target, either an ethnic or financial, group, that 
is, either a rich person or an ethnic group. We are going to take from 
them, and we justly have a right to take from them, because they have 
abused the system, and we are going to transfer it to you, the 
individual, who will be the recipient of the Populist politics.
  Populist politics has always had a strong stream in American 
political thought throughout our time. When you couple Populist 
politics with dependency politics, you have a very effective force for 
political success and political elections--Huey Long being probably one 
of the best examples of that in our history, and one of the most 
egregious examples, also. That is not to say that all of it is Huey 
Long-type politics, but clearly that is the ultimate caricature of 
where those politics go.
  On the other side of the coin, you have the politics of the 
individual as expressed, obviously, by John Locke, but carried forth 
through our own Constitution through our Founding Fathers who believe 
very strongly that it was the individual who carried the force within 
the society, and there was a responsibility that individual took on and 
pursued, and the government had a role, but the role was prescribed to 
very defined areas. And the more freedom and rights we gave the 
individual, the more success the individual would be and, as a result, 
the more successful and the more prosperous society would become. That 
could also be carried to its extreme. But in the essence of this debate 
are those two core philosophical approaches: the politics of dependency 
versus the politics of the individual, and the politics of the State 
versus the politics of the entrepreneur.
  Granted, that may be too philosophical a tag to put on this whole 
debate, in many of its images that have occurred around here, but it is 
not too philosophical a tag to put on the outcome of this debate, 
because when you are dealing with 14 percent of the American economy, 
when you are dealing with everyone's lifestyle, you are obviously 
undertaking an act which is going to have catastrophic effect on the 
future course of this country.
  So there is a great deal more at risk here, or at issue here--
``risk'' may be the wrong term--than simply health care reform. At 
issue here is whether that continuum that came out of the politics of 
the State and politics of dependency, which is too large to have been 
discredited throughout this century, is going to be the course America 
follows.
  So whether we are going to say we do not need to take that course--to 
put it in its most obvious example, the question is whether or not we 
as a Nation wish to pursue a course which takes us down the path that a 
country like Sweden has taken, or many other European nations have 
taken, where essentially the Government becomes such an overbearing and 
major part of the entire lifestyle of everybody's existence that you 
have a cradle-to-grave society, where Government tells you how to do 
things, when to do things, where to do things and, in effect, ends up 
becoming a force of such dominance that it undermines the four 
characteristics of individuality, aggressiveness, entrepreneurship, and 
productivity, most importantly, that are the essence of producing 
prosperity.
  That is I think the key issue in this because what we are talking 
about is the prosperity of America, whether or not the culture that has 
produced a greater opportunity for prosperity and economic well-being 
and individual freedoms than any other culture that has ever been seen 
on this Earth, certainly any multiethnic culture seen on this Earth--I 
presume some narrow ethnic cultures, very small, that maybe have been 
competitive with us in economics and prosperity and maybe even in 
individual rights, but no multiethnic culture has ever accomplished 
what America has accomplished. And we have accomplished it because we 
have put great reliance on and confidence in entrepreneurship and the 
individual and the capacity of people other than the Government in 
Washington to resolve problems, whether it is in education or whether 
it is in just day-to-day life activities.
  Yet today we confront, I honestly believe, a philosophical choice of 
such significant proportions or maybe I should say a political choice 
of such significant proportions that the outcome philosophically will 
be to dramatically adjust our course as a nation down the road of being 
a government that is a dependency-politics-driven government. And I 
recognize that that is good politics if you want to get reelected and 
if you want to maintain power, as has been shown for years by the House 
of Representatives. The best thing to do is vote programs, vote 
benefits, vote for something for someone, and then create an atmosphere 
where that individual or that group or that philosophically identified 
organization finds itself dependent on you, the elected official, for 
some percentage of either their financial well-being or their political 
placement.
  That has always worked throughout time, and it works very well today, 
and you find yourself admiring those who within our institutions are so 
successful at promoting that as a way of maintaining power. And that is 
what it is about when you get right down to it--maintaining power.
  But as you look at these documents you have to say to yourself, where 
do we draw the line? At what point do we as a nation say we just cannot 
take that extra step because that step puts us on a slippery slope that 
moves us so quickly into a society dominated from the center without 
the freedom of the individual initiative, without the capacity of the 
entrepreneur to be successful, that we will undermine the inherent 
engines of prosperity that make us work as a society. You can only 
succeed in this concept of the politics of dependency and the politics 
of the State as long as you have producers who can carry the burden.
  Mark Twain wrote a nice little short story on this topic where he 
talked about it in very simple terms. But essentially the success or 
capacity to survive in the politics of dependency requires that you 
still have a productive sector that you can raid every so often in 
order to fund the free lunch and the guarantee of something-for-nothing 
government. Yet at some point you cross a line as nations like Sweden 
have found that they have and New Zealand, and you find their 
productivity has dropped so far and your sectors that your individuals 
who were aggressive initiators and inventors are no longer that and no 
are longer productive, and the quality of life and standard of living 
for everyone starts to drop. It is a bell curve basically of what 
happens in this area.
  But this administration understands that. I suspect if Huey Long had 
gone to Wellesley he would have produced this document. It is an 
excellent piece of populist politics, and it is a true exercise in 
dependency politics. Therefore, I think and I feel very strongly that 
it must be defeated.
  The complexity of it, which has been talked about at some length, is 
only one example of its natural elitism. You know there is an 
attitude--it is almost an utopian attitude of elitism that says 
essentially anyone who drafts something like this is saying: ``Hey, 
listen; I know a lot more than you know.'' The 500 people who gathered 
in this room of intellectuals and academics and congressional staff, if 
there were any of any significance--there was not a provider person. 
``We actually know better than you do how to run your lifestyle.''
  The essential theme of this bill and the original Clinton bill was: 
``Listen. We can fix the health care system because we are smart, 
smarter than you, and if you do not understand that we will. We regret 
it. It means you are probably not bright enough to understand it.''
  That is the theory behind this. Or ``You are just not compassionate 
enough to understand it. So, therefore, just stand back and let us 
manage your life for you and everything will be fine.''
  It is utopian elitism that runs through all of this that creates 
these types of documents with these huge imaginations of structure in 
their attempt to address problems that are humorous. Sometimes they are 
so complex, and yet when passed they have immediate and personal 
impacts on people, and affects their life and how their life is going 
to proceed.
  The original goals of health care do not require this sort of action 
to be accomplished. They do not require the results of the folks 
sitting in the room and thinking up all the answers to all the problems 
in order to address them.
  The original goals of health care were to improve quality, to control 
costs, and to expand coverage. And it does not take this opus to do 
that. In fact, I would argue and shall argue as I proceed in this 
discussion that this proposal has substantially reduced the quality of 
health care in this country and well-expanded coverage--I will give it 
not dramatically--but a well-expanded coverage and every expansion is 
helpful. It certainly will not control cost and will aggravate the 
Federal deficit dramatically.
  So, if we wish to address these goals, I think we can do a much 
better job than this, and we can do it without the officiousness and 
huge bureaucracy and top-down approach that is designed in this bill.
  Let us talk about a few specifics, a few of the areas that this bill, 
this 1,400-plus page bill creates problems in. Right off the top there 
are 10 major problems with this bill.
  First, it creates 17 new taxes, some fairly substantial new taxes, 
and these are taxes that are going to have to fall basically on the 
middle class. You are talking about raising $300 billion of new taxes 
in this bill over the 1995 to the year 2004 period. That is a huge 
amount of revenue to come out of the American sector, and it means that 
funds that might have been used for education, funds that might have 
been used for infrastructure, funds that might have been used just to 
create a new job here or there, will be going into this bill.
  And what will they be going for? They will be going for a subsidy 
program which involves subsidizing one out of every two Americans. 
Under this bill, one out of every two Americans end up getting 
subsidized. That is a staggering figure. Somewhere between 115 million 
and 120 million people are going to end up being subsidized. That is 
good politics of dependency. I have to argue that is the ultimate.
  One out every two Americans coming to depend on the Government for a 
benefit inevitably puts in power a lot of people for a long time who 
are going to guarantee that benefit. It also means you have inherently 
undermined the capacity of the rest of society to be productive when 
you get to that level of subsidy, with $1.5 trillion in new 
entitlements over the period of time, just a huge expansion in spending 
and entitlement action activity.
  Here we have this President appointing an entitlement commission and 
asking that entitlements be brought under control. We have here speech 
after speech on the floor of this Senate about bringing entitlements 
under control so we can balance the budget and start to do something 
about the huge debt passing on to the children and the next generation 
making their capacity for survival dramatically reduced because we are 
giving them so much debt they have to bear.
  We are going to take this piece of legislation here and create, I 
lost count because nobody ever seems to be able to figure it out, it 
seems like five major new entitlements costing well over $1 trillion, 
and we are not going to raise $350 billion in taxes to pay for them, 
but we are not going to pay for them all. So we are going to aggravate 
the deficit, in my opinion, dramatically under this bill.
  That is unconscionable. We have put a mandate in place in this bill 
on the employer and the individuals mandates across the board, not just 
on the idea that what they must pay in insurance premiums, which is a 
payroll tax, which is in this bill, and you know it is called the 
trigger. There is this argument there is a trigger. The payroll tax is 
really never going to occur or may not occur. It may occur in some 
States and may not occur in other States. The trigger event is 95 
percent coverage, which is an interesting number. I am not sure how it 
was picked, but I suspect it was picked because even Hawaii, which has 
had allegedly universal coverage for years does not have 95 percent 
coverage.
  It has somewhere in the vicinity of 93 or 94 percent coverage. So 
every State is going to get triggered in, and there will be a mandate. 
It is just that it is structured politically very intelligently. Nobody 
in this Presidency is going to be in office when the trigger hits, so 
nobody is going to have to pay the political price for it. And, 
obviously, a lot of people who are involved in this bill will not be 
around, so they will not have to pay the political price for it. But it 
is there and it is going to occur.
  It is a mandate of significant proportions on small and medium-sized 
business men and women running a business that is trying to be fairly 
productive or just barely making it or maybe not even making it. This 
type of a new payroll tax is going to just have a horrendous impact on 
them.
  Take New Hampshire, my State, for example, which has its largest 
employment in the sector of hospitality activity, which is hotels, 
restaurants, and tourism activity. They are our largest employers.
  Most of these folks offer their people insurance, but they have a 
large percentage of people, usually, who are part-time people. They are 
spouses of somebody who has a full-time job and they do this to 
supplement their income, or they are college students supplementing 
their income, or somebody in transition in lifestyle supplementing 
their income, or maybe they are just ski bums. They come up and work 
for a few months and take a few months off, and that is the lifestyle 
they pursue.
  But, in that industry, for example, a mandate is devastating.
  I recall very vividly somebody who runs a small motel up in Conway, 
NH, testifying before one of the many health care forums which I have 
held, and I have held a tremendous number throughout the State. He 
said, simply, ``Listen, I have pushed the numbers. I have taken a 
pencil to the paper on this. For me to be able to pay for the mandate 
in this bill''--it was the Clinton bill at that time, but the mandate 
in this bill is only 30 percent less than that--``I am going to have to 
sell another thousand rooms a year. I can't sell another thousand rooms 
a year.'' He said, ``If I could sell another thousand rooms a year, I 
would sell another thousand rooms a year.''
  Like President Clinton telling a pizza seller, ``Well, just raise 
your prices to cover this.'' He cannot do it.
  And his reaction was, ``I am going to have to lay people off. I am 
not going to be able to maintain the number of people.''
  A little later, I want to get into how this actual mandate works if 
one State should, by chance, end up out from underneath it. It is an 
overwhelming implication for the States in their activities as to how 
they would ever comply with it.
  Another major problem with the bill is price controls. How many times 
have we, as a society, and has this world proven in a democratic 
society that price controls do not work; that price controls inherently 
constrict an economy in a way that undermines not only the goal, which 
is to contain costs, but also, more significantly, undermines 
initiative and incentive and creativity.
  Take the drug industry, for example. The drug industry has been one 
of the popular whipping boys for this administration as it has gone 
down the road in pursuing health care. And, of course, populism demands 
an enemy list, and drug companies have been excellent to put on that 
list. That list has been sort of a rotating list. It was once doctors 
and then Congressmen with their health plans, and then it is drugs. But 
they make a good target, let us face it. They make a lot of money.
  But if you take the biotechnology industry, which does not make a lot 
of money--it costs $300 million to bring a new drug on the market and 
it takes 10 years to bring that drug on the market. What is the effect 
of price controls on a industry like that? Well, the effect of price 
controls on an industry like that is they are not going to get anybody 
to invest $300 million and wait 10 years for them to bring a new drug 
on the market.
  It does not work that way. If you are an investor or group of 
investors and you have that type of money to invest and you get to the 
end of the line after it has been out for 10 years, looking to see if 
this experimental drug is going to work, and you find that drug is 
going to be subject, when it does work, which a long shot, is going to 
be subject to a price controlled event of some nature--granted, the 
Mitchell bill is not as restrictive as the Clinton bill on this, but 
the concept is still there. And you can see it, the gleam is still in 
the back of somebody's mind, that somebody is going to figure out how 
to take this Clinton price language and upgrade it to some sort of 
control.
  But the practical effect is the investment, instead of going into 
research on a drug or new drugs that might cure some sort of 
neurological disease, is going to go into developing some software or 
developing a new widget or gadget in some other sector of the economy.
  And we saw this almost instantaneously. After the Clinton bill was 
initially introduced, there was a dramatic drop in investment in 
initial offerings for biotech companies. There has been some abatement 
of that now, because there is less fear of it, but still the philosophy 
of price control has that impact on the marketplace. It retards 
research and it does not in the end ever control costs in any 
significant way.
  Then the bill imposes new taxes that will raise the cost of coverage 
for families for health care. There is a 1.75 premium tax in this bill, 
plus, because of all the obligations they put on the States, which they 
do not pay the States to execute so the States are going to have to 
probably go out and raise revenue to pay for the administration cost, 
which they are required to do under this Federal bill. And under the 
Federal bill, in our graciousness, the Clinton-Mitchell bill has said, 
well, the States can go out and tax premiums. So they are going to get 
hit, on top of this 1.75 percent, with probably an additional State tax 
to pay for the costs which are generated by this bureaucracy which the 
States are going to have to put in place in order to comply with the 
Federal bill.
  And, of course, the bill does have massive bureaucracies. And I am 
going to talk at length about that and especially as it affects States. 
And the bill really takes health choices away from us as American 
people and puts them in the hands of the bureaucracy.
  Those are just some of the problems with this which basically 
underlie this huge piece of legislation that has been brought forward 
here by Senator Mitchell and which is basically the Clinton-Mitchell 
bill.
  It is a massive document. We have not had the time, even though we 
have been at it now for a few days, to really analyze the whole thing. 
We keep finding these little problems within it, fairly significant 
problems, and we bring them forward, but I do not think we have seen 
all the problems that exist in this bill. And so, I do think we need to 
go forward and continue to air the issues which this bill raises.
  What I want to talk about in specifics relative to this bill today is 
its impact on the States, because I used to serve as the executive of a 
State. I looked at this bill and I was stunned at the burden which this 
bill is going to put on State governments.
  There are 177 new responsibilities in this piece of legislation that 
States are going to have to comply with--177. Now, I have to tell you, 
as a former Governor and as a State administrator, one or two Federal 
responsibilities can ruin your day, can make your life miserable.
  Take, for example, some of the Federal responsibilities that are put 
on States through the EPA.
  I recall in New Hampshire, it took us 16 years--16 years--to build a 
17-mile section of road in New Hampshire. We had four lanes going in 
and four lanes going out and it narrowed down to two lanes. For 16 
years, we had to deal with Federal regulations coming out of the EPA to 
try to get those two lanes up to four lanes. That was the only major 
east-west highway in the State. And during that time, approximately 20 
people died in that two-lane piece of road. That was the most dangerous 
piece of road certainly in the State and probably in New England.
  But we could not get the Federal Government to change its 
regulations, to modify its regulations, to allow us to go forward in a 
timely manner and to build a road. Even though all the major groups had 
signed off on it in the State, even though Federal Highway signed off 
on it, and Fish and Wildlife had signed off on it, the Corps of 
Engineers had signed off on it, we still could not get it built.
  That was just one group of responsibilities that were put on us by 
the Federal Government. Now we are going to have 177 new 
responsibilities put on the State governments, none of which, by the 
way, are paid for under this bill. So the Federal Government is telling 
the State government to pursue all these new actions, but it is not 
saying to the State governments we are going to help you pay for these 
costs.
  I want to run through some of these because they are significant. 
Even though they are only a small section within the bill, they are 
very significant responsibilities. And somebody has thought these up, 
that is what amazes you. Somebody in some room somewhere in this 
building, one of these buildings, thought up all these little ideas--
well, not little ideas--these grandiose ideas and said, ``Let us stick 
that in the legislation.'' It is like dropping a very huge rock in a 
small pond, because the waves this is going to create out in the States 
are going to be overwhelming. The unintended consequences cannot even 
be conceived. Obviously they are unintended, but the unintended 
consequences will be massive and the effects will be dramatic.
  In many cases the effects will be to significantly diminish the 
quality of life and the health care of various people throughout our 
country. I will give specific examples of why I think so, why 
specifically in New Hampshire it is going to significantly diminish the 
quality of health care. But first let me go into some of these 177 new 
responsibilities, because they are really overwhelming in their impact 
on the States. You have to feel sorry for the State legislatures and 
Governors and bureaucracies within the States that are going to get 
stuck with these.
  They start right off with one that sort of sums it all up in some 
ways. ``Satisfy all its responsibilities.'' This is section 1412, 
``Satisfy all its [the State's] responsibilities under the Act,'' 
including the development of a health care system that can obtain 
Health and Human Services approval, or face a variety of sanctions 
including having the Health and Human Services Secretary assume the 
State's responsibility under the act and having a 15-percent premium 
tax imposed on its citizens.
  In simple language what that says is, if you do not do it our way, 
States, we are going to come in and we are going to tax your people 
into oblivion. This is true Federal bureaucratic elitism.
  Yesterday we had an amendment to knock out the $10,000 fine, which 
was the penalty fine against any employer who decided they wanted to 
offer more of a benefit than the standard care benefit, or less of a 
benefit. It applied to every employee. So that was an example, another 
example of this type of attitude.
  But this one says, essentially, every citizen in the State will be 
subject to a 15-percent premium tax if the State government does not 
meet the arbitrary, capricious, officious attitudes or views of the 
Health and Human Services Department here in Washington, developing 
these health delivery services. I find that insulting. I thought we are 
a federal system. We are obviously not a federal system--not as far as 
President Clinton is concerned, or the Mitchell-Clinton bill is 
concerned. We are a system where you put a gun to the head of the folks 
out there in the States and say either you do it my way or we are going 
to come in and tax you into oblivion.
  Mr. COATS. Will the Senator yield at that point for a question?
  Mr. GREGG. I will certainly yield to the Senator.
  Mr. COATS. I would just note the Senator from New Hampshire is a 
former Governor. Of course we have heard the rhetoric here all week: 
No, this is not the Federal Government takeover of the health care 
system. Much of it is going to be administered by the States.
  I think the point the Senator from New Hampshire is making is that a 
great deal of the responsibility of the State is being dictated by the 
Federal Government.
  I wonder, as a former Governor of New Hampshire, if the Senator could 
give us his perspective on just what a State like New Hampshire would 
be faced with in terms of putting together the kind of agencies and 
governmental functions in order to carry out some of the 
responsibilities that are now going to be laid on the States through 
the Mitchell bill?
  Mr. GREGG. I thank the Senator from Indiana for his question. I think 
it is a good point. Essentially, the States have no flexibility in this 
bill. The States are told how to structure their health care system and 
then they are told how they are going to administer the system. And 
then the Federal Government does not even have the courtesy of paying 
for it after they tell them they have to do all these things.
  The practical implications for a State like New Hampshire, which is a 
small State, are, we would literally probably have to add more 
bureaucracy and more new State employees to administer this plan than 
we presently have in our largest department, which would be Health and 
Human Services or our Highway Department. We would probably have to 
create literally a brand new government simply to administer this plan.
  I said sort of off-the-cuff, and half seriously, we would have to 
pick a new place to have a State capital in order to handle the number 
of people we would have to add to administer what is requested of us in 
this proposal.
  Let me go through some of these additional things. You can understand 
that fairly quickly--well, not fairly quickly, because it takes a long 
time to go through 177, and I plan to go through maybe them all or at 
least a high percentage of them. But I think it is important to go down 
them because we cannot take this bill up until we understand what we 
are doing to our States. So let us talk about it.
  The first was, if you do not do it our way we fine you 15 percent. 
Unbelievable; everybody in the State gets fined 15 percent. They are 
not comfortable just going out and fining the Governor. As Governor I 
used to get sued all the time. No, they are going to fine everybody in 
the State 15 percent.
  Second:

       Require that each health plan (whether insured or self-
     insured) or long-term care policy issued, sold, offered for 
     sale, or operated in the State be certified by the 
     appropriate certifying authority as a certified standard 
     health plan, a certified supplemental health benefits plan, 
     or a certified long-term care policy.

  That means the insurance--I presume in most States it is going to be 
the insurance commission who is given the obligation of checking every 
plan offered in the State to see it meets, not a State definition of 
what is a standard plan, supplemental health plan or long-term care 
plan, but a Federal definition. And, for anyone who has ever tried to 
figure out what a Federal definition is of anything, it is a very 
difficult process because of the complexity of the situation. I suspect 
these will be moving targets which will be very hard for any insurance 
commissioner to confirm. So it is going to be a huge regulatory burden.
  Third, ``Establish rules for the event a capacity limitation applies 
to a plan.''
  That is section 1111. I do not know what it is. I do not know what 
the rules would be, but obviously they have to put some rules in place.
  Fourth:

       Establish procedures and methods to assure equal 
     opportunity of enrollment for all families, regardless of 
     when during the open enrollment period, or the method by 
     which, the enrollment has been sought, in accordance with 
     rules established by the HHS Secretary.

  Again, what we are saying to the States is you shall set up a 
bureaucracy to basically monitor everyone in the State on the issue of 
open enrollment, on the issue of equal opportunity. But you shall do it 
under a set of standards set up by the Health and Human Services 
Secretary.
  The burden there is, just statistically, probably beyond the capacity 
of most States to do.
  Fifth:

       Implement procedure by which individuals enrolled in a 
     standard health plan may disenroll from such plans for good 
     cause (as defined [guess who] by the Health and Human 
     Services Secretary) at any time during a year and enroll in 
     another standard health plan, in a manner that ensures 
     continuity of coverage for standard benefits package or the 
     alternate standard benefits package for such individual 
     during the year.

