[Congressional Record Volume 140, Number 139 (Thursday, September 29, 1994)]
[House]
[Page H]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: September 29, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]


                              {time}  2040
 
                           INCREMENTAL REFORM

  The SPEAKER pro tempore (Mr. Roemer). Under the Speaker's announced 
policy for February 11, 1994, and June 10, 1994, the gentleman from 
Washington [Mr. McDermott] is recognized for 30 minutes as the designee 
of the majority leader.
  Mr. McDERMOTT. Mr. Speaker, as you are aware, I have made an effort 
to talk on a regular basis about various issues in health care reform. 
Tonight I want to talk about the suspension of health care reform in 
this session of Congress.
  And I want to talk about how we cannot allow themselves to be 
distracted in the next session of Congress, as we were in this session, 
by the false promise that incremental reform, health insurance reform, 
somehow will get us part way to our goals.
  We cannot be distracted by the notion that we can avoid giving every 
American health insurance that can never be taken away.
  Now some people are saying it will be harder next year to guarantee 
every American health insurance that can never be taken away. Some 
people are saying we can only take small steps. A lot of people have 
convinced the American people that true health reform really cannot 
happen.
  Mr. BUYER. Mr. Speaker, will the gentleman yield for a parliamentary 
inquiry?
  Mr. McDERMOTT. I yield to the gentleman from Indiana.


                         parliamentary inquiry

  Mr. BUYER. Mr. Speaker, I have a parliamentary inquiry.
  The SPEAKER pro tempore. The gentleman will state it.
  Mr. BUYER. Mr. Speaker, my question is, on Special Orders, that the 
Special Order was yielded to the gentleman. However, the gentlewoman 
from Ohio is no where in the well. Is the gentlewoman supposed to stay 
here and be present in yielding 30 minutes to someone else on other 
issues, when I have reserved the time?
  The SPEAKER pro tempore. Under the Speaker's announced policy, each 
party leader has an hour to designate to their individual speakers. 
Under this arrangement, the gentlewoman from Ohio was designated by the 
majority leader for 30 minutes, and the gentleman from Washington was 
designated by the majority leader for 30 minutes, a total of an hour.
  The gentleman from Indiana will be recognized shortly for a portion 
of the minority leader's hour.
  