  Again, what you are saying to the States is that basically they have 
to be the mother, here, of all these different individual plans and all 
the different enrollment activities within these plans. Not within the 
context of what they deem to be appropriate, what the State regulatory 
authority deems to be appropriate, but within the context of what is 
given to them from on high, from the mount, the Health and Human 
Services Secretary.
  Again, I am not sure how you would set up a computer system to handle 
that one, but you would have to probably have every State in this 
country purchase a supercomputer, not just a regular computer system. I 
suspect just to administer that one section, you would require some 
sort of supercomputer capabilities, because I do not think your 
standard computer systems that most States have in place can handle it.
  Sixth:

       In accordance with HHS standards--
  Once again Health and Human Services standards.

     ensure the broad availability and processing of enrollment 
     forms, including direct enrollment through the mail, and 
     other such processes as the HHS Secretary may designate.

  I think the important point to note here is that everything--
everything--the State has to do, comes from a directive from the Health 
and Human Services or the Labor Department in each one of these. There 
is no flexibility. The States are not given any flexibility. What we 
are setting up here is a massive bureaucracy of disproportionate impact 
in a small State like New Hampshire where you will, basically, have the 
Government from Washington telling the government of the States exactly 
what they will do and, basically, telling every individual through the 
States exactly how they shall act as it comes to their health care 
structure. It is Orwellian in the extreme, to say the least.
  Seventh:

       With respect to a child-State supervised care, consider the 
     child as a family of one and enroll the child with State 
     agency who has been awarded temporary or permanent custody of 
     the child in a high-cost sharing plan, unless the State 
     agency has established a special health service delivery 
     system designated to customize and more efficiently provide 
     health services to children in a State-supervised care, in 
     which case the State agency will enroll the child in the plan 
     appropriate to ensure access to such a special health service 
     delivery system.

  That sounds fairly benign, but what it means is, that for every child 
who is in the State of New Hampshire's DCYS system, we are going to 
have to get a Federal waiver for each child and the process of getting 
a waiver is not simple. You are talking about a huge number of people 
having to fill out a tremendous number of forms and then do it again 
and again and again for each child who we want to move into a system 
that is something other than what is the high-cost plan which the State 
presently has.
  Believe me, in New Hampshire, we do an excellent job of taking care 
of our children. We are rated No. 1 in the country for caring for 
disadvantaged children. We are No. 1 in the country in the area of 
immunization. We are No. 1 in the country for mental health care, both 
for children and for adults. We have a very strong commitment in this 
area, and we have unique services which I suspect would not fall into 
this category that is being set out as a high-cost plan.
  Therefore, we are going to find ourselves having to waiver each one 
of these children in order to have them take advantage of a service 
which we have been delivering and which has been doing good things for 
that child for years.
  Eighth:

       Establish fair marketing practice laws standards, including 
     to prevent selective marketing, to govern the marketing of 
     standard health plans through use of direct marketing, 
     agency, or other arrangements to distribute health plan 
     information.

  That is, the Federal Government is telling the States that they are 
going to have to become the marketers of the health care plan. So 
States not only are going to have to manage the health care plans, they 
are going to have to market the health care plans. That means a whole 
new agency.
  The State of New Hampshire will now have, I guess, a State of New 
Hampshire agency for the purposes of advertising health care plans and 
will have to go out and buy TV time, radio time, and newspapers, and 
put out press releases and do all that sort of stuff. Not something 
that really a public entity is all that good at usually, especially on 
a complex issue like health care.
  Ninth:

       Impose no limit on the ability of any plan to contract with 
     a provider of health services located outside the geographic 
     boundaries of a community rating area or the State.

  If you are going to go to this concept of community rating and you 
are going to go to this concept of managed care, you basically have 
punched a huge hole in cost control when you start saying, ``But there 
shall be no limits on who a provider can contract with.'' You are 
essentially saying a New Hampshire community-rated HMO will have to 
contract with, let us say, somebody on Cape Cod who has a service in 
alcohol treatment, or something like that. It is a huge hole in the 
cost containment elements of health care if you are going to go to 
managed care promotion programs.
  I do notice there are other people who want to speak. So let me move 
along to some of the other issues I think are significant in this bill.
  I appreciate the President's attention.
  The PRESIDING OFFICER. The Chair inquires, did the Senator indicate 
there were 177 points?
  Mr. GREGG. That is correct. There are 177 of these obligations that 
the States undertake. I was on No. 9. So I am going to give you a break 
and move ahead a little bit to some of the more egregious ones and 
their impact on the States.
  No. 19--but believe me, the ones in between are pretty egregious.
  Nineteenth:

       Have a program of reinsurance and risk adjustment that 
     governs how a purchasing cooperative that requires direct 
     payment of premiums shall forward to the standard health plan 
     the amounts collected on behalf of the enrollees in such 
     plan.

  It is just staggering to imagine how you are going to do that.
  Twentieth:

       Develop rules under which each purchasing cooperative in a 
     community rating area shall provide the State with 
     information on its membership and marketing fees.

  Again, this gets the State into the business of being the public 
relations agency on health care within the State.
  Twenty-second:

       Use the actuarial data to make a determination that each 
     plan's marketing fees are based on a legitimate variation in 
     marketing and distribution costs across alternative 
     distribution sources.

  Again, very complex to do that.
  Twenty-third:

       Have a program of reinsurance and risk adjustment that 
     governs how the purchasing cooperative selected by the 
     employer shall be responsible for forwarding premium payments 
     to the appropriate plan or cooperative for each community-
     rated employee.

  They are talking about setting up a system in New Hampshire under 
that little section there that will affect 1.1 million people. How you 
do that without creating a massive new bureaucracy is beyond me. You 
have to add literally hundreds of employees to the State payrolls to 
track that one item right there. That does not account for all these 
other items we have put in here that are just beyond comprehension in 
the level of new management burden put on the States.
  Twenty-eighth: ``Manage premium and cost-sharing discounts and 
reductions.''
  Thirty-eighth:

       Consult with the HHS Secretary in its establishment of 
     standards for guaranty funds to be established by States for 
     community-rated health plans.

  So the State becomes the insurer and has to set up the insurance 
accounts to make sure that these community-rated plans, if they do go 
under, are properly indemnified. And to do that, we have to go to 
Health and Human Services for direction.
  Thirty-fourth:

       In order to obtain start-up grants, provide assurances, 
     satisfactory to the HHS Secretary, that amounts of State 
     funds (at least equal to the amount made available) will be 
     expended for start-up purposes.

  That is pure blackmail, that is what that section is. That is 
blackmail. First, they are going to dump all these new programs on the 
States, and then they say to the States, ``We're not even going to give 
you the start-up funds; we are not even going to give you the start-up 
funds unless you put forward a certain amount of money.''
  It is hard to believe that the people who drafted this amendment have 
ever gone back to their States--that section right there. If they have, 
they would be tarred and feathered if they ever admitted to having put 
that amendment together.
  Forty-third:

       Enter into agreements with the Secretary of Labor in order 
     to enforce responsibilities of employers and large employer 
     purchasing groups and requirements for employer-sponsored 
     health care plans.

  This is an interesting one. Now we have the Secretary of Labor, that 
we have to negotiate with on the issue of enforcement, and before we 
can do anything on enforcement, it looks like we are going to have to 
follow the directives of the Secretary of Labor for the same sort of 
precision and officiousness that we are seeing here in the area of 
Health and Human Services.
  Seventieth:

       Designate public access sites within each community rating 
     area through which residents of such areas can obtain 
     consumer information concerning health plans and purchasing 
     cooperatives offered in such areas, in a manner that ensures 
     access to such information by the health care consumers.

  That means, once again, that the State is in the PR business, and I 
presume it also means that the State is essentially going to have to 
set up kiosk which they are going to have to man, where they are going 
to talk about health care. It does not say how we are going to pay for 
that. It just says States have to do it; they will probably have to 
have a kiosk in every mall in the State. Every mall will have its own 
New Hampshire health insurance State government information center. How 
much is that going to cost? How confusing is that going to be to the 
public?
  Seventy-second:

       Provide such public access materials to employers located 
     within the State.

  That is the effect of what I was mentioning.
  Moving on to 86, which I find to be one of the most egregious in the 
entire group. There are so many egregious ones it is hard to 
differentiate standards of level of aggravation they are going to 
create to States.
  But this one certainly is one of the worst. This is classic special 
interest politics.
  Eighty-sixth:

       Before initiating the process of implementing its home and 
     community-based care program--

  Before it can do that, the State must:

       Commence negotiations with labor unions representing the 
     employees of affected hospitals or facilities, to address the 
     impact of the implementation of the program upon the work 
     force, and methods to redeploy workers to positions in the 
     proposed system, in the case of workers affected by the 
     program.

  (Ms. MOSELEY-BRAUN assumed the chair.)
  Mr. GREGG. Well, I am glad to see that this bill has not been 
affected by special interests. States must under this language 
negotiate with the labor unions before they can set up the home- and 
community-based programs. They are told what they have to negotiate, 
what the outcome of the negotiations have to be, for all intents and 
purposes.
  Talk about special interest politics. When did State governments get 
into the business of labor negotiations dealing with health care 
centers? What expertise, to begin with, and what right does the State 
government have to go in and be the negotiator of this issue? Clearly 
none.
  But they are demanded. It is a demand in here. Why? Because some 
labor union said it is important, probably for support of this bill. I 
do not know. But clearly it was put in there to take care of the 
special interests known as the health care labor unions.
  Seventy-eighth:

       Enact or adopt long-term care standards that conform with 
     the Federal standards to be promulgated by the Health and 
     Human Services Secretary, at the risk of having the HHS 
     Secretary assume responsibility over long-term care policies 
     in the State.

  Now we were back at this other page where the State--that is, that 
other authority where the State--remember this one--must satisfy all 
responsibilities under the act and if it does not satisfy all 
responsibilities as approved by HHS, the State gets hit with a 15-
percent premium on every consumer in the State. Every consumer gets hit 
with a 15-percent premium if we do not do it exactly the way HHS wants 
us to do it.
  Now we have a section that says not only that, but we are not happy 
with hitting you with a 15-percent premium, State governments. We are 
going to take over your system on long-term health care if you do not 
do it exactly as the Secretary of HHS promulgates.
  By the way, HHS has promulgated nothing in this area. And I presume 
when you look at the length of this act and number of initiatives--I 
think there are 800 initiatives that the Secretary of Health and Human 
Services is required to pursue under this act; there are 50 new 
bureaucracies also, but at the time they got around to promulgate this, 
the States would obviously have had to go forward, and then the States 
would find that they were not in compliance and the Secretary of Health 
and Human Services would come in and take over their plan.
  That is clearly an aggressive use of the Federal power to dominate 
the States, and it delivers a blow to the States from which they would 
not be able to recover.
  The theme of this bill is either you do it our way or we put a gun to 
your head and we shoot you. And our way is this huge bureaucratic 
entity called the Mitchell-Clinton bill, which creates all this in cost 
for the States.
  Ninety-third:

       Not later than January 1, 2001, achieve the integration of 
     the mental illness and substance abuse services of the State 
     and its political subdivisions with the mental illness and 
     substance abuse services offered by the health plans pursuant 
     to title I of this act.

  I do not know how that works, but I do know that when you start 
talking mental health and start talking about, in New Hampshire at 
least, having the Federal Government come in and tell us how to do 
mental health, we get very upset. Why? Because we deliver the best 
mental health care in the country. We have spent a lot of resources and 
effort on our mental health delivery in New Hampshire, and we are very 
proud of it. It has been rated the best, not by us--obviously, we would 
rate it the best--but by such diverse groups as Ralph Nader and his 
organization. We are very sensitive when we start seeing the Federal 
Government coming in and telling us how to manage our mental health 
system. But this bill tells us exactly how to manage it, every part of 
it.
  Ninety-seventh:

       Report annually to the Health and Human Services Secretary 
     on the incidence and prevalence of mental illness and 
     substance abuse disorders in prison population, changes in 
     such incidence and prevalence in prison population, and the 
     potential causative factors with respect to such changes, 
     including an estimate of the extent to which the denial of 
     treatment--

  Now catch that one.

     to which the denial of treatment, or the provision of 
     inadequate treatment, to the individuals with mental illness 
     and substance abuse disorders is contributing to criminal 
     activity of such individuals.

  I get the feeling here that we are setting up for something, some 
special agenda. We are not treating those prisoners nicely enough. We 
do not have enough TV's, not enough basketball courts. We are very 
concerned about that. And we are setting up here for a nice little 
lawsuit brought by some organization which is interested in pursuing 
prisoners' rights. States are going to have to comply with this 
language or they lose, or they get hit with a 15-percent surtax on all 
their individuals because this is a part of the bill and if you do not 
comply with this language, if the States did not supply this 
information on denial of treatment, then they get sued, then they get 
hit with a 15-percent premium, and the HHS Secretary has the right to 
come in and take over the plan.
  Ninety-eighth:

       Receive grant assistance for the State's development and 
     operation of comprehensive managed mental health and 
     substance abuse programs that are integrated with the health 
     delivery systems established under this act, provided such 
     programs promote the development of integrated delivery 
     systems for the management of the mental health and substance 
     abuse services provided under the comprehensive benefits 
     package, give priority to providing services to low-income 
     adults with serious mental illness or substance abuse 
     disorders and children with serious emotional disturbance or 
     substance abuse disorders and provide for the phase-in of 
     such services for all eligible persons within 5 years, ensure 
     that individuals participating in the program have access to 
     all medically necessary mental and substance abuse services--

  Remember, ``medically necessary'' is now a term defined not by the 
doctor but by a bureaucracy here in Washington. A group of seven people 
will be defining what is medically necessary and appropriate under this 
bill, not your doctor.

     promote the linkage of mental health and substance abuse 
     services through primary and preventive health services, and 
     meet such other requirements--

  Such other requirements. My goodness, how many other requirements can 
they think of?

     as the Secretary may impose; and provided the State has a 
     detailed plan that is approved by the Secretary.

  Now, of course, if you do not do that, they come in and they take 
over your mental health system. They are not content with taking over 
your health care system generally. They are not content with taking 
over your long-term care system generally. They want to take over your 
mental health system, too, because they know best. They know best. The 
people who wrote this bill, who sit down here in Washington, know best 
for you how your health care system should be delivered in your State 
and how you, as an individual, should interface with your doctor and 
your hospital. It is the ultimate in utopian elitism and arrogance.
  One hundred third:

       Establish a limited service hospital program that includes 
     a rural primary care hospital program and/or medical 
     assistance facility program.

  I think most States have already done that. And they have worked hard 
at it. I do not think we need the Federal Government to come in and 
tell us we should do it again. If we do not do it, I guess they come in 
and they take over our rural delivery systems.
  It will make the States make the maintenance of efforts payments. 
Maintenance of efforts payments are a tax on States, and a fairly 
significant tax. In many instances under this bill it is going to be 
rather large. Essentially, it says that the States shall pay the 
Federal Government for the right to participate in this new health care 
consortium which basically tells the States exactly what to do, when to 
do it. It does not reimburse the States. But we do have maintenance of 
efforts payments in here to make sure the States send tribute to 
Washington.
  Then there is a requirement to make available through a consumer 
information advocacy center to all individuals a summary of the State 
health plan reports in the consumer report cards. That is an 
interesting authority required of the States. Remember, if we do not 
comply with that, we will end up once again with the HHS Secretary 
having the right to come in and take over the system, and assess a 15 
percent premium tax on all consumers in the State.
  What this essentially says is that there is going to be an advocacy 
group set up, another new Federal advocacy agency I presume with all of 
new advocates in it. And those advocates are under this. What they 
produce as their report card the State are going to have to distribute 
throughout the States. Maybe it will work. Advocacy is always good. But 
you know what you are saying here is that essentially we basically have 
nationalized the system. So in order to replace what is usually a 
market force event which would have businesses going out and talking to 
the employer, or yourself, or your labor union going out and talking to 
different insurance companies, trying to offer a plan, who has the best 
plan, and who offers what, we will have to have a group of advocates do 
it now because essentially we set up a structure which has eliminated 
the market face and the forces of exercise of the delivery of health 
care.
  The list goes on and on. I skipped over an awful lot to get to No. 
116. But I want to talk about a few more of them in specifics also 
because some of the ones I just laid out I think are reasonably 
egregious. In fact, they are dramatically egregious. But in addition, 
there are some that are even in my opinion more significant.
  Mr. ROCKEFELLER. Will the Senator yield?
  Mr. GREGG. While I am searching through my papers, I yield to the 
Senator from West Virginia for the purposes of a question.
  Mr. ROCKEFELLER. I am just interested in terms of the time, my own 
schedule, and perhaps others. The Senator has taken about hour and a 
half. I wonder how long the Senator plans to continue to talk for the 
purpose of convenience of Senators, including the Senator from West 
Virginia?
  Mr. GREGG. I would expect that I will be speaking on this subject for 
an additional half an hour, I inform the Senator from West Virginia.
  Mr. ROCKEFELLER. I thank the Senator.
  Mr. GREGG. Mr. President, we have gone through some of the highlights 
of some of the 177 additional requirements put on the States 
remembering that the basic schematic goal of this whole exercise is to 
have the Federal Government take over the health care system of 
America, and specifically to put the States in the position of being a 
functionary of the Federal HHS Secretary, making them essentially the 
carriers of the water of the bad news of the bureaucracy to the people 
in their States, with very little flexibility. It is not going to work 
obviously. Common sense tells you it is not going to work. But I 
recognize that common sense does not necessarily hold the day.
  So let us talk in specifics, beyond the items that I mentioned about 
some of the more major events that this bill puts on the States, and 
how they will impact the States. Probably the most significant one, 
from the standpoint of how people's lives are affected is this whole 
issue of subsidies, the integration of subsidies, and how the States 
integrate subsidies, because how States take care of their medically 
needy people today, Medicaid people and people who are not on Medicaid 
but are low-income individuals, is obviously important.
  In New Hampshire I think we have done a fairly good job. There is 
more we can do, and we are trying to do. In fact, in the last 
legislative session, many initiatives were passed. But under this bill, 
I think people need to understand the complexity of the new premium 
subsidy program and how it impacts the States.
  Under this bill, there is a full subsidy for low-income individuals 
from 100 percent of poverty phased out as they get up to 200 percent 
poverty. There is a full subsidy for children under 19, and pregnant 
women 3 months after their pregnancy up to 185 percent of poverty. It 
phases out to 300 percent poverty. There is a subsidy for unemployed 
people up to wages of 75 percent of poverty for a period of 6 months.
  What does that do to States? Remember that the States already have 
Medicaid. So they must continue to comply with the Medicaid Programs, 
and administer their Medicaid Programs under this bill. But under the 
Mitchell-Clinton plan, the States must offer wraparound coverage; that 
is, to continue to offer Medicaid services that are not offered in the 
Medicaid recipients standard plan. In other words, the Medicaid 
recipient falls under the standard plan. But, to the extent that 
Medicaid services exceed the quality that you would get from the 
standard plan, the States must offer a wraparound so that the Medicaid 
recipient will actually receive a higher benefit package--this is the 
welfare recipient--than the average American would receive under the 
standard plan. The States have to pay for this.
  This would be extremely complex to undertake. The plans would have to 
have an incentive to limit coverage. They would have no incentive to 
limit coverage, and you would end up with an increased Medicaid 
wraparound. The coverage and the costs would shift directly to the 
State. It would be a dramatic cost shifting event.
  Further, States set Medicaid income eligibility thresholds within the 
Federal parameters. But the Clinton-Mitchell subsidy thresholds do not 
correspondence to the State threshold. This will make for an 
administrative nightmare.
  Also, the subsidy programs would be a tremendous undertaking because 
you would have problems confirming involuntary determinations as to 
unemployment subsidies, and determining pregnancy. You have to go in 
now and you have to determine when someone is pregnant, and when they 
are not pregnant. Can you imagine the personal information we are going 
to have to take from someone on that issue? Then you have the issue of 
when someone is working and when someone is not working. You have to 
verity State residency claims and income claims.
  The complexity is huge. I am not saying it cannot be done. I suspect 
those complex things can be done. But what they are going to require is 
a dramatic increase in costs.
  CBO has questioned this implementation of this system. In fact, they 
have estimated it would cost the States $50 billion over 10 years just 
to institute the subsidy. Where do they get that $50 billion? And $50 
billion I know in Washington does not sound like much money for some 
reason.
  I was stunned when I went to one of my first committee markups. They 
knocked all the zeros off, and all they were talking about was 50. I 
said, ``What is 50?'' They said, ``That is $50 billion.'' Well, $50 
billion would run the State of New Hampshire, actually run the entire 
State government, for 50 years-plus. So $50 billion is a lot of money 
when you are talking about passing the health care costs on to the 
States. All is not going to fall to New Hampshire. I hope not. But a 
significant number of dollars are going to fall on New Hampshire and 
all the other States, $50 billion among our States. And $50 billion per 
State over 10 years, that is $100 million if you were to spread it 
evenly. Obviously, you cannot spread it per capita. But that is a huge 
sum put on our State governments.
  You also have a new program called the outreach enrollment system. 
Under this provision, States would have to establish a system under 
which individuals would be presumptively eligible for a subsidy and 
enroll in the plan at the point of service by the provider.
  So what you have is when somebody walks into the doctor's office, 
they are presumed to be a subsidized individual. I can understand why 
the Clinton-Mitchell plan takes that view, because they are subsidizing 
to 115 to 120 million people--1 out of every 2 people. If you do not 
happen to be a subsidized person and you are walking down the street, 
you could probably be safe to say the person walking beside you is 
subsidized and be accurate. The point is that there is a presumption of 
eligibility when the person walks into the provider's office, and the 
enrollment and subsidies are valid for 60 days.
  In other words, people can declare themselves eligible for subsidies 
at the doctor office and have a plan pay for. Then the actual 
eligibility is determined later. If mistakes are made, who bears the 
cost? Well, the taxpayers bear the cost. This type of enrollment works 
in increasing coverage only if significant followup occurs to determine 
actual eligibility and to permanently enroll the individuals in the 
plan. States are thus required to undertake significant outreach 
efforts of this type, including the provision of an enrollment package 
to each provider in the State;
  However, given the significant burdens, even standard enrollment and 
reconciliation would impose the follow-up outreach efforts and would be 
likely to fall by the wayside. This could lead to a significant drain 
on the Treasury. It is a payment taxpayers would have to make. Over 30 
States now have provider enrollment already through contracting through 
private vendors. New Hampshire is one of them. If you do not, you are 
going to have to set up a system, and it will be extremely expensive. 
The Clinton plan authorized a 1-percent tax on States. I mentioned that 
earlier. States can assess this tax on premiums in order to pay for the 
cost. Well, I would hate as a Governor--and I suspect most legislators 
in the State legislature would not want to --to raise the premium tax 
in order to comply with a Federal rule which they had an absolute 
inability to monitor, to adjust, to effect. But that is what is being 
asked here.
  The Health and Human Services Secretary essentially says you shall do 
this one--there are 177 mandates--and then you are going to have to add 
probably half again as many new State employees to administer as you 
presently have, and they say: ``We will be nice and let you assess a 
tax on the premiums that your people pay.'' That is not something that 
I think most States want to do. But it is, again, a gun-to-the-head 
type of legislative action undertaken by the elite few here in 
Washington.
  There is also the 1.75-percent tax, which is assessed against all 
people's premiums in this country, which is in the bill, and which is 
already in place if this bill passes. Remember, that is assessed 
against everybody, so State governments pay it, too, on their 
employees. That is a big dollar item, a 1.75-percent premium tax on 
State employees. That is a big number, and where does that come from? 
Well, in New Hampshire, it will come from the taxpayers to fund that 
tax on their State employees, and then they will also have to pay that 
tax on themselves, so they get to pay it twice. Are they not lucky as 
citizens of our country living in the States?
  I have tried to go through this and analyze this bill as it is in a 
New Hampshire-specific way. I will read through some of the effects of 
this as it impacts New Hampshire. New Hampshire will have to develop a 
brand new untested health care system and get HHS approval or face the 
prospect, as I have mentioned before, of having New Hampshire citizens 
subject to a 15 percent premium tax. That is for starters. New 
Hampshire will have to submit--and all States will actually--a complex 
application to HHS by January 1997, and have it approved and updated 
every year.
  Even if we could do it, I would not want to do it that fast. It is 
just very hard to take a system like the New Hampshire system, which is 
working extremely well, and throw it out the window and replace it with 
this new we-know-best Federal system, and do it in the timeframe that 
this bill has suggested.
  I have mentioned a couple times that the New Hampshire system is 
doing very well. I want to read some statistics to support that, 
because if this goal is to improve health care--and I think that should 
be one of our goals--we ought to acknowledge that there are some places 
in this country where health care is fairly good, and in those places 
we are trying to solve the problems we have, but we think we are doing 
a good job. New Hampshire, for example, in national rankings, was rated 
No. 3, I guess, in the health of its people. It was rated the third 
most healthy State in the country. There are a lot of different 
statistics that went into that. We are rated the second best State in 
the country in the area of infant mortality. We have one of the lowest 
rates in the country. We are rated the lowest State in the country in 
the cost people have to pay for their health care, even though we have 
the best health care and the healthiest people in the country. We are 
No. 1 in the country in childhood vaccination. We are right in the top 
of the country in annual health care payments--we are in the bottom, 
but the top as far as cost goes. We have one of the lowest costs in the 
annual health care payments made by families and by individuals, so 
that we are a very inexpensive place to purchase health care. Yet, we 
deliver extremely good health care. As I mentioned, we are rated first 
in the country in mental health care.
  We have accomplished this through a lot of work. It has been creating 
a very integrated system. Yes, we have uninsured people in New 
Hampshire, about 10 percent. We have tried to address that, most 
recently in legislation passed this year by the New Hampshire House. We 
do have a lot of services that are supplied to the State for free by 
many of our service providers. But we have a system that is working 
very, very well, for the vast majority of the people who live in the 
State. They get first class health care, and get it promptly and at a 
fair price. Before we throw that system out for this huge new 
bureaucratically-driven health care, I think we ought to expect that we 
are going to get something better. And we are definitely not.
  To continue, under this proposal, if New Hampshire fails to meet the 
conditions of compliance, HHS can reduce the amount of payments for 
academic health centers and health research entities. And even if New 
Hampshire wants to continue to deliver the type of health care we are 
delivering--and it would probably be significantly different from what 
is planned under this bill--if we were continue to give the people the 
best health care in the country at the lowest cost in the country, with 
the best vaccination rates, mental health care, the best care for 
children in disadvantaged situations, we would be fined. Then we would 
start to see that in order to force compliance with this brand new huge 
bureaucracy, which would create mediocrity, in my opinion, we would 
start losing some of our payments to critical institutions, such as all 
academic health centers--and we do have one excellent one in New 
Hampshire--the acute care portion of the Medicaid program in New 
Hampshire would retain responsibility for continuing the Medicaid 
program, which includes the highest cost parts and the long-term 
care, plus determining eligibility and administering three new subsidy 
programs, huge cost to the State. New Hampshire would be responsible 
for implementing at least three new multibillion-dollar subsidy 
programs for the temporary unemployed, the low-income, pregnant woman 
and child, and hard to reach low-income groups like the homeless, and 
again no reimbursement for those costs, and CBO has acknowledged that 
it would be difficult for States to pursue that.

  New Hampshire can expect that this would affect almost 370,000 
individual residents in these subsidies programs. New Hampshire must 
pay the amount of the premium assistance subsidy directly to the health 
plan in which the individual is enrolled.
  New Hampshire must receive review applications once a year and 
revision of whenever estimates of income change and changes to 
complement status of family members.
  New Hampshire must then revise the amount of premium to reflect the 
changes. All this is required of the States to do.
  New Hampshire must conduct year-end reconciliation to each family 
income for the year based on each recipient's time with the State.
  New Hampshire does not have a State income tax. How are we going to 
do this one? Reconcile everybody's income or at least 370,000 citizens' 
income in the State? What an outrage.
  New Hampshire is required to verify the information by cross-checking 
with the Federal tax returns. I presume we can do that if we ever get a 
computer big enough. New Hampshire has to determine who underpaid, who 
overpaid, and how to make adjustments.
  New Hampshire would be financially responsible for premium assistance 
based on eligibility determination error to the extent New Hampshire's 
error rate exceeds a maximum permissible error rate set by the 
omnipresent Secretary of HHS.
  New Hampshire has to determine which families in the area have 
adjusted income below 200 percent of the applicable poverty level. New 
Hampshire would have to assure broad availability and processing of 
enrollment forms and provide direct enrollment through the mail while 
remaining in compliance with any other rules established by HHS, the 
omnipresent Health and Human Services Secretary.
  New Hampshire would have to set up an outreach program and require 
certain health center providers to fill out application forms for new 
patients declaring they are financially eligible for subsidy.
  Enrollee disenrollment from each standard plan must be reviewed to 
determine whether there is a pattern disenrollment that does not 
reflect the distribution of such plans reenrolling membership.
  New Hampshire will need to establish a new 1 percent premium tax to 
pay.
  New Hampshire is required to set up new insurance regulations. New 
Hampshire would be required to enforce complex new insurance laws, 
certify and accredit and enforce health plan standards, charter HIPC's 
and monitor the transfer of billions of dollars in insurance premiums 
paid by employers and individuals.
  I think that is an important point: the idea that the State 
governments are essentially going to be conduits for all the cash and 
payments that are flowing through this system. Most States are not 
capable of managing those types of cash transactions and certainly not 
for overseeing them, taking the marketplace entirely out of the 
exercise. It is now all government, no marketplace.
  New Hampshire would need to establish fair marketing practicing laws 
and standards, prevention of selective market and governance of State 
health plans through the use of direct marketing, agency and other 
arrangements to distribute health plan information.
  We will probably have to buy a television station and go public 24 
hours a day on this issue. Maybe we can get a new license they auction 
off down there. New standard, data, and other documentation in 
addition.
  New Hampshire would need to comply with the HHS omnipresent standards 
to be published relating to management of finances, maintenance of 
records, audit procedures, and financial recording requirements.
  New Hampshire would be required to establish a new risk adjustment 
organization, and using the methodologies developed by the omnipresent 
Health and Human Services Secretary, apply the per capita adjustment 
amount to community-rated and experience-rated and the multi-State 
plans and the health plans offered within each community rating area.
  We are smart in New Hampshire, but I do not think smart enough to do 
that one.
  New Hampshire would have to comply with the new community rating 
requirements.
  New Hampshire would have to collect data on patient care, health 
spending, the functioning and efficiency of health plans, and the 
omnipresent Health and Human Services Secretary will determine what 
those reports and audits by New Hampshire were required.
  Remember, under this bill your private medical information becomes a 
very public event. Under this bill researchers have the right to query 
you on your health care situation even without notice. They can come to 
your house and say ``I want to know how your health care is doing. I 
want to know what happened here.''
  You have to theoretically respond to them. I expect in New Hampshire 
you will run into folks who will not take kindly to that and throw you 
out the door. As a practical matter under this law you are supposed to 
respond.
  New Hampshire would have to develop and publish annually--in a format 
designated by the National Quality Council, an agency of the 
omnipresent Health and Human Services Secretary--the performance of 
each plan offered in New Hampshire with respect to a set of national 
standards.
  New Hampshire would have a new State health care delivery system. 
Ours is not good enough. The fact its plans are ranked to be the best 
in the country with the lowest cost in the country does not matter. Out 
the door. Get a new one here, something designed in Washington by a 
group of folks who know best what the people of New Hampshire should 
have.
  A new cap on entitlement replaces the disproportionate share hospital 
payments. While disproportionate share payments are reduced according 
to level of insured, New Hampshire has a new national $2.5 billion 
program which bypasses State government and goes straight to the 
hospitals serving vulnerable populations.
  So you change the playing field fundamentally.
  New Hampshire is required to identify all hospitals in which the low-
income utilization rate exceeds 25 percent and provide a list to the 
Secretary. The State must also report the total of inpatient hospital 
days for hospitals in New Hampshire for the year in accordance with 
reporting procedures established by the omnipresent Secretary of HHS so 
the Secretary can calculate low-income days and each hospital receives 
an allotment directly from the Secretary on a quarterly basis.
  New Hampshire must designate medical assistance facilities, rural 
primary facilities, hospitals that serve the population and essential 
community providers.
  New Hampshire must have planning and have startup funds. New 
Hampshire must match the planning and startup funds. I talked about 
that earlier, the fact we get hit with a penalty if we do not match 
startup funds. New Hampshire would be required to oversee the HIPC's. 
New Hampshire will have to charter and certify the HIPC's and establish 
the voting rights of members to select its board of directors.
  Maybe New Hampshire does not need a HIPC. We do have the best health 
care in the country and do it without a HIPC. We probably do not need a 
HIPC. Under this we have to establish one.
  New Hampshire will have to determine the regional boundaries, and 
community rating areas must contain at least 250,000 individuals and 
not divide metropolitan areas. That is going to be a interesting 
statistical event in a State of 1,150,000 people.
  New Hampshire would need to coordinate operations in a community 
rating area when a HIPC has operations in neighboring States, including 
the adoption of rules, contracting health with plans, enforcement 
activities and establishment of fee schedules for health providers. So 
we will end up obviously because we, like most States, have a number of 
sister States in a very complex operating structure with our sister 
State of Vermont, or sister State of Maine, or our sister State of 
Massachusetts.
  I am not sure what happens to the people who live along the Canadian 
border who go over to Sherbrook for an operation. It will be an 
interesting exercise to say they are treated but the complexity for 
doing it is extraordinary. They would lose choice under the Clinton-
Mitchell plan also, the standard benefit package, and the alternate 
benefit package will contain the same benefits. Only the costs sharing 
will vary.
  For example, in New Hampshire, Christian Scientists complained 
forcing them to buy assistance will be a double blow. They will not use 
the benefits they pay for and will not get the benefits they will use.
  New Hampshire opthalomologists have spoken to me about the Clinton 
plan, the Government funded centers for cataracts. They will not be 
able to compete, and a patient will lose the choice of eye doctors.
  New Hampshire residents, really I suspect, as they look in depth at 
this plan are going to find that its massive expansion of obligations 
on the State create huge new bureaucracies which will fundamentally 
undermine the quality of care our State has. I do not today, which is 
excellent.
  I do not think I have to rely on my own hypothesis on this. CBO, 
which has done analysis of this bill, which probably did one of the 
most devastating statements in this area, it said in addressing State 
responsibilities it said like several other proposals this one would 
place significant responsibilities on the States. I am quoting CBO on 
the States for developing and commending the new system, and it is 
doubtful that all States would be ready to assume that new 
responsibility in the timeframe envisioned. In addition, it says many 
of the States would simply be unable to comply with this language. 
States would bear the responsibilities for the requirement of the end 
of the year reconciliation processing which the income of subsidized 
families was checked to ensure that the families receiving the 
appropriate premium subsidy, reconciliation would be a major 
undertaking. Even if Federal income tax information could be used, many 
of the families receiving the subsidies would not be tax filers. 
Tracking people who move from one State or another during the year 
would also be difficult and would require extensive cooperation among 
the States. Probably be impossible. That is my parenthesis.
  And it goes on and on.
  It just basically points out that--another language: ``It is doubtful 
that all States could develop the capabilities to perform these 
functions in the near future,'' talking there about monitoring the 
health insurance industries.
  The language of the CBO report is just replete with statement after 
statement of the affects of this plan and its inappropriateness on the 
impact on the States.
  In addition, the National Governors Conference, taking a long look at 
the Mitchell-Clinton plan, concluded also that large sections of it are 
going to have extensive negative impacts on the States. In one area, 
the plan concerns the following four categories.
  One, that it does not integrate Medicaid into the new low-income 
programs.
  Two, the adjustment factors to increase the States' main efforts of 
the contribution over time is higher for most States than the expected 
Medicaid growth.
  What that means is the Federal Government is essentially extorting 
from the State money that it would not have gotten under the 
traditional payment process. There is no Federal funds to administer 
low-income programs, as I pointed out before, which cost almost $50 
billion to the States, which is a huge sum.
  And most standards, results, and regulations set by the Federal 
Government are nearly impossible--in the National Governors 
Association--nearly impossible to administer the plan.
  Well, I have gone on for quite awhile here, but I think it was 
important. I could have gone on for a lot more time. I think it was 
important to go through in some depth how this plan basically takes 
control of State governments' function in the area of health care and 
how it puts onto the States this huge new structure of bureaucracy.
  What is the bottom line? Many people sort of tune out and say, 
``Well, that's just the State government. So what?''
  The bottom line is it affects the people who live in those States. 
The people who live in those States and have to pay new taxes and are 
put under the auspices of having basically to deal with Washington for 
their health care rather than their State government, are confronted 
with this huge new bureaucracy which will be confusing and hard to deal 
with.
  In States like New Hampshire, which have such a strong tradition of 
delivering quality health care, it essentially undermines everything we 
have worked so hard to accomplish.
  Now, yes, we all recognize that there needs to be reforms, that we 
need to address things like portability and preexisting conditions, and 
small-market reform, antitrust reform, and malpractice reform, and make 
sure that the low-income working person has fast and first insurance.
  But this is not the way to do that. We do not need to have a basic 
national Federal takeover in the name of dependency politics of our 
health care system in order to accomplish those goals.
  And, in fact, this language--I think I have made the case--will 
significantly diminish the quality of care that is delivered, at least 
in the State of New Hampshire, because it will create huge 
bureaucracies and drain off huge amounts of resources to comply with 
ideas and initiatives which come there from Washington which may 
either, one, have no bearing on the quality of care in New Hampshire; 
or, two, which may actually undermine our present quality of care in 
New Hampshire.
  The arrogance of this bill to come forward and say that we know best 
here in Washington how you in New Hampshire should run your health care 
system is what I find most frustrating about it. Because there are 
places in this country--and there are a lot of them--that are working 
hard to address health care and improve health care. They do not need 
to have the Health and Human Services Secretary essentially take over 
the government of the State in order to address that issue.
  Rather, what they need is targeted reform, which will improve those 
functions of the health care system, which should be addressed from the 
national level. Those targeted reform ideas have been proposed. They 
have been proposed by Senator Packwood and they have been proposed on 
the House side by Congressman Bilirakis and Congressman Rowland, Dr. 
Rowland. They are out there.
  The only reason we are going forward with this bill is because of the 
point I made at the beginning of this discussion. It is this 
philosophical drive to move to dependency politics, the politics of the 
State, where you bring everybody under the control of--not under the 
control, but at least under the obligation; or not everybody, but a 
large percentage of the population becomes committed to or dependent on 
the Federal Government. And the Federal Government or the central 
Government becomes the center of power for the domination of the style 
and activities and delivery of the service.
  That is a mistake. We do not need to step off onto this road with a 
giant leap. Regrettably, all government is moving to the left. But we 
do not need to assist it by taking this giant handspring in that 
direction through the passage of this bill.
  I yield back my time.
  I thank the Chair for her courtesy and I thank the Senator from West 
Virginia for his patience.
  The PRESIDING OFFICER. The Senator from West Virginia.
  Mr. ROCKEFELLER. I thank the Senator from New Hampshire and others.
  I wish to speak, Madam President, on health care reform. But it just 
seemed to me that, almost without exception, those who have come to 
speak on the other side about health care reform have, in almost 
identical words, disparaged the Mitchell plan.
  What I keep looking for is something that they say they are for, and 
I just never hear it.
  If we are discussing health care plans, we ought to be looking at the 
Mitchell plan and at the Dole plan. So that is a little bit of what I 
propose to do today. If the majority leader comes in, he may want to do 
a unanimous-consent request and I will yield to that.
  Madam President, in the very simplest of terms, our debate on health 
care reform has come down to defining objectives. I have been working 
on health care--as has the Senator from Oregon, who is on the floor, 
and the Senator from Iowa, who is also on the floor, and others--for a 
long time. It has been a major concern, taking up a lot of my time for 
many years. I have looked at and I have studied more proposals, more 
plans, more analyses, more bills than I can count or that I wish to 
think about counting. And today I support Senator Mitchell's bill.
  But I also see, happily, some areas of agreement with those on the 
other side of the aisle. It might be nice to mention that. I understand 
it might be hard to tell from watching all of this, but it is true; I 
think there are areas of agreement.
  For example, Democrats are as committed as Republicans to ensuring 
that every American will be able to keep the health care plans that 
they now have if they want to. Both parties are in agreement on that.
  If you have Blue Cross and if you like Blue Cross, you should be able 
to keep Blue Cross. If you have health coverage with Aetna and you are 
satisfied with that health coverage with Aetna, you should keep Aetna, 
by all means.
  The Mitchell bill lets Americans do just that, stick with the insurer 
that they have if they like that insurer. So we do agree on some key 
health care issues.
  But behind this agreement there are some important differences, and 
it is important to talk about both plans and some of these differences. 
Let me try to explain why the Mitchell bill stands out to this Senator 
as the proper course for reform and why the Dole plan worries me.
  In simplest terms, the Mitchell bill is intent on providing health 
care security for the American people. That is what we have said from 
the beginning. But the Dole plan tips the balance in favor of insurance 
companies. This difference is, obviously, very critical and I believe 
it is what makes the Dole bill dangerous and the Mitchell bill a far 
safer course for all of us.
  With the Mitchell bill, we can see the progress that this Nation will 
make toward ensuring health insurance. Ensuring the insurance is always 
worth the premiums that people pay, always affordable and always 
secure; always there when you need it.
  With the Dole bill, every American will still be at risk of paying 
premiums month after month, year after year--but finding their claims 
rejected just at the time that they need to use the coverage. The 
Mitchell plan offers reforms that will mean something to American 
families, real substance for real people in my home State of West 
Virginia, in the Presiding Officer's home State of Illinois. As we 
think of real families, working families, people we know, we want them 
to have health insurance that they can count on. The Mitchell bill does 
that for them and it will mean a great deal to them. It eliminates 
loopholes.
  I refer to this chart. The Mitchell bill eliminates loopholes, limits 
on coverage, fine print, and deceptive practices. Too often fine print 
is used to deny people care when they need it most, or to let insurance 
companies cut and run from people just when medical bills get too high.
  That bit of common sense in the Mitchell bill is long past due. Is 
that not exactly why people purchase insurance? So they have this kind 
of protection? That is what they pay their money for, to help them in 
the event their medical expenses get too costly. That is what insurance 
is for.
  Today, insurance for senior citizens has a large hole in it. A visit 
to the doctor to find out that you need medicine is covered, but the 
medicine that the doctor may say that you need is not. That is a very 
large hole. The Mitchell plan plugs that hole by covering prescription 
drugs.
  For senior citizens, the Mitchell plan has prescription drugs and 
long-term coverage.
  Consumers will never have to fear losing their coverage under any 
circumstances. No more being dropped arbitrarily or canceled. The 
Mitchell bill stops those practices, and it provides help with premiums 
if you are between jobs.
  We are told that in the course of a lifetime, young people will have 
5, 7, 8, even 10 different jobs. There are a lot of people ``between 
jobs'' in my State, and I want them to have insurance between jobs 
while they are looking for other jobs.
  So, the Mitchell bill is about getting and helping people keep good, 
reliable health insurance.
  The Dole bill, however, is another story.
  I refer to this second chart. Those insurance company loopholes and 
fine print that today can be used to deny or cancel insurance, stay in 
place in the Dole bill. Promises made in the Dole bill are meaningless 
because they apply to coverage that people cannot afford to buy or 
keep. Insurance does not mean anything unless you can keep it. 
Insurance companies' costs are completely uncontrolled in the Dole 
bill, and insurance bureaucrats can continue to dictate to doctors what 
care they give.
  The story I love to tell in West Virginia is of a two-physician 
practice. In the two-physician practice in one of our cities there are 
18 people working, 9 of those people practice medicine, 9 of those 
people do paperwork. Four of the nine people who do paperwork spend all 
day on the telephone to the insurance companies asking permission to do 
what the doctor in that office knows perfectly must be done, but they 
have to get permission from the insurance company to do that. That is 
outrageous. That is anachronistic, but that is our current system and 
that system is preserved under the Dole bill.
  For those fortunate enough to get and keep coverage, there is not 
much to gain. The Dole bill offers no protection against sudden premium 
hikes. Even the most fortunate will be constantly at the mercy of 
insurance companies' radical rate hikes.
  Under the Dole plan, Medicare gets cut. Yes, it does under the 
Mitchell plan as well, but under the Mitchell plan there is 
prescription drug and long-term care covreage in return for those cuts. 
Under the Dole plan, no prescription drug or long-term care coverage is 
offered. So that is a very substantial difference: The Dole plan cuts 
Medicare and offers no long-term care, no prescription drugs; the 
Mitchell bill cuts Medicare but provides prescription drug and long-
term care coverage. Major, major differences. The Dole bill not exactly 
the reform people want and need.
  People who lose jobs, people changing jobs are simply out of luck 
with the Dole plan. Perhaps it boils down to a different understanding 
of what the word ``insurance'' means. I have with me Webster's 
Dictionary. I want to read what the word ``insurance'' means in the 
Webster's Standard Dictionary: ``To guarantee protection and safety.''
  To guarantee protection and safety. To guarantee protection and 
safety. I repeat that because I fear that if we keep going the way that 
we are, or if we choose the Republican route, insurance will no longer 
mean a guarantee of protection and safety. Instead the word 
``insurance'' will, more and more often, be linked with the words 
``abuse,'' ``fraud,'' ``loopholes.''
   Democrats want to restore the value of having health insurance.
  Today, too many policies are downright dangerous--in fact, even 
hazardous to people's health care. Filled with loopholes and fine print 
that can leave you financially and physically ruined when the medicine 
or the care that you need is denied because your coverage is 
incomplete.
  Remember those employees in the doctor's office spending their days 
on the phone to insurance offices trying to get permission for 
treatment? Well, they do not always get the answer yes. And when the 
answer from the insurance company is no, the American people are the 
losers.
  Americans should not need a magnifying glass to understand what they 
are buying in a health insurance policy. We do not have to be auto 
mechanics to go out and buy a car and know that it will not blow up 
when we step on the gas pedal. We do not need to be chemists to buy 
pajamas for our kids and know that they are fire retardant. We should 
not have to be lawyers or insurance experts to be sure our health care 
coverage is worth the premiums we will pay.
  Democrats want Americans to choose among a wide variety of good 
insurance plans. The Mitchell bill guarantees a choice of plans, and it 
also guarantees that the plans are sound.
  Let me read to you some clauses from a couple of health insurance 
plans. These are real health insurance policies--not from fly-by-night 
companies or tiny companies run out of the trunk of a car, but 
mainstream companies with well-known services that have limits and 
exclusions.
  (The PRESIDENT pro tempore assumed the chair.)
  Mr. ROCKEFELLER. Here is one example. I urge those listening to try 
to keep up with this as best they can. This is on page 6 under 
``Sickness,'' and it says:

       Sickness means illness or disease of any insured which 
     first manifests itself 30 days after the effective date of 
     this policy and while this policy is in force. All sickness 
     due to the same or related cause or causes which continues or 
     recurs shall be considered one and the same sickness or ``any 
     one sickness'' unless periods of confinement to a hospital or 
     service, treatment or expenses incurred resulting from such 
     Sickness are separated by an interval of at least 90 
     consecutive days--

  At the beginning in the same paragraph, we had 30 consecutive days.

     between the end of one such period and the beginning of a 
     subsequent such period.

  And then it says:

       Any loss which results from hernia, disease or disorders of 
     the reproductive organs, hemorrhoids, varicose veins, tonsils 
     and/or adenoids, or ottis media shall be covered only if such 
     loss occurs after this policy has been in force for a period 
     of 6 months --

  This is 30 days, 90 days and now 6 months, all within two sentences 
of one paragraph.

     from the Effective Date of This Policy provided these 
     Sicknesses are not excluded by rider and endorsement and 
     these Sicknesses are not preexisting conditions.

  Mr. President, this is absurd. The people of West Virginia are highly 
intelligent. But when you get something like this, it is impossible to 
understand what it means. This is what would be allowed to continue 
under the Dole plan and would not be allowed to continue under the 
Mitchell plan.
  Just one more. On page 10--and there is a lot more reading here--
there is something called ``Exclusions, Exceptions and Limitations.'' 
And then it says: ``Coverage is not provided under this policy for loss 
due to''

  And then a list of things which goes on for 15 different exclusions. 
Number 6 excludes ``childbirth or pregnancy.'' Childbirth or pregnancy 
cannot be covered.
  It is just incredible to me that in America, if a woman gets married, 
then gets pregnant, does not have health insurance, and she and her 
husband go out and try to buy health insurance so they can have good 
prenatal care, they cannot buy it because they have--here it is--
pregnancy is a preexisting condition. I do not think they would 
necessarily know that with this insurance policy unless they read it 
very, very carefully.
  There is another exclusion here, number 5, which amazes me:

       Participation in aviation except as a fare-paying passenger 
     traveling on a regularly scheduled airline flight.

  I can draw no conclusion from that except it means if you are in one 
of those cost-saving or frequent-flier plans, it may be that if you get 
sick, you are not covered. I do not know what that means, though I am 
trying my best to make sense of it.
  I will read exclusion number 14:

       The correction of a congenital anomaly or abnormality after 
     an insured is age 19.

  Congenital anomaly means that you had something all your life. It is 
congenital. Your insurance coverage is clearly, on this last issue, 
wiped out.
  This should be very distressing to us all. This is a major company's 
insurance policy, and it is something that most people, would put faith 
in and surely accept. But indeed there is the work of the devil in the 
details. This is just outrageous.
  I will just use one more example from another health insurance policy 
written by a major company. And on page 11, under ``Limitations and 
Exclusions,'' it reads:

       This certificate does not cover any charges for any 
     services, treatment, or supplies: furnished as a result of, 
     or in any way related to a Pre-Existing condition.

  Mr. President, that is what the Mitchell bill eliminates and what the 
Dole bill allows to continue. And once again, here in another health 
care policy it excludes ``for pregnancy or childbirth, except for 
Complications of Pregnancy.''
  Well, that means no prenatal care. And since it says ``childbirth'' 
is not covered, I assume it means no well-baby checkups.
  Insurance policies are major forces in people's lives. And within 
this handful of insurance policies are some extraordinary exclusions 
and limitations which are stopped in the Mitchell bill yet which will 
continue in the Dole bill.
  Some have argued for years against requiring seat belts in cars. They 
called seat belts expensive and unnecessary. Some still argue against 
helmets for motorcycle riders because they want the freedom to take 
risks with their physical safety, not necessarily understanding that 
their physical safety could coincide with the physical safety of 
another person.
  The truth is that the costs for victims of accidents without 
seatbelts or without helmets are not borne by the individual who takes 
the risk--too often we all pay the cost for those reckless decisions. 
That is wrong
  Those who argue today that we should allow dangerous and hazardous 
insurance policies to be sold using the rhetoric of freedom and choice 
are simply protecting insurance companies' power and profit. Nothing 
more.
  We do not want any bureaucrat--no Government bureaucrat and certainly 
no insurance company bureaucrat--to decide what illnesses or accidents 
qualify for care.
  If you buy insurance, and you go to your doctor and your doctor tells 
you that you have cancer or that you are suffering from depression or 
you have some other ailment, your doctor should not have to call any 
insurance company to ask for permission to treat you. It will not 
happen under the Mitchell bill and it will continue under the Dole 
bill.
  Increasingly, that is the system that we have in this country. 
Insurance company bureaucrats blocking coverage for whole categories of 
services. I am not talking about legitimate arguments against 
questionable or experimental treatments. I am talking about the 
wholesale exclusion of whole categories of necessary care: Preventive 
care, prenatal care, pregnancy-related services, preexisting 
conditions, prescription drugs--all legitimate and necessary services, 
all denied today by health insurance companies.
  Republicans want to protect insurance companies' prerogatives, 
speeding us on a path to insurance company dictatorship.
  This is not just a fear for the future--it is a reality that many 
Americans are now living with.
  I have visited with them in West Virginia. Whenever possible, I visit 
families that have some kind of health care problem so I can better 
understand their concerns and better represent them.
  Let me just share a letter from a constituent who has been frustrated 
and exhausted by insurance company rules and insurance company control. 
In a letter written just 3 weeks ago, Clarence Wickline, of Peterstown, 
WV, wrote:

       I have Blue Cross and Blue Shield insurance. They take it 
     out of my check every week.
       My daughter was scheduled for surgery last week. She had 
     all of her blood work and everything done and was going to 
     check in the hospital the next day. The insurance company 
     called the surgeon and refused to pay for it. So she couldn't 
     have surgery.

  Clarence Wickline concludes with:

       I really don't think it's fair. Thanks for listening.

  That a straightforward letter from a straightforward West Virginian 
who pays his insurance premiums and gets left out in the cold the one 
time his family needs their insurance.
  Now, there has been plenty of technical talk about reform over the 
past year--mandates, triggers, alliances, cost shifting, redlining. It 
is hard to keep track of all of it, there is so much of it. And for the 
American people watching us and following the debate, it must be pretty 
confusing.
  I am trying to put reform in simple terms. In real-life terms that 
tell people how the different health care reform plans will affect 
them, because we have two different plans--the Dole plan and the 
Mitchell plan.
  If you are a middle-class, hard-working American consumer, the 
Mitchell plan looks out for you and delivers a real measure of reform 
that you will see. You can keep your plan or choose a new option, but 
no matter what, your insurance will always be worth the premiums that 
you pay for it.
  If you are an insurance company, the Dole plan looks out for you. 
Business as usual. Loopholes for preexisting condition exclusions, 
limits on portability, higher premiums, no guarantee of choice--as full 
of holes as swiss cheese. In short, allowing this kind of insurance 
represents a reckless disregard, in this Senator's judgment, for public 
safety.
  With those objectives, it is pretty clear that the Mitchell plan, in 
this Senator's judgment, is a moderate, thoughtful, and sensible 
approach that seeks to be effective but not intrusive. It makes sure 
insurance will be, for you and your kids, ``a guarantee of protection 
and safety.'' And you and your doctor will always know that your 
insurance will provide the care that you need. Insurance company 
bureaucrats will not be able to cut you off.

  That is meaningful reform. That is real reform for real people who I 
represent. It is not enough to say, as Republicans do, that we want you 
to keep your insurance. Getting to keep something labeled insurance 
that is gutted and loophole-ridden and weakened is not worth much. But 
that is what the Republican plan will do.
  For all of those people whose letters that I read earlier, and the 
millions of others whose letters and phone calls we get, we must pass 
reform that makes health insurance a dependable, sure thing, not a 
gamble left to the whim of insurance companies.
  I thank the Presiding Officer. I yield the floor.
  Mr. MITCHELL. Mr. President, I hope in a few moments to be able to 
announce or propound a unanimous-consent agreement with respect to 
further proceedings on the pending amendment.
  I know the Senator from Indiana was going to seek recognition. I 
merely request that we are ready to proceed, if he would permit us to 
go ahead and propound the agreement.
  Mr. COATS. Mr. President, I would be happy to accommodate the 
majority leader's request in that regard.
  Mr. COATS addressed the Chair.
  The PRESIDENT pro tempore. The Senator from Indiana [Mr. Coats].
  Mr. COATS. Mr. President, Senator Mack and I have an amendment at the 
desk which I think would most appropriately be entitled ``Let the 
sunshine in.''
  In 1972, the Congress enacted an important act which has greatly 
contributed to openness and accountability in the executive branch. It 
is called the Federal Advisory Committee Act.
  That act requires that any Presidential or executive task force, 
which includes private citizens, conduct its meetings in public. Let me 
restate that. The Federal Advisory Committee Act requires that any 
Presidential or executive task force, which includes private citizens, 
conduct its meetings in public.
  The requirements of the Federal Advisory Committee Act, I think, are 
reasonable--Congress has determined that--and are there to ensure that 
the public, not included in those meetings, have access to Government 
activities which will directly affect their lives.
  The Congress now has for over 20 some years upheld that particular 
statute. I think it is important. What it means is that all meetings 
will be open to the public. This is a Government of, by, and for the 
people. We can only assure that right, if the people are given access 
to what this Government is saying and doing.
  The act requires that there be advanced notice of meetings. The act 
requires that the public be informed of the agenda of the meetings.
  That means in this case that decisions made relative to medical care 
for 250 million-some Americans, whether it be the benefits that they 
will be entitled to, whether it will be medical services that are 
deemed appropriate and necessary, whether it be the cost of certain 
procedures, that those decisions, some affecting the most personal of 
all matters that affect our daily lives, be decided in a forum whereby 
the public is aware of the agenda up for discussion, where it has an 
opportunity to comment, where it has an opportunity to respond, 
testify, and to file statements; that those meetings be open to the 
general public. Records would have to be kept as mandated under FACA. 
The minutes, working papers, drafts, subsidies, et cetera, would be 
made available to the public.
  I note that the majority leader is seeking recognition. I would be 
happy to suspend at this particular point.
  The PRESIDENT pro tempore. Without objection, the Senator will retain 
his right to the floor.
  The majority leader.
  Mr. MITCHELL. Mr. President, I thank my colleague.


                           Order of Procedure

  Mr. President, I have discussed with the distinguished manager of the 
bill, Senator Moynihan, and the minority manager, Senator Packwood, and 
others how best to proceed.
  The pending amendment is amendment No. 2568 offered by Senator Mack. 
The amendment is not disputed. We are prepared to accept the amendment 
without further debate and by voice vote.
  I inquire of my colleague from Oregon whether that would be agreeable 
for our colleagues, or whether they wish a vote on it, and further 
amendments?
  Mr. PACKWOOD. No. We would like to vote on it. When I talked to the 
majority leader earlier he was saying 6 o'clock or so. I ran it by our 
side. We would like to vote at 6:45, if we could.
  Mr. MITCHELL. Accordingly, then, Mr. President, I ask unanimous 
consent that the Senate vote on the Mack amendment at 6:45 p.m. today; 
that the time between now and then be equally divided, and under the 
control of Senators Moynihan and Packwood, or their designees; that no 
second-degree amendments to the amendment be in order, or amendment 
language may be stricken by the amendment; further, that following the 
vote on the Mack amendment I be recognized to offer the next amendment.
  Mr. COATS. Reserving the right to object, just for a matter of 
clarification, I do not know if Senator Mack asked for the yeas and 
nays on the vote. My understanding is that there will be a recorded 
vote at 6:45 p.m.
  Mr. PACKWOOD. We will ask for the yeas and nays. There will be a 
recorded vote.
  I might say to the majority leader, the amendment is perfectly 
acceptable. It is one that I think will have good support, and is not a 
surprise amendment.
  Mr. MITCHELL. Mr. President, I want to make clear that this vote at 
6:45 will not be the last vote. We will continue.
  Mr. PACKWOOD. As the majority leader indicated, he is hoping we will 
accept his amendment. I indicated there might be some people who would 
want to talk it, and would want to vote on it tonight.
  The PRESIDENT pro tempore. Is there objection to the request? The 
Chair hearing no objection, it is so ordered.
  Mr. MITCHELL. Mr. President, I thank my colleague. I thank the 
Senator from Indiana.
  The PRESIDENT pro tempore. As the Chair understands the request, the 
time beginning now is equally divided, which includes the time which 
will now be used by the Senator from Indiana.
  Mr. MITCHELL. That is correct.
  Mr. PACKWOOD. It does not include the time used today, but equally 
divided from 2:30 on.
  I yield further time as the Senator may require.
  The PRESIDENT pro tempore. Is it the Chair's understanding that the 
time that will be used by Mr. Coats will be charged against the time 
under the control of Mr. Packwood?
  Mr. PACKWOOD. No. The time that he has used to date is not charged, 
and it starts running right now.
  The PRESIDENT pro tempore. The Chair thanks the Senator.
  The Senator from Indiana [Mr. Coats] is recognized.
  Mr. COATS. Mr. President, I thank both the majority leader and the 
managers of this bill.
  Mr. President, to pick up where I was, we were discussing the Federal 
Advisory Committee Act.
  I noted that it was an important act that was enacted by the Congress 
in 1972. The purpose was solely to give the right of the American 
people the opportunity to know what was being debated by members of the 
executive branch that affected their interests. They would have the 
right to know what the agenda of the meeting was, and they would have 
the right to receive minutes of the record. They would have the right 
to insist that such meetings be held in public.
  It is important, particularly in the context of the legislation that 
we are talking about now because, while most Federal meetings obviously 
have an effect on some Americans, when and if the legislation here 
regarding health care is passed, particularly if the Mitchell bill is 
passed, the decisions will be made that are among the most, if not the 
most sensitive, and the most intimate, regarding not just a few but all 
Americans. It is important that our Government continue to allow each 
of us who are affected by these decisions the opportunity to comment 
and respond.

  We have heard, time and time again, that the bill before us is not a 
Government-run bill. As I have pointed out on this floor, there are 55 
new Government agencies created by the bill that is before us--55. I 
have detailed and outlined those by section. There are 815 new duties 
that flow to the Secretary of Health and Human Services and 83 that 
flow to the Secretary of Labor. But I am especially troubled by the 
fact that in the creation of two of these agencies--perhaps the two 
most powerful agencies--perhaps the two new agencies that have the most 
influence over the personal lives of more than 250 million Americans, 
those agencies being the National Health Benefits Board and the 
National Health Care Cost and Coverage Commission. Those two agencies 
will be exempt from the provisions of the Federal Advisory Committee 
Act. That means that the decisions of those agencies will not be 
available to the public for scrutiny until those decisions have already 
been made. It will be a fait accompli. What is deemed medically 
necessary and appropriate, what prices, what price controls, what cost 
controls may be placed on the development of new technology, new 
innovations, and the diagnosis and treatment of disease, those 
decisions will not be available to the public under the provisions of 
the Mitchell bill.
  I think that is wrong.
  So the purpose of the amendment Senator Mack and I are offering is to 
strike those two sections--actually, we are striking three sections, 
and I will explain the third in a moment--because that opens up the 
decisionmaking process to the public.
  Let me describe what the National Health Benefits Board does. Under 
the Mitchell bill, the National Health Benefits Board is given the 
authority to decide what benefits will be contained in the standard 
benefits package that every American will be required to purchase. 
Everyone offering a health care plan in America will be required to 
incorporate the decisions of the National Health Benefits Board as to 
what those benefits shall be. There will be no opportunity for 
discretion.
  Fortunately, yesterday we removed a provision which would have fined 
any provider of health care $10,000--or any individual who purchased 
health care would have been fined $10,000--if that provider or that 
individual had a health care policy that deviated in terms of benefits 
provided, deviated one iota from the decision of the National Health 
Benefits Board as to what the package should be. It is a one-size-fits-
all mentality. If you are an 18-year-old single individual, just out of 
school, on your first job, earning perhaps a lower wage than you would 
like, but the going rate for a new hire, you are going to be mandated 
to have coverage for a package designed by the National Health Benefits 
Board. That package is the same package that will be available to a 
married couple with two children, and it is the same package that will 
be mandated to individuals whose children are grown, who might be in 
their retirement years. Every American will have to have exactly the 
same package, regardless of your health care needs.
  Obviously, we know that the insurance industry today and the health 
care coverage today is designed with a whole cafeteria of benefits that 
you can select and choose based on your own particular health needs or 
the health needs of your family. Obviously, there are those who do not 
choose certain lifestyle behaviors, who would like to have the 
opportunity to purchase health care at perhaps a discount by not 
engaging in those behaviors. So there are policies today that are 
available to those who do not smoke. We know that that lowers their 
health risk, the risk of lung cancer, and so they are able to reduce 
their premiums somewhat.
  Obviously, an individual or a couple, where the female of that 
marriage is past childbearing age, does not need to have a policy 
covering childbirth and does not need to have a policy providing 
maternity benefits, and, therefore, they can purchase policies that 
exclude that particular type of coverage. It is that selection, that 
wide array of benefits and opportunities for different benefit 
packages, that is an important competitive component of our health care 
system today. Yet, the Mitchell bill would require that we all obtain 
exactly the same benefit package.
  Those decisions are going to be made by the National Health Benefits 
Board, and the public ought to have input as to what those decisions 
are. Yet, there is a specific exclusion for that board's actions, based 
in the Mitchell bill. On page 129, section 1216 is ``Applicability of 
Federal Advisory Committee Act.'' It says on line 15: ``The Federal 
Advisory Committee Act shall not apply to the Board''--the board being 
the National Health Benefits Board. The Federal Advisory Committee Act 
is specifically exempted, and all its provisions, from actions by the 
board. We do not think that is right, and that is why we attempt to 
strike it.
  The National Health Care Cost and Coverage Commission is the 
Government-appointed rationing agent which is authorized to monitor all 
health care expenditures in the United States and propose premium caps 
and other mechanisms to control prices and limit health care spending. 
This Government bureaucracy will be making hundreds of health care 
decisions which affect the health care of every American. Decisions 
which are currently made by patients and their families and their 
doctors will be made by bureaucrats in Washington.
  That particular board is also exempted from the provisions of the 
sunshine law, the law that I have been referring to. The Federal 
Advisory Committee Act does not allow these practices to take place. I 
might note that it is in section 10001, page 1390.
  Mr. President, one of the reasons why we insisted on some time to 
understand this bill--and just now we are able to delve into the 
minutia of the bill and expose provisions which we do not think are in 
the best interest of Americans--is because it is so complicated. When 
we are talking about section 10001, we are talking about a lot of words 
between the first section and that section. That section also 
specifically exempts a new Government agency, the National Health Care 
Cost and Coverage Commission, from the FACA. That language reads on 
page 1409, specifically: ``FACA Not Applicable. The Federal Advisory 
Committee Act shall not apply to the Commission.''
  There is another somewhat more obscure agency, called the Agency for 
Health Care Policy and Research, created in this bill. That panel is 
also exempted from portions of the sunshine law. It is somewhat 
different, but we strike that also, because it says that that 
particular agency is covered by this provision. It says:

       Panels convened for the purpose of carrying out paragraphs 
     (1) and (2)--

  Which refers to the actions of the Health Care Policy and Research 
Agency.

     shall not be considered advisory committees within the 
     meaning of section 3(2) of the Federal Advisory Committee 
     Act, and prior to publication by the Administrator, clinical 
     practice guide, performance measures, and review criteria as 
     described in section 912(a) are not subject to the 
     requirements of section 552 of Title 5, United States Code.

  They are exempted from the provisions of the act. So the amendment 
before us is designed solely for the purpose of giving the public 
access to decisions made by Federal boards created under the Mitchell 
bill which will affect every living American.
  I am pleased to join my colleague, Senator Mack, in offering this 
amendment. We think it is important. We have reason to believe that 
Senator Mitchell and his proponents have had an opportunity now to 
review the bill and apparently will agree with us that this amendment 
is necessary to correct provisions that are incorporated now in the 
Mitchell bill.
  Senator Glenn, the distinguished chairman of the Senate Committee on 
Governmental Affairs stated:

       I do know that openness in Government spawns confidence. 
     Secretiveness in Government begets suspicion, and that is 
     what I think we have a surplus of in Washington right now.
  Mr. President, openness does spawn confidence. Secretiveness does 
beget suspicion. And we do have a surplus of suspicion in Washington 
right now. It is almost paralyzing our efforts.
  We keep hearing several of our colleagues talk about the numerous 
public hearings held in the Labor Committee and Finance Committee on 
health care reform. But yet we are presented with a bill that is not 
the Labor Committee bill nor the Finance Committee bill, but a new bill 
written behind a closed door, written in secret--true, incorporating 
provisions of the Labor Committee bill and the Finance Committee bill--
but with many new provisions.
  So when it is presented to us, first in volume 1, then in the 
corrected volume 2, and then in the corrected volume 3, I think it is 
perfectly appropriate to ask for time to study this mammoth volume and 
understand the provisions, as we have done in the last 2 or 3 days.
  We are now beginning to shed light on the Mitchell bill and as light 
is shed on the Mitchell bill, we find provisions that not even the 
majority can support or defend, and they are coming to the floor saying 
either, ``Yes, that is there inadvertently,'' or ``We now recognize it 
should not be there, and we will join with you, almost unanimously join 
with you, in removing that section.''
  We have removed the $10,000 fine for an employer offering an 
additional benefit to an employee. Perhaps an employer says, ``I do not 
agree with the National Health Benefits Board. I would like to offer 
two mammograms per year to my female employees over 50 years of age.'' 
That would have been subject until yesterday to a $10,000 fine for 
offering an additional benefit. Perhaps there is something unique about 
the business of that particular employer and they want to provide a 
benefit that the board has overlooked or excluded for whatever reason. 
That employer would have been subject to a $10,000 fine. Fortunately, 
we have been able to eliminate that.
  This now goes to the heart of the secret matter, the meetings in 
secret. This whole row started, of course, back last year with the 
meetings with the First Lady and Mr. Magaziner. There is now a Federal 
lawsuit on the matter. That was attempted to be settled. But I think 
there is interest in receiving the documents that were part of all that 
discussion. That is now in Federal court. I will not delve much into 
that.
  But what we are after here is openness. If we are going to define the 
benefits, if we are going to define the costs, if we are going to 
define the procedures, if we are going to make the decisions that go to 
the personal, intimate details of individuals' lives or loved ones' 
lives, it ought to be done in the open.
  Mr. President, I will close by quoting from Justice Brandeis, who 
said, ``Sunshine is the best disinfectant.'' We are now in the process 
of letting the sun shine on the Mitchell bill, and we are finding that 
it is a great disinfectant. There is a lot of infection in here that 
needs to be disinfected.
  Mr. President, let the sun shine in.
  With that, I yield the floor.
  The PRESIDENT pro tempore. The Senator from Arkansas.
  Mr. PRYOR. Mr. President, I enjoyed my colleague's statement.
  The PRESIDENT pro tempore. Who yields time?
  Mr. PRYOR. Mr. President, I think I am managing for the moment. So, I 
yield myself as much time as I need. I just have a question.
  The PRESIDENT pro tempore. The Senator is recognized for as much time 
as he needs.
  Mr. PRYOR. Mr. President, I enjoyed the statement of the Senator from 
Indiana. He is talking about letting the sun shine in, letting all 
Government decisions be made out in the public in the sunshine, in 
meetings, et cetera; meetings with the First Lady.
  I wonder if the Senator from Indiana would state his position on how 
much sunshine there should be present when two U.S. Senators meet with 
a Federal judge. Should that meeting be in the sunshine? Should that 
meeting be in public, I ask the Senator from Indiana?
  Mr. COATS. Mr. President, if that is a question propounded to the 
Senator from Indiana, I will be happy to respond to the Senator.
  First of all, it is a question that we are not deciding here today. 
Obviously, it would be nice to shift the focus from what the amendment 
says and what we are attempting to do with the Mitchell bill. On that, 
however, a vote has been ordered so Members of Congress all have the 
opportunity to comment on that.
  Mr. President, I have no idea what two Members of Congress discussed 
with a member of the Federal judiciary over lunch. I was not at that 
meeting. I was not invited to that meeting.
  If the question is, does a U.S. Senator have the right to have lunch 
with a member of the judiciary to discuss the baseball strike, to 
discuss family--perhaps they are from the same State and they are 
personal friends: How is the family doing; how is your wife; how are 
the kids since we have seen them last--I think they should have every 
opportunity and right to do that.
  I have no idea what was discussed in the meeting that the Senator 
from Arkansas is raising. And so whether or not his question is even 
applicable to the situation which we are discussing now, I have no 
idea.
  Mr. PRYOR. Mr. President, I do not have any reference, when I asked 
the question through the Presiding Officer, I have no specific 
reference to a particular meeting between a Federal judge and two U.S. 
Senators.
  What I would like to assure the Senator from Indiana is that I 
strongly support the amendment giving this additional sunshine into 
these particular boards and these meetings. I support that position. I 
am going to vote for it.
  But I just wondered how far the Senator from Indiana wanted to carry 
this, and how much sunshine the Senator from Indiana wanted to actually 
penetrate some of these decisions and some of these so-called meetings 
that affect people's lives.
  Mr. COATS. Mr. President, if I could respond to the Senator from 
Arkansas, clearly when Congress has established an agency or a function 
of Government that comes within a law that Congress has passed, and 
that agency is making decisions relative to things which affect 
Americans, I think we want to uphold the law and not exempt that agency 
from discussion and debate that affects their lives.
  But it is impossible for this Senator to say, well, every meeting 
between a U.S. Senator and some other representative of Government--for 
instance, we have a new special prosecutor in the Whitewater case, 
Kenneth Starr. We go to church together. Now, sometimes after church, 
we happen to run into each other leaving church.
  Is the Senator from Arkansas saying that if I say hello to Mr. Starr 
on the way out of church, that should be a public meeting, or if he 
says ``How is the family?''--our two sons play Little League baseball 
together, so we have gotten to know each other on an informal, personal 
basis--is that meeting supposed to be subject to the open sunshine law?
  What if Mr. Starr said, ``How about breakfast in the morning?'' We 
both live out in the same area. ``How about getting together for bacon 
and eggs at McDonald's, or a cup of coffee?'' Am I supposed to give 
notice that we are meeting, that the public is invited, and that 
minutes should be taken of our discussion?
  I am not sure what the Senator is referring to.
  Mr. PRYOR. Mr. President, I am not sure this argument is really going 
anywhere, and I will conclude and yield to my friend from Pennsylvania.
  But I do think serious questions arise when Members of this body meet 
with a U.S. Federal District Judge or a member of the court of appeals, 
or what have you, relative to a matter which might or might not be 
pending at the moment.
  If I might ask the Senator from Indiana one final question along this 
line; that if the Senator might support maybe an amendment or maybe a 
clarification of his amendment to include such meetings between U.S. 
Senators and a Federal judge?
  Mr. COATS. Well, Mr. President, I think a good question has been 
propounded to the Senator from Indiana. I think if the Senator from 
Arkansas has a concern about meetings between Senators and other 
Federal officials, that Senator should offer an amendment addressing 
that concern.
  Right now we are dealing with an amendment to the Mitchell health 
care bill which specifically goes to two agencies, three agencies, 
actually, that are created in the bill. It is a written provision in 
this bill that states that those agencies will be exempt from the law.
  I think Congress wants to uphold that law in regard to the meetings 
with Federal agencies that involve the public, particularly when they 
meet to decide questions that are so personal and go directly to their 
health. That is the issue before us.
  If the Senator from Arkansas wants to address a separate issue 
relative to whom Senators can meet, when they can meet, under what 
conditions they can meet, I think that is a subject for lengthy debate. 
We are going to have to understand what it is exactly the Senator is 
propounding. Does it include lunch in the Senate dining room? Does it 
include a casual greeting at church? Does it include a conversation in 
the dugout at the little league field? Does it include riding on the 
same plane where you happen to sit next to each other in the seats in 
the plane?
  I am not sure what the Senator is getting at. I do not have any idea 
why two Senators in the U.S. Senate, what the purpose of meeting with 
the Federal judge was in the Senate dining room, what they discussed. 
And so, I guess I am at a loss to respond to the Senator from Arkansas, 
because I do not know what it is he is asking us to do.
  Mr. PRYOR. Mr. President, I would just like to conclude by saying 
that we will probably never know what was discussed, because it was not 
in the sunshine, it was not in a public forum, the particular meeting 
that the Senator brings up.
  But with that in mind, Mr. President, I just want to reassure the 
Senator from Indiana that I support his amendment. I think it is a good 
amendment. I think there will be a lot of votes for that amendment. I 
assume it will prevail.
  Mr. President, I yield as much time to the Senator from Pennsylvania 
as the Senator from Pennsylvania so desires.
  The PRESIDENT pro tempore. The Senator from Pennsylvania [Mr. 
Wofford], is recognized for as much time as he may consume under the 
control of the Senator from New York [Mr. Moynihan], or his designee.
  Mr. WOFFORD. Mr. President, I, too, am happy to support the amendment 
of the Senator from Indiana and the Senator from Florida. I think the 
amendments so far presented and adopted in this body have thrown light 
on the problem--the preventive care for children and pregnant women 
amendment; the amendment ending the fine proposed, instead allowing my 
preference of letting State insurance regulations prevail as the main 
method for compliance; major steps forward in building on the rural 
health delivery provisions in the Mitchell bill. These were all good 
steps.
  And I am happy to see that we will have a sunshine provision applying 
to the agencies in the bill.
  It seems to me, Mr. President, that indeed our duty right here in 
this body is to throw light--I hope it is sunshine--on the 
problem and on the issues. Because the people certainly have been 
enduring a fog of confusion that, outside this body, if not within it, 
has spread over this vital problem of guaranteeing for all Americans 
the kind of health insurance options in the private health insurance 
system that we Members of Congress enjoy and benefit from and have 
arranged for ourselves.
  That duty of ours to throw light is made heavier because on this 
issue, which is so vital to one-seventh of our economy, a study of the 
whole lobbying and advertising effort by the Annenberg School of 
Communications at the University of Pennsylvania, has concluded that 
more money has been spent on the onslaught related to this bill and the 
President's bill than in the whole Presidential campaign of 1992 for 
Bush and Clinton combined.
  So, indeed, we have a duty to throw light and to cut through the fog 
of confusion.
  And we will need to throw that light on the issues that the Senator 
from Indiana also moved into about why we need a standard benefits 
package, not to create one size fits all. It is not to limit people 
from going beyond what the minimum standard benefits package is. People 
can do that. No one is proposing taking that away in any form. But it 
is necessary, among other reasons, to give consumers the kind of 
protection from lemon policies and dishonest insurance companies, the 
kind of proper protection that Members of Congress have.
  We need basic standard benefits and consumer safety in lots of fields 
in our life. You can get any size or flavor of baby food, but not baby 
food that has glass in it. Cars; we can choose any make of car, but it 
must include safety belts. Kid's pajamas, any size or color. They 
cannot be a pajama that is going to burst into flames.
  And, as to health insurance, we need to see that fee-for-service, 
HMO, or preferred provider choices are available. But that we do not 
have the fine print and loopholes that can cut you off just when you 
need it, which is as bad a crisis to any individual or family as any of 
the examples I just gave.
  So, let us cut through the fog of confusion. Part of the need for 
sunshine, I believed, when I came to this body 3 years ago, was on what 
the benefits are that the Congress had arranged for itself. I found, 
through a friendly letter from the attending physician, that we had 
free health care through the attending physician, while working 
families certainly have no such free medical care.
  Well, we fixed that. We got rid of the free health care Members used 
to get from the very fine office of the attending physician that we 
have. Now we pay an annual fee for that extra service, along with our 
contribution to the health insurance plan of our choice.
  But, apparently, some of our colleagues still do not understand what 
working families go through; that, in this very period of talk, it is 
estimated that some 700,000 Americans have lost their health insurance 
in less than a week and a half, but no Member of Congress has lost his 
or her health insurance during that period.
  Up in Pennsylvania, I have been pressing a very simple proposition, 
that our duty in this great debate is to see that we extend to all 
Americans the kind of affordable coverage and choice of private health 
insurance plan that Members of Congress have arranged for themselves.
  Mr. President, I find that that proposition does more to cut through 
the fog of confusion than all of the complexity that is being used as 
an excuse for doing nothing. It reminds me of a proposition I put forth 
in 1991 that the people of Pennsylvania responded to. If under our 
Constitution you have a right to a lawyer when you are charged with a 
crime, it is even more important to have a right to see a doctor if you 
are sick. People exploded with recognition of this self-evident truth. 
And I am finding today up and down Pennsylvania there is that same kind 
of igniting of people's reason, leading them to say yes. Leading them 
to say ``Yes, that's right,'' when I say that it is self-evident that 
the kind of choice of private health insurance that Members of Congress 
have should be the model for the kind of choice the American people 
deserve to have.

  Mr. REID. Will the Senator from Pennsylvania yield for a question?
  Mr. WOFFORD. I will happily yield to the Senator from Nevada.
  Mr. REID. The Senator from Pennsylvania has raised an interesting 
point.
  I ask the Senator if he believes that one reason our health care 
package has hit such a hard note with the American public is because 
under our plan, our employer, the taxpayers of the country, pay 72 
percent of our premiums? Is that true?
  Mr. WOFFORD. That is true. That is the average. That is the average 
portion, depending on which plan you choose. It is not a one-size-fits-
all plan. You may choose a fee-for-service plan that might be a little 
higher, an HMO plan that might be less, and the proportion of the 
Federal Government's contribution varies according to that. But the 
average contribution is 72 percent. For the standard option Blue Cross 
& Blue Shield, the most popular choice, it is a 75-percent contribution 
from our employer.
  Mr. REID. That is what this Senator has. Would the Senator agree that 
one reason the American public likes our plan is because it prohibits 
preexisting condition exclusions?
  Mr. WOFFORD. It does.
  Mr. REID. Would the Senator agree that is a reason the American 
public likes our plan?
  Mr. WOFFORD. It does.
  Mr. REID. Probably----
  Mr. WOFFORD. May I read from the plan? This is what I would like the 
American people to hear because I think they would like it: Coverage 
without medical examination or restrictions because of age, current 
health or preexisting medical conditions.
  Mr. REID. In fact, would the Senator agree that millions of Americans 
are envious of our health care plan? Would the Senator agree with that?
  Mr. WOFFORD. As they learn about it, as we put some sunshine on the 
kind of system that we have arranged for ourselves.
  Mr. REID. Would the Senator also acknowledge that one reason our plan 
is so important to us--and I would assume the American public would 
like it also--is because, as the Senator has so well stated, there is a 
choice of plans?
  Mr. WOFFORD. There is a choice of a whole menu of plans. Do you 
recall how many you had to choose from?
  Mr. REID. So many I could hardly keep track of all of them.
  Mr. WOFFORD. My wife tells me it was 25 or 30 different plans, Blue 
Cross & Blue Shield, Aetna, a whole variety of HMO's.
  Mr. REID. Is the Senator also aware that one of the things in Senator 
Mitchell's bill that is patterned after what we have, and that is that 
when people are provided the choice, if this legislation passes, like 
the Federal plan, there would be comparative information on price and 
coverage?
  Mr. WOFFORD. That is what we all need in order to choose well. And we 
are given it. In fact, I think the Federal employees plan could do a 
little better job, but as we begin to think through how to make our 
system better, and once we have a standard benefits package in this 
country, I think any agency that is helping to provide choices--whether 
they are new, voluntary purchasing cooperatives or the Federal 
Employees Health Benefit Plan open to people--will give more consumer 
information, therefore more real choice to people, to know how to 
choose well.
  (Mrs. MURRAY assumed the chair.)
  Mr. REID. Would the Senator also acknowledge one reason our plan--and 
I ask the Senator if he would agree--works so well is because it is a 
community-rated system? That is, no one is discriminated against 
because they are of childbearing age or they are senior citizens. There 
is no discrimination as to age or gender. Is that true in the plan that 
we have?
  Mr. WOFFORD. Yes.
  Mr. REID. I also ask the Senator--in our plan, it is my understanding 
that the overhead costs are extremely low. In fact, our plan, which 
has, including all the rest of the employees, about 9 million 
employees----
  Mr. WOFFORD. And their families; including their families.
  Mr. REID. And their families. It is my understanding that plan is 
administered by fewer than 200 people; is that true?
  Mr. WOFFORD. I think the last I heard it was something like 170 
employees.
  Mr. REID. Yes. So would the Senator agree that for these and many 
other reasons, the American public is beginning to focus on what we 
have and what they do not have?
  Mr. WOFFORD. As they should be, it seems to me, Senator.
  Mr. REID. I would just close by rhetorically stating to the Senator, 
there has been no Senator in the U.S. Senate who has raised this issue 
earlier or more loudly than the Senator from Pennsylvania. The Senator 
from Nevada applauds the outstanding work the Senator has done in 
trying to bring this out into the open and put some sunshine on it.
  Mr. WOFFORD. I appreciate the kind words. In addition to being loud 
and early, I hope the proposition is clear. And this is the way I would 
put the question to our colleagues who are saying there should be no 
such system made available to the American people; that it should not 
be guaranteed, the kind of guaranteed health insurance we have for the 
American people, with the employer contributing about three-quarters.
  I say to my colleagues on the other side of the aisle, support the 
plan you live under or live under the plan that you seem to support.
  Mr. LEVIN. Will the Senator yield for an additional question?
  Mr. WOFFORD. I will yield to the Senator from Michigan.
  Mr. LEVIN. Among the many points which have just been made in the 
conversation between the Senator from Pennsylvania and the Senator from 
Nevada, there was a reference to a number of private insurance 
companies. I think that is an important point. I want to make sure we 
are correct, that the Government plan that was made reference to, the 
so-called Government plan that we have, is a private insurance plan. We 
have a whole menu of private insurance that we are offered through a 
Government plan. But it is not Government-run insurance. Is that 
correct?
  Mr. WOFFORD. The Senator has made a crucial point for people to 
understand.
  Mr. LEVIN. We hear over and over again, Government-run insurance, 
Government-run health insurance. That is the attack on the Mitchell 
bill, despite the fact that the Democratic leader has over and over 
again gotten up and said this is not Government-run insurance. This is 
private insurance which, hopefully, will be made available to every 
American the way private insurance is made available to Members of 
Congress, our families, and all Federal employees.
  So I wanted to be sure that point is clear, that the so-called 
Government insurance that is made available to us is not Government-run 
insurance. It is made available to us by the Government--mostly at 
taxpayers' expense--but it is private insurance. All those companies 
with all those plans that are offered to us on that menu are private 
insurance.
  Mr. WOFFORD. One reason our premiums are reasonable is that, with 
that big purchasing power of a pool of 9 million people, Madam 
President, with that big purchasing power, those insurance companies 
are competing for our business and we have the choice, an opportunity 
within 31 days from the date of your appointment, to enroll in the 
health benefits plan with group-rated premiums and benefits, a choice 
of plans and options so you can get the kind and amount of protection 
best suited to your personal and family and health needs and finances; 
guaranteed protection that cannot be canceled by the plan.
  Mr. LEVIN. One final question I could perhaps ask and that is the 
reference in the first paragraph, ``An opportunity within 31 days from 
the date of your appointment to enroll in a health benefits plan.'' 
That is a private insurance health benefits plan; is that correct?
  Mr. WOFFORD. Yes. The most popular one chosen, as chosen by the 
Senator from Nevada, is the standard option Blue Cross & Blue Shield 
plan.
  Mr. LEVIN. I thank the Senator.
  Mr. WOFFORD. That is what Congress gets. Yet our Republican 
colleagues are getting hoarse talking about the dangers socialized 
medicine and a Government bureaucrat telling them what doctor to go to. 
They do not have Government-run health care that tells them what doctor 
to go to. They have this range of private health insurance options. Not 
only the year they enroll, but they have it every year. They can vote 
with their feet. They can choose and they can make these plans compete 
for our business, which is one reason, I think, we like this.
  Some may have heard that I, myself, as a sign of how serious I am 
about winning this battle that Harry Truman started for private health 
insurance, a little while ago sent my first check back to the Treasury 
of the United States for $306.41, the Government's, my employer's, the 
taxpayers' contribution to my health insurance. I sent it back and said 
I am going to continue doing so until we win this battle and the 
American people have that kind of choice of private health insurance.
  I have not seen any volunteers. I challenged my colleagues who will 
not even discuss, will not consider a rule, even in the year 2001, by 
which employers are asked to contribute--the way most people with 
private health insurance in this country today get it. They get it with 
the help of their employer. I challenge them to practice what they 
preach. If they do not believe that the American people should have 
that kind of choice of private health insurance plan, then give it 
back. Give it back to their employer, the American taxpayer. I will 
renew that challenge from time to time. So far there are no takers.
  I went a little beyond that the other day, and I am serious about 
this, too. If in this battle--is this the battle of Gettysburg? I come 
from the State that saw the Civil War battle surge right into our 
State. I do not know whether this is the battle of Gettysburg. I do not 
know how far we are in the war. I thought we were further along than we 
seem to be at this moment and this hour, in that long battle Harry 
Truman started.

  But if we should get blocked this year and this Congress by the 
naysayers, if we get blocked, I will offer an amendment to disqualify 
every Member of Congress from participating in the Federal employees 
benefits plan until we take action so that the American people have 
that kind of protection and guarantee.
  Let me tell you, if we are going to end up having more study, then 
let us study it while we are on the same playing field as the American 
people. When they go to sleep at night, they are afraid if there is 
great restructuring--we had two great corporations announced thousands 
of new jobs that are being lost in Pennsylvania just this very week. 
All of those families now have had the fear come to them as a reality 
that they are one pink slip away from losing their health insurance.
  If we are going to study more, if we get blocked in taking action, 
let us study with that kind of fear over ourselves and that kind of 
heat below us. Let us be on a level field with the American people. 
That is why the Mitchell bill, I think, among the many other ways, is 
reasonable, moderate, good, has responded to the concerns that people 
have had, has disposed of some of the problems that many of us had, for 
example, took the mandatory alliances off the field--that horse was 
taken off the field, even though it continues to be flogged.
  What we have is voluntary purchasing groups that give the American 
people the kind of purchasing power that we, Members of Congress, 
enjoy. And we have opened up the Federal employees benefits plan to 
small business and individuals so they can actually buy into the 
Federal plan if they want to have that as one of their choices.
  That is why I say we have it within reach to get private health 
insurance for the American people, private health insurance the way 
Congress has arranged for itself.
  Mr. PRYOR addressed the Chair.
  The PRESIDING OFFICER. The Senator from Arkansas.
  Mr. PRYOR. Madam President, I wonder if the Senator will yield for a 
question?
  Mr. WOFFORD. I yield to the Senator from Arkansas.
  Mr. PRYOR. Madam President, I would like to compliment the 
distinguished Senator from Pennsylvania on his statement. I hope I have 
not interrupted him at a bad time. But I first ask the Senator from 
Pennsylvania if he had the opportunity to hear a speech yesterday by 
the distinguished majority leader. In my opinion, it was the best 
political analysis of where we are at this moment on this particular 
issue. I wonder if the Senator had the opportunity to hear his very 
fine statement.
  Mr. WOFFORD. I did, and I agree with the Senator from Arkansas. As 
one who has lived, breathed, eaten, stayed up at night on this issue 
for now 3 years in this body, I think it was the most important, 
perhaps, single speech in this debate, and I urge every one of my 
colleagues who missed it to read the majority leader's talk yesterday.
  Mr. PRYOR. Madam President, if I might have a few more moments of the 
Senator's time, I think it is worthy to quote a paragraph or two from 
Senator Mitchell's speech of yesterday, if I may have the liberty to do 
that. And I do quote from Senator Mitchell's speech as follows:

       So I hope the American people will not be fooled by the 
     rhetoric they are hearing here today. And I hope the American 
     people will also think about the irony of these Republican 
     Senators getting up here day after day after day and 
     denouncing Government health insurance and Government health 
     care as bad for their constituents, even as they benefit from 
     it themselves . . . participates in the Government-run health 
     insurance system that is available to all Federal employees, 
     and the Government pays 72 percent of the cost of that health 
     insurance for these Republican Senators who are standing here 
     and telling their constituents that it is bad for their 
     constituents, even as they participate in it for themselves 
     and for their families.

  I am wondering, because the Senator from Pennsylvania had great 
experience in this whole issue of health care from the time of many 
years ago--especially highlighted in his campaign, his brilliant 
campaign, I might say, when he was elected to the Senate--I am 
wondering if the Senator from Pennsylvania has heard of any of our 
colleagues on the Republican side, or even the Democratic side of the 
aisle, canceling their particular Federal Employees Health Benefits 
Program?
  Mr. WOFFORD. Not yet, but let the heat go higher.
  Mr. PRYOR. I want to say I think what the Senator from Pennsylvania 
has done has been very unique in, basically, saying that until we pass 
something, the Senator from Pennsylvania is not going to participate in 
it. I admire the Senator from Pennsylvania very much in doing that.
  I think yesterday Senator Mitchell, in his statement, also talked 
about Walter Reed Hospital, and the Bethesda Naval Hospital. I quote 
again from Senator Mitchell's speech:

       If Government health care is so bad, why do these 
     Republican Senators insist on having it for themselves? And 
     then if they get sick, if the doctor says, ``You've got to go 
     to the hospital,'' they go to Bethesda Naval Hospital or the 
     Walter Reed Army Hospital--Government hospitals.
       Well, my gosh, ask yourself, Mr. and Mrs. America--

  So spake the majority leader yesterday--

     if these Government facilities are so bad, why do these 
     Republican Senators want to go there themselves?

  Madam President, I think Senator Mitchell's speech was a timely 
speech. It was certainly one, I think, that was timely to the extent it 
sort of set the record very clear on what we are doing here at this 
moment on the health care issue. I did not want to take all the time of 
the distinguished Senator from Pennsylvania. I, at this time, 
relinquish the floor back to him.
  Mrs. BOXER. Will the Senator yield to me for a question?
  Mr. WOFFORD. I yield to the Senator from California.
  Mrs. BOXER. I just want to thank the Senator for raising this issue. 
It makes a lot of people uncomfortable around here because they have 
something for themselves and their families, but they are standing here 
and basically saying they do not think the American people should have 
what they have.
  It reminds me, when I was growing up--that was a long time ago, I say 
to my friend--we used to have an expression, a shuck and a jive, and 
that meant you are kidding somebody. It was like somebody would come 
over to you, I say to my friend from Pennsylvania, and say, ``I live in 
a beautiful home. It's a large home. It has six bedrooms. It has a 
swimming pool. It's fully air conditioned. It's fabulous.''
   And the person says, ``Gee, I'd just love to have a place like 
that.''
  And the person looks at you and says, ``Oh, but there's so much 
maintenance. It's really rough. If I were you, I'd just stay where you 
are. You don't really need to live like me because, you know, it may 
look good on the outside, but on closer inspection it's not so good.''
  That is a shuck and a jive, because the American dream is to have a 
home and to have health care and to have a reasonable job, a good 
education for our kids. When someone tells you, ``It's good for me but 
not for you,'' you have to start worrying about it.
  I think yesterday when the majority leader made that statement which 
was quoted by my friend from Arkansas, it hit to the nub of it. It hit 
to the nub of it.
  So I ask my friend this question, and I do not like to use the word 
``hypocrisy'' because it is not a nice word, so I will not. But I would 
say to my friend, does he believe that when a Member of the U.S. Senate 
stands up here and says that that Senator does not believe the American 
people deserve to have health care that can never be taken away, health 
care that is basically a benefits package that is reasonable, one in 
which the responsibility is shared by the employer, and the irony of it 
is, these Republican Senators see nothing wrong with the taxpayers 
paying for their insurance because our boss--our boss--the people of 
America--they are the taxpayers--and they pay that share, they see 
nothing wrong with it? I do not know whether they have given it up. I 
do not think so. Outside of the Senator from Pennsylvania, I have not 
heard of anyone else.
  Does the Senator think that is--not to use the word hypocritical--
shall we say, a little suspect? Would the Senator say that a person's 
motives might be a little suspect or a little bit--I do not want to 
characterize it in a way that will hurt my friend because that is not 
the point here--a little disingenuous, perhaps a little disingenuous, 
when he has good health care for himself and his family, he sees 
nothing wrong with taking it, his employer pays for it, and yet he does 
not want to have that for the people in his State? Does the Senator see 
something a little disingenuous with that?
  Mr. STEVENS. Madam President, will the Senator yield?
  Mrs. BOXER. I ask that question to my friend from Pennsylvania, who 
has raised this issue.
  Mr. WOFFORD. May I respond first, if the Senator from Alaska will 
wait for a moment.
  I agree with the Senator's characterization. I also appreciate how 
she told me that she was uncomfortable, she told us how she was 
uncomfortable having this guaranteed health insurance even more so 
since her spouse also has health insurance.
  Madam President, that is one of the facts of life at this very moment 
that all of us should ponder. Those spouses of employees in 
Pennsylvania who just lost their jobs this week, they are going into 
the job centers that I used to run, the unemployment offices, they are 
going into those offices and I know what will happen if I visit them in 
those offices. I have been doing it the last 6, 7 years.
  I ask people in the front row of the unemployment office waiting to 
apply for unemployment compensation, ``Do you have health insurance?'' 
And usually 7 or 8 out of 10 say ``No.'' And they are scared. The other 
two or three have spouses working somewhere else where their employer 
contributes to their health insurance. And that is the roll of the 
dice--7 or 8 out of 10 when they lose their job lose their health 
insurance.
  I think, as we move forward in this debate, we should remember that 
every day as we talk, more Americans fall into that gap, into that 
hole.
  I see my frequent TV debating partner, Senator Gramm, is on the 
floor, and I know he now or soon in these days will tell us more about 
the horrors of Government-run medicine. But he looks well to me. He is 
fine on the stump, in our debates, without any noticeable ill effects 
of his Government-provided plan with Blue Cross/Blue Shield through the 
Federal Employees Health Benefits Plan.
  Mr. STEVENS. Will the Senator yield?
  Mr. WOFFORD. The Senator from Alaska.
  Mr. STEVENS. Madam President, I hear the Senator say quite often that 
Members of Congress have something different from other people. I am 
sure he is aware of the massive plans that are out there for employees 
living in Pennsylvania, for instance, of United States Steel, the major 
industries. Their plans are much better than that for the Federal 
employees. As a matter of fact, they are much better than that for 
Members of Congress.
  I wonder if the Senator knows that Members of Congress pay an 
additional premium for their health insurance. Right down here at the 
Capitol Physician's Office, we pay an additional premium of almost 
$1,000, I think it is between $600 and $1,000--it depends on how it is 
established each year--in addition to the premiums we pay for Federal 
Employees Health Benefits. We pay more than any other Federal employee. 
Does the Senator know that? We pay more than any other Federal employee 
for health insurance coverage. Does the Senator know that?
  Mr. WOFFORD. Does the Senator from Alaska recall that before this 
Senator came into this body, the Senators and Members of Congress got 
that service from the attending physician free? I put a motion before 
this body to see that we paid the fair market price of that extra 
service, and action was taken on that after I had about 30 cosponsors 
of my amendment.
  So I do, indeed, recall that, one, Congress for decades had that 
additional free health care; and, second, that now Congress pays that 
extra fee. But I am talking about now----
  Mr. STEVENS. Madam President, I wonder if the Senator will yield 
again. Even before the Senator's initiative, the health insurance 
coverage that we had as Government employees paid a portion of the cost 
at the Capitol Physician's Office, at Walter Reed, and at Bethesda. 
Those were not free. They were paid for as employees of the Federal 
Government.
  The Senator is correct that we now pay an additional amount for the 
special emergency services down here. But if the Senator goes down and 
has a blood test, if he goes down and has an x ray, those are repaid by 
the health insurance and have been for many years.
  I keep hearing the Senator say that somehow or other, Members of 
Congress are different from other people in this country. We have a 
plan that is quite similar to the larger employers' plans. It is less 
beneficial than the employees of United States Steel, the big union 
companies of the automobile industry; the massive plans of this country 
are not as beneficial to the employees of the Federal Government as 
this plan is, and Members of Congress are treated no differently from 
any other employee in the Federal Government.
  Why does the Senator from Pennsylvania mix that with Members of 
Congress? Why does the Senator not put up the benefits of all Federal 
employees?
  Mr. WOFFORD. If the Senator will yield----
  Mr. KENNEDY. Regular order.
  Mr. STEVENS. Postal employees go beyond that, far beyond that.
  The PRESIDING OFFICER. The Senator from Pennsylvania has the floor.
  Mr. WOFFORD. The Senator is, in my humble opinion, taking my points 
both too personally and falsely. I am in no way saying that the Federal 
Employees Benefits Health Plan is a bad plan. I am in no way saying it 
is the best plan. The State employees plan in Pennsylvania, of which I 
once was part, is somewhat better than the Federal employees plan.
  That is not my point at all. I am very pleased that there are 9 
million Americans, Federal employees and their families, who have these 
benefits, who have a guaranteed private health insurance choice that 
cannot be taken away, with their employer contributing approximately 
three-fourths.
  The point is, let us do it for the American people. And my point to 
the Senator is, if he supports this kind of plan, then make it 
available to the American people. And if the Senator opposes making 
this available to the American people, making this a model of what the 
American people can have, then live under the system he supports, which 
is not making it available to the American people. Do not ask our 
taxpayers, our employer, to pay for our health insurance unless we 
establish this principle for the American people.
  Mr. STEVENS. Madam President, I hope that the Senator was listening 
to me this morning. I tried to point out in conversation with the 
Senator from Massachusetts that the system we have is a model system. 
There is no question about that. I am sure the public knows that this 
is a model system. It is a plan that ought to be followed for other 
people in the country. We ought to find a way to extend it.
  I invite the Senator's attention to the Heritage Foundation proposal 
of 2 years ago. It would have done just that. I do not see any Member 
on the other side of the aisle endorsing the Heritage Foundation plan. 
Instead, they are trying to tell the American people to come join this 
plan that we have for Federal employees. But Senators do not take the 
time to tell the American people that by 2005, you will destroy that 
plan. You have enlarged it out to the point where it is no longer a 
plan. But you have offered the Federal employees supplemental benefits 
beyond this plan after 2005.
  There is a promise in the Mitchell bill to negotiate supplemental 
benefits. Why do you not tell the American people that as soon as they 
join this plan, you are going to give Federal employees supplemental 
benefits beyond the plan? That is what the Mitchell bill says. It is 
duplicitous for us to try to present to the American people the health 
benefits of Congress, what Congress gets. Congress does not get any 
benefits. We get benefits as Federal employees. There is no 
congressional plan. There is no congressional plan.
  Mr. WOFFORD addressed the Chair.
  Mr. STEVENS. I belong to the Treasury Department plan.
  The PRESIDING OFFICER. The Senator from Pennsylvania has the floor.
  Mr. WOFFORD. Madam President, me thinks the Senator protests too 
much.
  Mr. STEVENS. Not if he answers the questions, I will not.
  Mr. WOFFORD. I--and more importantly, the majority leader, in his 
bill--am not saying this is the cure-all that every American will be 
part of. We do open it to a lot of Americans as a choice. But the main 
choice that is new, in my opinion, is the voluntary purchasing 
cooperative, not the mandatory alliance but the purchasing groups that 
on smaller scales in communities will be one of the choices people will 
have through which they can get private health insurance at reasonable 
rates the way we have arranged for ourselves.
  Mrs. BOXER. Will the Senator yield? Madam President, will the Senator 
yield to me?
  The PRESIDING OFFICER. Will the Senator from Pennsylvania yield?
  Mr. WOFFORD. I yield to the Senator from California.
  Mrs. BOXER. I thank the Senator for yielding to me. I want to really 
thank the Senator. We have hit a sore spot today--I think that is 
good--because what it really comes down to is a very simple point.
  People get up here on the floor, and they talk about sunshine and 
opening up the commissions. I am with you on that. I am for sunshine. 
But what I am really for in addition to the sunshine, what is to the 
main point, is that the American people have a chance to have what 
every single Member of Congress has--health care that can never be 
taken away; a nice package, so nice, that not one Republican who 
opposes giving that to the people of America has ever given it up, 
according to the Senator from Pennsylvania and according to the Senator 
from Arkansas.
  My question to the Senator is this, and my last question to the 
Senator, so that this debate will be understood. That question to the 
Senator is this: Is it not so that under the Mitchell plan we are 
amending and debating, the Federal Employees Health Benefits Program 
will be opened up on a voluntary basis to all Americans who at this 
time have no access to such a good plan? Am I correct on that?
  Mr. WOFFORD. The Senator is correct.
  Madam President, I know that Senator Mack from the Sunshine State of 
Florida has been wanting to talk about his amendment for some time, or 
Senator Gramm, whoever it may be. But I appreciate Senator Mack a 
little earlier saying he is agreeable to my going forward on this.
  I just want to say a last word about sunshine; for the moment, just a 
last word. When I think of sunshine, I think of something that is warm, 
and constructive, that is trying to make things grow. It is not just 
harsh light. It is the warmth that you get from the sun. I realize 
there is a certain heat, a sore point that the Senator from California 
said we were touching that produced the heat from the Senator from 
Alaska.
  But what I recommend, I beg of ourselves, is that we recall the first 
great Republican, Abraham Lincoln, who asked us and who did everything 
in his power to show how you tap the better angels of our nature.
  As we talk about sunshine, let us somehow recognize that the spirit 
of destruction of saying no, the negative case is, of course, the easy 
case. The hard thing to do is to build and to come together, and reach 
beyond party lines. We have a historic chance to do that in these next 
days. Let us raise our sights to that standard.
  Mr. PACKWOOD. Madam President, I listened to the debates on 
amendments and how the amendments changed the bill all the time, and 
that when we offer amendments there are mistakes. I am reminded of 
little kids with a dead body where the kids kept changing the clothes, 
but the body was still dead. The Clinton-Mitchell bill is that body. It 
is dead. We can change the clothes on it all we want. It is still dead.
  I yield 10 minutes to the Senator from Texas.
  Mr. GRAMM. Mr. President, I thank our colleague from Oregon.
  I want to remind my colleagues, especially those on the Democratic 
side of the aisle, that we do not have health insurance that is always 
there. After the votes are counted in November and many of your 
colleagues are back in their State working for a living, they could 
lose their Government health insurance. They do not automatically get 
to take it with them.
  Let me also say I am going to take my Democratic colleagues seriously 
on this issue when they offer an amendment stripping away these 
insurance benefits. When they offer an amendment taking these benefits 
away from Government employees, including Members of Congress, I am 
going to view this tactic as something other than a PR stunt that was 
discovered after spending $2 million on focus groups. The pollsters 
posed the question, when the American people disagree with us on the 
total substance of the President's health care proposal, what can we 
say that they would agree with? That is where this element of the 
debate came from.
  I am not going to spend my 10 minutes trying to convince the American 
people that everything they just heard about choice is not true. The 
American people already know it is not true. One of the wonderful 
things about the health care debate is that the President and our dear 
Democratic colleagues have grossly underestimated the ability of the 
American people to understand.
  Let me just say in simple English in about a minute why everything 
that I have heard about these great choices and about this so-called 
freedom of choice is simply not true.
  The Mitchell bill by law tells you what your health insurance has to 
cover. If you are a widow in Arkansas, 64 years of age, you are going 
to have to pay for prenatal care and for immunization benefits for 
children who you do not have. If you do not drink, and if you are a 
teetotaler and you had never touched drugs, nonetheless you are going 
to have to pay for alcohol and drug rehabilitation services that will 
drive up your premium by 12 percent, and you are going to have to do 
that because the Government is going to make you have it.
  But on the other hand, if you now have a particular benefit that you 
like, say a pharmaceutical benefit, or perhaps coverage for 
orthodontist services in your policy that you and your employees picked 
because you wanted it for your families, there could be as much as a 
66-percent tax placed by the Mitchell bill on that benefit.
  The Mitchell bill's proponents will say, ``Well, you can keep it. You 
just have to pay the 66-percent tax.'' Well, other than my family and 
my dog, I do not have an asset that is valuable enough to me that I 
could afford to pay a 66-percent tax to keep. On either my family or my 
dog, I would pay that tax to keep them. But I would not do it for my 
truck. And most Americans would not be able to afford it.
  If that is freedom of choice, you have it under their plan. There is 
only one problem that our colleagues on the left hand side of the aisle 
have, and that is that the American people have broken this code. Where 
are we in this debate? Basically where we are is that the Mitchell bill 
is deader than Elvis. If we had a vote on the Mitchell bill today, it 
probably would not get 35 votes.
  The House is getting ready to adjourn on Saturday, and they are not 
coming back until after Labor Day. The question is what should we do?
  I want to make a proposal. First of all, I want to let my colleagues 
know something that I assume most of them already know. But I would 
suggest they go back to their office and check on it.
  First, we all get a lot of mail. Senator Kennedy and I go back and 
forth as to who gets the most mail in the Senate from one month to 
another. Maybe all the right-thinking people write me and the wrong-
thinking people write him. I do not know what kind of message he is 
getting. But we get a lot of mail. Yesterday, I got over 3,500 letters, 
and that is a new record for me.
  Yesterday, 1,005 people called my office in calls that were 
completed, and they said to me, ``Kill the Mitchell-Clinton bill.'' 
Most of them said it in a more emphatic way, the way we talk in Texas. 
But I am not going to say that here. And 133 said pass the Mitchell 
bill.
  I also got calls about this so-called crime bill that will let 10,000 
drug felons out of jail early. Seven-hundred and sixty-two people said 
do not pass that bill, and 68 people said pass it.
  The House is getting ready to go home, and here is what the chairman 
of the Health Subcommittee of the Ways and Means Committee in the House 
said about that. He said, ``I have said repeatedly the one thing 
leadership does not have to give away is time,'' said Representative 
Pete Stark of California, chairman of the Ways and Means Subcommittee 
on Health. ``Members go home for 2 weeks. It gives people a lot of time 
to complain,'' he said.
  Obviously, there are a lot of people around here who are scared to 
death that, if they go back home to the source of political power in 
America, if they listen to the people who do the work, pay the taxes, 
and pull the wagon in the country, that this health bill is dead.
  I submit that come Saturday when the House leaves, it is only a 
matter of a day or two until we too are going to go back home.
  When we go back home, all these people who are calling your offices 
are going to be able to tell you how they feel. I believe that it is 
time to go back and listen to the voice of America. We have a so-called 
mainstream group of Democrats and Republicans who have been working on 
a health care reform plan. I do not know the details of their plan. But 
I know two things about it that tell me that when they are talking 
about mainstream, they are talking about mainstream Washington. They 
are not talking about mainstream America.
  Their first idea is to have the Government tell us what kind of 
insurance we have to have and what it has to include. Their second idea 
is to impose a 25-percent tax on those who dare to buy insurance that 
is beyond what the Government says they ought to have.
  I submit that this so-called mainstream group is out of touch with 
mainstream America. We can fix that by having Congress admit that the 
Mitchell-Clinton bill is dead. We can do it by stopping carrying around 
this corpse, changing its clothes, putting more powder on its face, 
and, instead, admit that the American people have rejected this bill.
  Let us go back home, listen to the people, come back in September and 
see if we can sit down and write a bill that has broad, bipartisan 
support.
  Mr. DASCHLE. Will the Senator yield for a question?
  Mr. GRAMM. I have only 10 minutes, and I have listened for hours as 
my colleagues have gone on.
  Let me tell you why I believe the Mitchell bill is dead. Listen to 
these numbers and see if this does not stun you--even for Washington, 
DC.
  The purpose of the Clinton health care plan was to do something about 
the fact that 14.1 percent of the GNP of the United States is spent on 
health care. The President, the First Lady, everybody at the White 
House, and most Democratic Members of Congress have said: My goodness, 
this has to be stopped, it is killing the country, bankrupting the 
Nation.
  So CBO looks at the Mitchell-Clinton bill and what does CBO say? They 
say, sure enough, you have done something. Within 10 years, under your 
bill, we will not be spending 14.1 percent of GNP on health care; we 
will be spending 21 percent of GNP on health care. Is that a solution? 
Is that solving the problem?
  Listen to this as an example of Government work. There is a great 
problem in that 37.3 million people last year, on at least one day, did 
not have private health insurance. About 75 percent of those people 
changed jobs. So if we made insurance portable, we would solve a big 
problem. How does the Clinton-Mitchell bill fix this problem? To try to 
help 37.3 million people get insurance, the Clinton-Mitchell bill 
provides subsidies to 100.3 million people to try to help the 37.3 
million people who do not have insurance. Their bill provides subsidies 
to over 100 million people. But guess what? The subsidies are so poorly 
targeted, that they still leave 13.3 million people uninsured. So you 
begin with a problem of 37 million people without insurance. You 
subsidize 100 million people, and yet you do not solve the problem of 
13.3 million. Does this bill deserve to be saved? Should we not put 
this bill out of its misery and let it die a quiet death, in dignity 
and privacy?
  Mr. PRYOR. Will the Senator yield? I would like to yield the 
distinguished Senator 3 additional minutes so that he might have the 
opportunity to answer some questions from our side.
  Mr. GRAMM. If I may have the 3\1/2\ minutes, I would be happy to 
yield.
  Mr. PRYOR. I will yield if you will answer some questions.
  Mr. GRAMM. I will certainly yield for a question.
  Mr. PRYOR. I yield 3 minutes more to the Senator.
  Mr. DASCHLE. I thank the Senator. The Senator said it is imperative 
that this body support the will of the people. A poll came out this 
morning that indicated 77 percent of the American people support an 
assault weapons ban. I would ask the Senator from Texas whether he 
supports an assault weapons ban using the criteria he laid out, the 
criteria by which he maintained we should determine our support for 
legislation.
  Mr. GRAMM. I am looking for the same poll. Let me say that when you 
ask the American people if they would rather have the anticrime 
alternative I offered, which was 10 years in prison without parole for 
possessing a firearm during the commission of a violent crime or a drug 
felony, 20 years for discharging it, life imprisonment for killing 
somebody, and the death penalty in aggravated cases, by a substantial 
margin the American people prefer that option over gun control.
  Mr. DASCHLE. The Senator did not answer the question. The question 
was: Do you support what 77 percent of the people said in this 
morning's poll that they support? Is the Senator prepared to vote 
according to the will of the people?
  Mr. GRAMM. If I can reclaim my time, I control the floor.
  Mr. DASCHLE. It is my time.
  Mr. GRAMM. If I might reclaim my time, my response is that I offered 
an alternative that is more strongly supported by the American people, 
that is a better, more effective alternative. I do not believe gun 
control works.
  If you do not give the American people criminal control, out of 
frustration they say, ``Let us blame guns.'' But if you are willing to 
grab violent criminals by the throat and not let them go, to get a 
better grip, something I am eager and willing to do, then the American 
people respond very strongly to it.
  I would have to say, Madam President, that the American people get 
very frustrated when they are told they have a tough crime bill, and it 
turns out that it has $8 billion of unadulterated pork in it, and it 
has a provision that overturns mandatory minimum sentencing, so that 
possibly 10,000 drug felons, who are in prison today for drug 
trafficking, will end up being let out of prison by this bill.
  So my response is that there is a better alternative that is more 
strongly supported by the American people. I say to my colleague, also, 
that if he will look at the poll this morning in the newspaper U.S.A. 
Today--and I hope they will note I mentioned their name--they will see 
the American people do not support this bill.
  The PRESIDING OFFICER. The time of the Senator has expired.
  Mr. PRYOR. I yield Senator Levin 5 minutes.
  Mr. LEVIN. Madam President, I think we have hit a sensitive nerve 
this afternoon on this Federal employees insurance. I noticed that 
sensitive nerve ending both by the response of the Senator from Alaska 
and the non-response from the Senator from Texas.
  It is not just us, it is 9 million Federal employees and their 
families who have this insurance. If it is good enough for us, why is 
it not good enough for the rest of the people of America? Is it the 
best plan in America? No, there are some better. Yes, there are some 
companies that offer even better plans than this. That is not the 
issue.
  We voted this for ourselves and 9 million Federal employees. The 
American people are entitled to an answer. If we voted it in for 
ourselves and the 9 million Federal employees and their families, why 
will we not provide them the same protection? That is the question they 
are asking.
  There can be a lot of give and take as to what is good and what is 
bad. But one thing is real clear, and that is this green booklet. This 
is available to every American. Ask your Member of Congress for a copy. 
Call up the office of your Member of Congress and say, ``I would like 
to take a look at that plan that you folks have provided for Federal 
employees and yourselves.'' It is a green book, called Supplement 890-
1. In that book, on page 4, it says that we are guaranteed ``protection 
that can't be canceled by the plan.'' Listen to this one.
  Mr. DASCHLE. If the Senator will yield. You mentioned a point raised 
by the Senator from Texas about what happens when a Senator retires or 
is defeated in an election. I believe the Senator misspoke.
  The fact of the matter is that if you serve in the body for 5 years 
and are eligible for Federal retirement benefits, you are entitled to 
maintain your FEHBP coverage. That coverage can never be taken away. 
Does that not make it similar to what the majority leader is proposing 
in his bill?
  Mr. LEVIN. It is not only true for current Federal employees; it also 
provides it for former Members of Congress, which is the point of my 
friend. This is obviously now a very sensitive question with the 
opponents of health care. They are not about to answer this question. 
Why, if we provide it to 9 million Federal employees, including 
ourselves, should we not take the steps within our power to make it 
available to the people who pay our salary, the taxpayers of this 
country, the ones who pay three-quarters of our premium?

  There is another provision in here, too. This is page 4. This green 
book is available to everybody. Go into your Member of Congress' 
office. Give him a call. Ask him to read the booklet. Page 4:

       Coverage without restrictions because of age, current 
     health or preexisting medical condition. No Federal employee 
     can be denied health care because of a preexisting medical 
     condition.

  It is right here in the book. If we hire someone on our staff back in 
our home State or here in Washington, that person could have diabetes, 
could have a heart condition, could have skin cancer. That person is 
entitled to health coverage.
  Some of us are trying to provide that kind of assurance to every 
American. Hey, we provide it to ourselves and 9 million Federal 
employees and their families. Why is it not good enough for every 
American family? The answer is it is. They are paying our salaries. 
They are paying three-quarters of our health care. They ought to have 
the same opportunity as every Federal employee has.
  Mrs. BOXER. Madam President, will the Senator yield for a question?
  Mr. LEVIN. I am happy to yield for a question.
  Mrs. BOXER. I thank the Senator.
  I want to just underscore the point that was made by the Senator from 
South Dakota. The distinguished Senator from Texas, who has been a real 
critic of the Mitchell bill, said it was as dead as Elvis, although you 
never know with Elvis. Elvis does pop up now and then. To make that 
kind of remark about a bill that we are amending on the floor, and then 
to make a misstatement that if the voters knock us out of here we do 
not have insurance, let me say to make sure that----
  The PRESIDING OFFICER. The time yielded to the Senator from Michigan 
has expired.
  Mrs. BOXER. Madam President, I ask unanimous consent that the Senator 
be given an additional 2 minutes.
  Mr. PACKWOOD. On whose time?
  The PRESIDING OFFICER. Does the Senator from Arkansas yield?
  Mr. PRYOR. If the Senator from Oregon will allow this, we yield 2 
additional minutes from this time.
  Mr. PACKWOOD. That is fine.
  Mrs. BOXER. I thank the Senator from Oregon for his generosity.
  I say to the Senator from Michigan we had a Senator on the other side 
who has been a leading critic of the Mitchell bill. He declared it dead 
and he said on the floor of this Senate that if the voters kick us out 
we lose our health insurance.
  The Senator from Texas, who made that statement, has been around a 
long time in Congress. As a matter of fact, I remember when he used to 
be a Democrat, and I served over on the House side.
  He has his health insurance. If the voters were to knock him out or 
knock me out--they have that chance--the truth is we would have health 
insurance that could not be taken away because we have been here in 
excess of 5 years.
  So I say to my friend from Michigan, just by way of underscoring his 
point, if it is good enough for us, should it not be good enough for 
Mr. and Mrs. America.
  Mr. LEVIN. I thank my friend from California.
  Mr. KENNEDY. Madam President, will the Senator yield for one final 
question?
  Mr. LEVIN. Could I quickly respond to that question, first?
  The PRESIDING OFFICER. The Senator has 50 seconds.
  Mr. LEVIN. I have 50 seconds to respond.
  The quick answer to that question is all Americans should have the 
same opportunity that we do for health care. That is what some of us 
are trying to achieve. It is not right that we have access to health 
care which is not available to all Americans, that we can obtain health 
insurance despite any preexisting condition, but other Americans do not 
have that opportunity.
  I would be happy to yield to my friend from Massachusetts.
  Mr. KENNEDY. Just a final question, and I ask the Senator from South 
Dakota the same question.
  Does he know of any job in America where after you have worked for 
that period of time, up to 5 years, and then you retire that you are 
guaranteed health insurance for the rest of your life effectively? Do 
not you think that ought to be of interest to some Americans as well?
  The PRESIDING OFFICER. The time has expired.
  Mr. KENNEDY. Could I have a minute to let him respond?
  Mr. PRYOR. I yield one additional minute to the Senator.
  Mr. DASCHLE. Madam President, the answer to the question from the 
Senator from Massachusetts is ``no.'' In fact, it is often just the 
reverse. I know so many occasions where people lose their health 
benefits when they are laid off or retire from their factory or their 
office job. They are no longer insured. They have limited access to 
care. They have no confidence that their insurance will be continued. 
It does not matter whether they are sick, whether they are healthy, 
whether they are rich or poor. They may lose their coverage.
  It is really ironic, Madam President, that this body on so many 
occasions exempts itself from laws that we insist the rest of America 
comply with, but on health care it is just the reverse. We are prepared 
to accept benefits that we are not willing to share with the rest of 
the country. That ironic twist is something we do not talk enough 
about.
  I yield the floor.
  The PRESIDING OFFICER. Who yields time?
  The Senator from Oregon.
  Mr. PACKWOOD. Madam President, I yield such time as the Senator from 
Florida requires.
  The PRESIDING OFFICER. The Senator from Florida is recognized.
  Mr. MACK. Madam President, I can understand why the discussion is not 
on the issue of my amendment. Frankly, I would suggest that this is 
probably somewhat embarrassing to those who have endorsed the Clinton-
Mitchell proposal. There might be those who feel that the discussion of 
meetings in secrecy somehow might be a silly idea. But I believe there 
is something very significant about a health care proposal which we 
claim is basically Government dominated, and Government controlled. We 
think the point that a couple of the major commissions that have been 
established under this bill will be able to carry out their work in 
secrecy is wrong.
  There may be those who want to say they did not know this was in the 
bill. Or they might say I certainly would not have supported that 
concept if I knew it was in there.
  But the reality is these boards, and two I am going to specifically 
talk about are exempt from having their meetings held in public. One of 
the demands we place on Government because of the freedoms we enjoy is 
the right to participate in actions taken by the Government which 
affect our daily lives. Our constituents can write us. They can call 
our offices, they can meet with us. They can attend hearings. They can 
read proceedings of the Senate in the Congressional Record. They are 
watching us in this historic Chamber today.
  But when it comes to health care, these freedoms are slowly being 
eroded by the Clinton-Mitchell legislation. This bill expressly grants 
secrecy to boards and commissions which will be making life or death 
decisions affecting ourselves and our families.
  The amendment we offer today restores some of the freedoms which have 
been taken away from the American people in the Clinton-Mitchell bill.
  Our amendment requires that all boards and commissions established 
under this bill must operate in the sunshine. It is not surprising, 
however, that secrecy has made its way into this bill. It began in 
secrecy at the White House with minutes and notes of meetings pried out 
only through court action.
  This bill has also been crafted in secrecy. Secrecy in Government is 
not the American way. Secrecy in Government has led to all sorts of 
abuses and denial of freedom in other lands. We must keep our system of 
Government open and accountable to the citizens of our country for 
public inspection and scrutiny.
  It is simply wrong that this legislation has in it so many elements 
of secrecy.
  The Clinton-Mitchell bill states that the Federal Advisory Committee 
Act shall not apply to the national health benefits board, the national 
health care cost and coverage commission, and the agency for health 
care policy and research. In addition, panels created by the agency for 
health care policy and research are exempted from the Government in the 
Sunshine Act.
  Let me try to put this into some perspective. This chart shows the 
requirements under the Federal Advisory Committee Act. It says that 
these meetings should be meetings in public, published notice of 
meetings in the Federal Register, let public know of the agenda for 
those meetings. The act requires boards to permit persons to obtain 
transcripts, appear and testify or file statements, make a record, 
minutes, working papers, drafts, et cetera, available, keep detailed 
minutes, permit citizens to purchase manuscripts and transcripts, keep 
adequate financial records. The act also requires there should be a 2-
year time period for the boards and commissions.
  That is the requirement for most Federal agency meetings. But for one 
reason or another, these two boards, the national health benefits board 
and the national health care cost and coverage commission, are exempted 
from those requirements.
  I want people to think about that for a moment because these two 
boards have a potentially significant impact on the lives of our 
friends, families and loved ones.
  The national health benefits board will meet at least four times per 
year. It define benefits. It will develop cost sharing schedules, 
address parity of mental illness and substance abuse service, decide 
what is medically appropriate and necessary, promulgate regulations or 
guidelines to clarify items and services covered, and submit to 
Congress an implementing bill with fast-track authority.
  Keep in mind that it is going to go on behind closed doors in 
secrecy, with no way for the public to have input on probably what is 
the most significant piece of this legislation, the determination of 
the benefits that will be in policies.
  Let me once again put this on a personal basis.
  Several years ago, my wife Priscilla told me she had discovered a 
lump in her breast. It was cancer. But, fortunately for her, it was 
discovered early. She is alive today, frankly, because of that early 
discovery.
  This benefit board is going to make the determination as to whether 
women are going to receive mammograms at the age of 50 and above, or 
whether it will be 40 and above.
  Mr. President, I have been active on this issue with respect to 
breast cancer. I have attended meetings where there were discussions as 
to whether the scientific data really does question whether it should 
be 50 or whether it should be 40. And there is one tremendous debate 
that is going on.
  But the thought occurs to me that allowing this board, behind closed 
doors and without input, is, in fact, a tragedy. It is an outrage.
  Now, my friends on the other side of the aisle do not want to focus 
on this, and I can understand why. But this is a significant issue. The 
key term is ``medically appropriate and necessary.'' How that board 
comes to a conclusion on almost every single medical procedure 
available to us in this country will affect each one of us personally, 
our moms and dads, our brothers and sisters, our grandchildren. And it 
is going to be done behind closed doors?
  Let me make another point. This same board, under ``medically 
appropriate and necessary,'' will promulgate regulations and/or 
guidelines to clarify items and services covered.
  A couple of days ago, I talked about a British citizen that had gone 
to a generalist and was referred to a specialist in England, and 
received a letter from the governing board indicating to him that it 
would be 2 years before he would be able to get an appointment with 
that specialist. My point is, in that same country, under these kinds 
of terms and with a similar board, they have decided--at least it used 
to be--they have decided if you are 55 years of age or older, kidney 
dialysis is not available to you.
  I do not think those kinds of decisions should be made by a seven-
member board behind closed doors. I think it is fundamentally wrong. I 
think people want to have confidence in their Government, confidence in 
their health care system. They want to have the ability to have input. 
It is that straightforward and that simple.
  Now, let me address this other commission, the National Health Care 
Cost and Coverage Commission. I know some people might say, ``Well, 
gee, I do not know, that is really one that is too important to focus 
on. After all, is the National Health Benefits Board not the key 
concern?''
  It is the key concern. There is no question about that.
  But I think it is important, as well. Because there are several 
things that this coverage commission is empowered to do. ``Determine if 
our Nation and each State has achieved 95 percent coverage.'' And then, 
``Develop legislation to achieve 95 percent coverage.''
  That legislation comes to us under fast track, and we lose our 
ability to effect that legislation. I do not think that a board of this 
kind, dealing with that kind of significant legislation, should do it 
behind closed doors.
  Mr. President, I suggest that when this does come to a vote, I 
imagine that most of my colleagues will agree with me. And I am happy 
that they will, because a health care plan, whatever kind of health 
care plan makes it through the Senate, the House, and eventually 
becomes law, should not have as one of its basic tenets, secrecy. The 
people of America demand that they have a right to express their 
concerns. They want to be able to say more specifically what kind of 
health care coverage and what kind of medical procedures may be 
available to them.
  I was driven to offer this amendment because of personal reasons.
  I go back to the point I made a minute ago. I think it is important 
that the people of our country have confidence, not only in the 
process, but in the people who make these kinds of delicate decisions. 
And I suspect that every Member of the Senate and most people who are 
hearing this debate have found themselves in positions where they have 
had to make some very difficult and tough decisions about the kind of 
health care for their loved ones to receive.
  Those decisions are being taken away from them. Those decisions are 
going to be made by these kinds of boards. These boards are going to 
determine what is ``medically appropriate and necessary.''
  No longer will that precious relationship that exists between the 
doctor and patient be the same if legislation like this is passed. 
Boards, acting behind closed doors, in the darkness of night, will 
decide what benefits you and your family will receive.
  Again, it is much more than just benefits. What we are talking about 
is specific medical procedures. They are going to decide what drug, for 
example, might be available. They are going to decide what kind of 
operating procedure might be available. And, under this legislation, 
you and I, as average Americans, will not have one opportunity to input 
the outcome of that decision.
  That is wrong and I think the American people reject it out of hand.
  I yield the floor.
  The PRESIDING OFFICER (Mr. Feingold). Who yields time?
  Mr. PRYOR. Mr. President, I yield such time as the Senator from South 
Dakota may desire.
  Mr. DASCHLE. I thank the Senator for yielding.
  The PRESIDING OFFICER. The Senator from South Dakota.
  Mr. DASCHLE. Mr. President, I had the opportunity to clarify the 
statement made by the Senator from Texas a couple of minutes ago with 
regard to what happens when a Member of the Senate exits the Senate. 
The answer is that a Senator is entitled to the same benefits beyond 
the time he or she may serve in the Senate, for 18 months, and then he 
or she may convert their group policy to an individual policy, through 
the same insurance company. This is an important point.
  Can we be consistent? Can we say, if it is good enough for us, it 
ought to be good enough for them? The question is not whether we have a 
government program or a private program. We can argue about the merits 
of either, and no one has done that more eloquently, as the Senator 
from Arkansas has stated, than Senator Mitchell. The majority leader 
has said over and over again, we can call this a horse if we want to, 
and we can continue to refer to it as a horse, but it is a desk, 
regardless of how many times we say it is a horse. We can call the 
health system under Senator Mitchell's bill a government program, but 
the bottom line is what we are trying to do for the American people is 
what we have already done for ourselves. We are simply trying to extend 
the Federal employees health benefits plan, a plan that 9 million 
Americans use as employees of the Federal Government, to all Americans. 
Is that a government plan or is it a private plan?
  We have made reference several times today to a speech made by the 
majority leader. I had the good fortune to hear another speech Monday 
evening, August 15, given by one of the real students of health care in 
the Senate, our colleague from Minnesota, Senator Durenberger. I doubt 
that he would mind if I read what he said that night:

       If we cannot understand the difference between the Federal 
     Employee Health Benefit Plan and a Government-run program 
     like Medicare and Medicaid, I, for one, am going to spend a 
     lot of time here educating my colleagues, and I do not want 
     to have anyone call it a filibuster. The Federal Employee 
     Health Benefit Plan or plans, if you will, are a series of 
     health plans which all of us have the opportunity to buy. But 
     they are all private plans everybody in this community can 
     buy, if they have an employer who provides it to them, or 
     they can buy it in the open market. There are Blue Cross-Blue 
     Shield plans in that, and I think there is a Kaiser plan in 
     this community. But they are private plans.
       What they do is ensure all of us access to the doctors, 
     hospitals and so forth that we need in this area, Washington, 
     DC, northern Virginia, Maryland, and so forth. But it is 
     basically a private plan.

  That is what our colleague from Minnesota said about what we have as 
Members of the Senate. It has been described on so many occasions as a 
government plan, but as he, the majority leader and so many others have 
so ably stated again this afternoon, what we want to do is simply 
provide the American people with the opportunity to have what we have; 
to give them the same access we have; to give them the confidence we 
have that when you lose your job or when you retire, you have the 
ability to cover yourself and your family. We have the confidence in 
knowing that if we get sick, we are still going to have the same 
coverage we have right now.
  I do not know that we can do any better than that. We have the luxury 
of knowing that we have a standardized plan that precludes preexisting 
condition exclusions or limitations, that precludes the fine print, 
that precludes a lot of the surprises that one finds in so many of the 
plans most Americans have today. We have an ability to go about our 
work, to do the best job we can as U.S. Senators, knowing we are well 
covered. There are no surprises in our policies. When we most rely upon 
the FEHB, we know it is there for us.
  I hope we can recognize that there is a substantial degree of 
misinformation in this debate. It is crucial that we recognize the 
importance of portability, the elimination of preexisting condition 
exclusions and fine print, and the extension of benefits regardless of 
one's employment status--that is all we are saying we want. We can 
categorize that as a government plan if we want to, but that does not 
change the facts. The fact is, very simply, that Members of Congress 
have a good system. If it is good enough for us, it ought to be good 
enough for all Americans.
  I do not know how many speeches I have heard on the floor over the 
last many years about why it is we ought to exempt ourselves from this 
or that law. Some of us are now arguing just the reverse. We have 
something many Americans do not have, and the question is, should we 
extend what we have to them? I believe that really is the essence of 
this debate.
  Mr. WELLSTONE. Will the Senator yield?
  Mr. DASCHLE. I will be happy to yield to the Senator from Minnesota.
  Mr. WELLSTONE. I will ask the Senator a question. I followed the 
debate from my office. This point came up some yesterday. I know we are 
going to come back to this in the debate.
  In the Federal employees benefit package there are a variety of 
different, if you will, benefit packages but in each and every one of 
them, you have a list of what is covered. In other words, you have a 
standard basic benefit package, and there are a number of them that you 
choose from.
  But would the Senator agree with me that the differences have to do 
with copays or deductibles, but it is not a situation where people can 
say, ``Listen, I am not a woman expecting a child.'' We went through 
this with the amendment of the Senator from Connecticut, Senator Dodd. 
Or, ``I am not a spouse or woman expecting a child or I do not struggle 
with mental illness or I do not know anybody who does; I do not come 
from an underserved community, I am not interested in public 
health.''--and therefore you can say, ``I want nothing to do with 
that.''
  Is it not true that in each one of these plans you have a standard 
package, the idea being we are all in this together? Is that not a part 
of what makes this insurance work?
  Mr. DASCHLE. The Senator is absolutely right. He was a participant in 
the debate yesterday when we discussed that issue. What we do not want 
to do is protect the fine print. What we do not want to do is allow 
practices utilized by some insurance companies, in which they surprise 
policyholders at the moment when they are most vulnerable. We do not 
have to worry about that as Federal employees. One ought not to have to 
worry about that under any circumstances in this country. But people do 
worry. There are so many tricks, there are so many gimmicks, there are 
so many ways insurance companies are able to get around their 
responsibilities even if someone has paid tens of thousands of dollars 
over the years to ensure protection for themselves and their families. 
They may not know their policy has a lifetime limit. They may not know 
their policy has a preexisting condition clause. They may not know 
their policy has many different categories of exceptions that sometimes 
get buried in the fine print on page 77 of their insurance plan.
  That is really what we are trying to address here. We are trying to 
standardize plans to keep the surprises out of insurance. We have that 
security. All Americans ought to have that same confidence. I 
appreciate the point the Senator from Minnesota made.
  Mr. WELLSTONE. If the Senator will yield? Let me just ask a couple of 
other questions because this will go to an amendment I will introduce 
on the floor soon.
  Is it not true--we have had this debate about universal coverage--
each Senator or Representative is covered and in a sense it is 
universal coverage? We do not have 90 or 95 percent; all of us are 
covered?
  Mr. DASCHLE. All of us are covered, all our families are covered, 
everyone who serves in the U.S. Senate is completely covered.
  Mr. WELLSTONE. Then, finally, is it not also true that there are no 
preexisting condition?
  Mr. DASCHLE. The Senator is correct. There are no ``preexisting 
condition exclusions or restrictions allowed.'' In fact, these kinds of 
exclusions are specifically prohibited under FEHBP.
  Every insurance plan that contracts with the FEHBP has to meet 
certain conditions. It has to be willing to accept certain criteria if 
it is sold through FEHBP. That is exactly what we are trying do here. 
We are trying to require insurers to say, ``We are not going to have 
preexisting condition exclusions, we are not going to have lifetime 
limits, we are not going to write into a plan the kind of fine print 
that is so often found in non-FEHBP private plans. FEHB plans are 
willing to accept this criteria. Why? Because FEHBP has access to 9 
million well-paid American people and their families. That is why these 
plans are willing to agree to go into that pool. That is why the plans 
are willing to leave out preexisting condition restrictions and the 
fine print they put in other policies.
  Mr. WELLSTONE. Because everybody is in this together.
  Mr. DASCHLE. Everybody is in this together. The universal coverage we 
get gives us the ability not only to have the confidence that we are 
not going to be surprised by what is in our policy, but it gives us the 
power to purchase. It gives us the ability to choose among plans that 
compete along with all the other plans for 9 million Americans. Through 
this system we get the cheapest, most accessible health care you can 
find in America today.
  Mr. WELLSTONE. I see my colleague on the floor. If I may make just 
the final point, if the Senator will let me ask a question and make a 
comment. The other thing that makes this work is that our employer 
contributes what, about 72 percent? Is that correct?
  Mr. DASCHLE. Our employer contributes 72 percent today, we contribute 
28 percent. Which is approximately the average in the country today. 
Employers in large corporations generally provide that kind of 
contribution to their workers' coverage. The Senator from Alaska was a 
little sensitive about that earlier, when he was trying to make the 
point we do not have anything unique. To a certain extent he is right, 
but there are truly unique aspects about what we have.
  The luxury of knowing that we cannot be dropped from our policy, the 
luxury of knowing that we have a significant purchasing power that 
gives us a good price for our policy. So we have some benefits that a 
lot of people do not have today.
  Mr. WELLSTONE. To conclude, let me ask the Senator's reaction to 
this. The point we are trying to make, which seems to be maybe the 
standard, almost 100 percent of the people in the country--is, ``Look, 
when you do your work representing us, we would like for you in your 
reform bill to make sure what is available to you and your loved 
ones''--and they do not say that in the spirit of angry people--``is a 
available to us.'' That is really the goal.
  Would the Senator think it would be a good idea, since this is the 
yardstick by which we measure our work, for an amendment to be offered? 
I am going to work out an amendment that essentially captures the 
spirit of that--what it is that you have and what you consider to be a 
plan that is good for you and your loved ones. This is what we want in 
the reform effort, this is what we want the final bill to live up to, 
to move toward, to capture.
  Mr. DASCHLE. I commend the Senator for his interest in this issue. I 
think that sends the right message. We want for you what we have for 
ourselves. We want to be sure that you have the same opportunities, the 
same confidence, the same stability that this provides all of our 
families and ourselves. As we go about our daily business, as we try to 
do the best job we can here in the U.S. Senate, we do not have to 
worry. We are protected. Why? Because we, over the years, decided it is 
in our best interest to have this kind of insurance. We have had the 
luxury to do that. A lot of Americans do not have that luxury or that 
power.
  Mr. WELLSTONE. I thank the Senator. I think what I will do, I am 
going to, the first chance I get, offer an amendment where we can have 
a vote and have everybody on record to this proposition that really, in 
this final reform bill and what we are working for, what we are working 
for is to make sure the people we represent have health care like we 
have: High-quality health care available to themselves and their loved 
ones. I will make sure we have a vote on the amendment and everybody 
can be on record, and then we can measure the different proposals in 
what we finally do by that standard.
  Mr. DASCHLE. I hope the Senator from Minnesota will share that with 
all of us.
  Mr. WELLSTONE. I will share that.
  Mr. DODD. Will the Senator yield?
  Mr. DASCHLE. I will be happy to yield to the Senator.
  Mr. DODD. I would like to address two questions to my distinguished 
colleague. The first picks up on the comment of Senator Wellstone. 
Yesterday, during some of the debate regarding the amendment that we 
adopted dealing with the accelerated benefits for pregnant women and 
children in the area of prevention, I heard one of my colleagues 
express the notion that we are all sort of islands unto ourselves and 
that there is a need to have so-called cafeteria plans where 
individuals, based on their family circumstances, their age and the 
like would tailor their health care plans according to their own 
specific needs. There is, I think, a genuine appeal to that approach.
  But I ask my colleague, whether there is not also a sense of 
community in this country that also should inform this debate. I see my 
colleague from Iowa on the floor, and his description of the barn-
raising effort is a good example. It was a great notion of community 
there. It was not possible for one family to put up the barn. We have 
all heard those stories over the years.
  In the educational system, I suppose in an ideal world, maybe each 
person or family would educate their own child, but we appreciate the 
value of the community coming together to provide education.
  There are certain issues that transcend the individual's needs, and 
it struck me that in a number of these areas, that is where the sense 
of community comes into play. A younger generation pays for the Social 
Security of a retired population. There are some younger people who 
argue, ``Why should I be paying for some retiree?'' And yet because 
there is this notion of community, we have accepted the idea that one 
generation contributes to the retiring generation's financial security, 
and it makes sense for all of us.
  I just wanted to emphasize that particular point. My colleague from 
Minnesota has raised it and I think it has value, the notion of 
community. It does not apply in every situation, but I think in a 
number of areas it clearly does. I just ask him for his particular 
comments on that.
  Additionally, I think it is important to expand on an issue raised by 
my colleagues from Michigan, Minnesota, and South Dakota--the idea of a 
Government plan. No one here that I know of is advocating a Government 
plan. Now some have argued for a single payer system, and I have great 
respect for those who do.
  But what is before us and what we are discussing is really an 
expansion of the private insurance industry. I am from Connecticut. No 
State has a greater interest in this issue. In my State of Connecticut, 
I have 55,000 constituents that work directly in the private insurance 
industry. Despite some of the comments that are made around in this 
Chamber from time to time, we think it is a good industry and has 
contributed significantly to the health and well-being of this country.
  One of the reasons why I am supportive of the general notions put 
forward by the distinguished majority leader, is because it takes the 
industry in my State, the private insurance industry, and it builds 
upon that industry. It does not try to set up a competing operation 
within the Federal Government or State governments, but it takes the 
private insurance industry, principally located in my home State of 
Connecticut, and says we are going to utilize that system and see to it 
that we can try to reach the other 40 million Americans, who have no 
insurance. Is that not, in fact, what we are doing?
  Mr. DASCHLE. The Senator from Connecticut is absolutely right on both 
points. Let me talk about the first one for just a minute, because I 
think he makes a point we do not talk about often enough on the floor: 
The sense of community. That really has been one of the most pervasive 
values that I think this country was based upon, all the way through 
the history, the development of this country. When my State was being 
discovered by the early pioneers, it was really the pioneers coming 
together as neighbors, as people in a very desolate part of the country 
helping each other so that they could survive first and flourish 
second.
  The interesting thing is that sense of community comes up the most 
when it is a time of peril or personal difficulty, as the Senator from 
Connecticut has indicated. It is at a time when a barn burns, or it is 
at a time of a flood, or a time when a community has been ravaged by a 
disaster of some kind. That is when we really see the value of that 
community spirit that built this country in the first place.
  What greater peril is there than for a family to experience a life 
crisis in health--a cancer, a serious illness of any kind, a death? 
That is the time when we really rely upon the community to help each 
other, to try to get through that difficult time financially and 
emotionally and in every other way. That is really the essence of 
insurance. That is really what we are trying to do here.
  Frankly, whether it is Government or private, that ought not matter. 
Let us get out of the semantics for a minute and just recognize that 
insurance is insurance regardless of what source that insurance may 
come from.
  As the Senator said--and that leads to a second point--we can call 
this desk a horse, as the majority leader has said, and if it is 
repeated often enough, somebody soon enough will call this a horse, but 
the fact is it is a desk.
  Someone can continue to insist what we are trying to do is provide 
Government insurance, but as Senator Durenberger said on Monday night, 
as the majority leader said often, as we continue to insist here, let 
us get the facts straight. Let us get rid of the misinformation. Let us 
quit the miscategorization here. Let us get down to the real essence of 
what it is we are trying to do. We are simply trying to provide the 
same coverage, the same insurance in that same community spirit to all 
the American people that we have felt to be so important for ourselves.
  Mr. DODD. I thank my colleague for yielding. I see our friend and 
colleague from Oregon here, Senator Packwood. He was my best and 
strongest supporter, I point out to my colleagues, on family and 
medical leave. I recall a day here during that debate when he was 
eloquent in describing the evolution of the concept of family and 
medical leave when people worked on farms. And if something happened to 
a child, there was always someone there. There was a sense of community 
on those farms.
  The world has changed, our Nation has changed and, unfortunately, 
when a child gets sick or a family member, there is not always someone 
there to be with them. Arguably, not everybody has a family in this 
country. Some people are single, some people are retired and family and 
medical leave is of marginal significance to them.
  But when we passed that legislation by almost 70 votes in the 
Senate--Democrats and Republicans coming together for the final version 
of that bill--no one made the argument that because it only benefited, 
a certain percentage of the population, that it was not worth 
doing, because we understood, I believe, the sense of community and the 
sense that from time to time we need to pull together, and even though 
someone else may be paying some small amount for that benefit, it is in 
everyone's interest to make that benefit available.

  I thank my colleague for yielding.
  Mr. DASCHLE. The Senator from Connecticut makes a very good point.
  There are others waiting to speak, and I will conclude with this.
  We talk about preexisting conditions and the fine print, Mr. 
President. I have something here that was offered to us by a 
representative of the insurance industry recently as an example of the 
fine print that is so often found in insurance policies today. 
References in these policies are made frequently to ``sickness.'' Here 
is what a standard policy includes as its definition of sickness. This 
is not an FEHBP policy, because we do not have this type of fine print. 
But you can find this type of language in other plans that are 
available across the country. And I quote from the insurance policy:

       Sickness means illness or disease of any insured which 
     first manifests itself 30 days after the effective date of 
     this policy and while this policy is in force. All sickness 
     due to the same or related cause or causes which continues or 
     recurs shall be considered one and the same sickness or any 
     one sickness unless periods of confinement to a hospital or 
     service treatment or expense incurred resulting from such 
     sickness are separated by an interval of at least 90 
     consecutive days between the end of one such period and the 
     beginning of a subsequent such period. Any loss which results 
     from hernia, disease, or disorder of the reproductive organs, 
     hemorrhoids, varicose veins, tonsils, or adenoids shall be 
     covered only if such loss occurs after this policy has been 
     in force for a period of 6 months from the effective date of 
     this policy, provided these sicknesses are not excluded by 
     rider or endorsement and these sicknesses are not preexisting 
     conditions.

  This is what the American people are up against, Mr. President. It 
takes not one lawyer but a bank of lawyers to interpret this. If I had 
this policy today, I would not have the slightest idea whether or not I 
was covered for my medical condition. That is the surprise method used 
by some insurance companies to avoid responsibility, to avoid having to 
own up to the expectations of their policyholders when that moment 
comes and they need care the most.
  So I am hopeful that we can end the surprises; that we can ensure 
that this piece of legislation does not become the ``Fine Print 
Prevention Act.'' We want to be sure that we can, of all the things we 
do, take out the fine print, put in the confidence, and do what is 
right not only for ourselves but the rest of the country.
  I yield the floor.
  Mr. PACKWOOD addressed the Chair.
  The PRESIDING OFFICER. The Senator from Oregon.
  Mr. PACKWOOD. I yield 15 minutes to the Senator from Idaho.
  The PRESIDING OFFICER. The Senator from Idaho is recognized for 15 
minutes.
  Mr. CRAIG. I thank my colleague from Oregon for yielding.
  I have been enthralled by the discussion that has gone on on the 
other side over the last few minutes in their use of the word 
``community,'' and the discussion of my colleague from Connecticut of 
the barn raising.
  I come from a rural State. I come from a State that is just 100 and a 
few years old. The reason we had barn raisings in our State was because 
there was not a government. The reason we developed a sense of 
community is because there was not a government. Governments do not 
create communities. They destroy communities. They destroy voluntarism. 
They destroy individuals coming together to provide for themselves and 
their community. We all know that.
  The reason there was a barn raising and the community gathered was 
because there was no FHA loan. There was no Federal program. No, the 
Government did not pay for the barn. The individual paid for the barn. 
He called up his neighbors and he said, ``Would you come and help me 
raise the barn?'' That is community action. That is in the absence of 
government.
  My colleague also mentioned he had 55,000 insurance employees in his 
State. My guess is that after the Clinton-Mitchell bill passes, within 
10 years, he will probably have 150,000 insurance employees in his 
State.
  One of the reasons that more than likely will occur is because of the 
phenomenal complication, the phenomenal intricacy that is involved in 
little terms like ``community ratings'' and ``geographic areas that 
result in 250,000 or more,'' that establish certain levels of costs and 
the kinds of necessary threadings and the loopholes or absence thereof 
that the insurance industries of this country will have to begin to 
comply with and the paperwork that will be required.
  Now, is that going to happen? Well, let me suggest that in any other, 
not federally run but federally controlled, federally monitored, 
federally designed health care system around the world, that is all 
true. I have to believe that in the Clinton-Mitchell approach that, 
too, will be the case--not tomorrow, or 2 or 3 years from now, but 
progressively over time as a National Health Benefits Board begins its 
approach put upon it by the pressure of the politics of America to say 
add this benefit and add this benefit and add more. There will be no 
Government program, or should I say Federal employees insurance 
program, after that.
  I thought that was a fascinating debate this afternoon. It will be 
the standardized approach that will be designed by this board. So let 
me at this moment then talk about the Mack-Coats amendment that is very 
important if we are going to march down the very dangerous path that 
this huge bill that none of us have really yet had the opportunity to 
detail may send us.
  If I as a Senator am going to be subject to the National Health 
Benefits Board, then I wish to know publicly what they are doing. I do 
not agree with Senator Mitchell that they ought to meet in private. I 
do not agree that their decisions ought to be secret. And the reason I 
do not agree with that is because it will affect me. But it will also 
affect every other American citizen.
  In 1974, I was a freshman State senator in Idaho, and one of the 
first pieces of legislation that I ever voted on was a bill called the 
Idaho Sunshine Act. That was a bill that came out of the State of 
Florida. We all know about it. It was the beginning of a period in time 
starting in the mid-1970's when we moved toward openness in government 
like never before, when we believed as legislators, whether it was at 
the State or the Federal level, that, doggone it, we were making 
decisions that were important enough that the public ought to be 
allowed to participate. And, thank goodness, we had a free press that 
said: You are darned right; it ought to be open. And we are going to 
continue to push you, public legislators, until you open government. 
And we opened it. We opened it aggressively through the 1970's and into 
the early 1980's, and we all are better off for it.
  Now, we are talking about probably the largest piece of legislation 
that in my 14 years of service to the State of Idaho I have ever had 
the responsibility of analyzing and voting for or against, the largest 
entitlement program in the history of the world, potentially the 
largest economic program ever in the history of this country. And yet, 
embodied within it, are boards and commissions that are to meet in 
secrecy.
  Why in the heck would anybody on that side of the aisle or this side 
of the aisle ever bring a bill to the floor of the Senate that had that 
kind of provision in it?
  The reason is simple. They did not know what was in it. They had not 
read what was in it. It had not been written in a committee. There were 
no committee hearings. It was a cobbled up piece of legislative trivia 
that now is falling apart. The reason I use those terms is because it 
is time we became very, very serious about what we do here. And that 
seriousness says that if we are going to redirect through a Government 
program one-seventh of the U.S. economy, we deserve to have open, 
public hearings, open committee hearings and subcommittee hearings, and 
bring about all the details and all of the tests that we normally 
afford any given piece of legislation.
  Why? Why, in the last minutes of this Congress before we go out on 
recess, were we asked to vote now on a 1,400-page piece of legislation?
  Well, there are a lot of reasons, I suspect. None of them are 
pressure from the American people. The American people are not saying 
we have to have this now. They are saying go carefully and go 
cautiously, because what you will do to us will be greater than 
anything you have done to us or for us since the Social Security Act of 
the 1930's. And so you must go carefully and you must go cautiously.
  As you go, why in the heck are you suggesting that any of those 
deliberations, any of those decisions that will provide or examine or 
determine or lay out, and therefore proscribe, all of the benefits that 
would be in a package, why should they be done secretly?
  Now we have a quasi-governmental body known as the Federal Reserve. 
They are allowed to operate in secrecy even though, after they have 
made their decision and implemented it, they can then announce it. Here 
is the reason: Because it is possible, if it were done in an open 
public forum, that an individual could move rapidly to profit by it. 
The Congress of the United States said that ought not be allowed. We 
ought not allow an individual to personally profit by an act of the 
Federal Reserve Board because they were in the right place at the right 
time, tied to the right institution, and could move rapidly to cause 
that to happen.
  But the Senate knows that a National Health Benefits Board is an 
entirely different creature. Because what they do, and their 
determinations, and as they send them to the U.S. Congress, they are 
going to tell the American people for what they will be covered, how 
their health care will respond as it relates to their needs. So it is 
time that we work the process, but a great deal more diligently than we 
have been allowed to on this most important piece of legislation.
  It is time that the meetings be public. It is time that we do 
everything that the Federal Advisory Committee asked us to do. And, by 
the way, we all know that the Federal Advisory Committee Act is a 
creature of this Senate, of this Congress. When we say to the executive 
branch of Government, here is how you will operate, here is how, or 
here is the forum in which you will make these decisions, and you know 
the litany as I know the litany--public meetings, published notice of 
meetings in the Federal Register except for reasons of national 
security, making meeting agendas public, permit interested persons to 
attend, to testify, to file written statements, make records, meetings 
of minutes, graphs, and other documents available to the public, keep 
detailed minutes or transcripts, and allow the public to buy them, make 
records of funds received and disclose them to the public.
  This is a simple summary of what that law requires. Why would 
possibly the most important piece of legislation in a quarter century 
be exempt from that process? Why would the boards and the commissions 
that are embodied and, therefore, created by this piece of legislation 
allowed to do that or to do differently than that?
  I will tell you why I think it is so. Because this was a badly 
thought up and quickly cobbled together piece of legislation, and 
therein lies the great tragedy. That is why we now day by day, hour by 
hour have to go through it section by section. And, yes, we are reading 
the fine print. We are finding out that there is a lot in it that we do 
not like. We are bringing those amendments to the floor, and our 
colleagues on the other side are agreeing with us. Neither they nor us 
want to be embarrassed by a final product that might leave this Senate.
  So I hope we would stay here and continue the process, and that the 
public is allowed to listen, as they are--this is an open forum and 
what we say and do here is public, and it is observed by the public--
and that we would work our way through this page by page, section by 
section until such time as it is either determined that this vehicle 
cannot pass, nor can it stand on its own, or we have simply been able 
to correct it.
  I am one who believes you cannot correct that much. I am also one who 
believes in health care reform in a substantially different approach 
than is embodied in this legislation. But everything that I believe in 
that relates to health care reform is open, is public, allows the 
citizens who will most be affected by the law to watch the 
determination of how that law will be administered and the effects it 
might have based on the policies that are created by it.
  So I hope that the Senate will support the Mack-Coats amendment. I 
thank my colleagues for bringing that issue to the floor as we work. I 
hope we will continue to try to make a very bad piece of legislation a 
slightly better piece of legislation.
  I yield.
  The PRESIDING OFFICER. Who yields time?
  Mr. DASCHLE. I yield such time as he may consume to the Senator from 
Connecticut.
  Mr. DODD. Thank you, Mr. President. I will not take much time here. I 
intend to digress from the subject matter of health care briefly to 
talk about the pending crime legislation.
  But before I do, I want to respond to my colleague from Idaho. 
Sometimes, in debate we engage in a little hyperbole. I know I have. 
But I do not want to let stand the notion that Government has destroyed 
voluntarism in this country. Quite the contrary. I served as a Peace 
Corps volunteer for 2\1/2\ years representing my country. That program 
was created by Government.
  There are thousands of others who serve as VISTA volunteers all 
across this Nation--another program set up by Government. The National 
Service Program, which in a bipartisan fashion we passed in this 
Congress, will ask thousands of young Americans to make a contribution 
to their communities. The United Ways across this country receive 
substantial support and backing from State, local, and the National 
Government. Teach America asks young Americans who finish college to go 
out and work in some of our toughest schools in this Nation. The Points 
of Light Program, which George Bush championed, encouraged and expanded 
voluntarism and has been strongly backed by Congress over the years.
  And the list goes on--Big Brothers, Big Sisters, police athletic 
leagues, and Boys Clubs--all rely on volunteers. In fact, I would argue 
that today there is a greater sense of voluntarism in America than 
maybe at any other point in our history.
  So the notion that Government destroys voluntarism or a sense of 
community I just cannot let stand without challenging----
  Mr. CRAIG. Will the Senator yield?
  Mr. DODD. I will be glad to yield briefly.
  Mr. CRAIG. I believe when the Senator served on the Peace Corps as a 
volunteer he was provided with the cost of living, to some extent. I do 
not dispute the fact that there are some Government programs that 
provide certain things that allow people to do something they otherwise 
would not. I doubt that the Senator could have personally volunteered 
on his own time without his own money to serve in the Peace Corps. I am 
not disputing that. What I am suggesting to the Senator is that while 
there are a good number of Government-sponsored programs that are 
called volunteer programs, the true definition of a volunteer is when 
you do something for someone else and you are not paid for doing it. 
That is the true sense of voluntarism.
  Mr. DODD. Mr. President, if I can reclaim my time. Let me reclaim the 
time.
  Mr. CRAIG. I do not dispute that.
  The PRESIDING OFFICER. The Senator will withhold.
  The Senator from Connecticut has the floor.
  Mr. DODD. I say to my friend that at $100 a month I considered my 
service in the Peace Corps to be volunteering, as do most of the people 
who have been through that program and similar programs.
  I just do not want to let stand here the notion somehow that is 
destructive. Over the years, many good people have served or 
volunteered and contributed to our country and our communities. The 
notion that Government programs destroy voluntarism just does not stand 
up in the light of day when you consider the thousands of people who 
have served and who continue to serve as a result of programs sponsored 
by the Government.
  Mr. LOTT. Mr. President, parliamentary inquiry.
  Mr. DODD. I would like to proceed, if I could, Mr. President.
  The PRESIDING OFFICER. The Senator from Connecticut has the floor.
  Mr. DODD. Mr. President, we are talking here about health care. 
Obviously, that is a critically important issue, critical to every 
working family in the country; in fact, to every American citizen 
regardless of age or geography. And it is vitally important that we 
continue this debate, in my view, and hopefully complete it with a 
product that we can all be proud of and return to our respective States 
and districts at the end of this process having done something that has 
defied 7 American Presidents and 30 Congresses over the past 60 years.
  However, Mr. President, that is not the only issue which presently 
occupies the minds and attention of the American public.

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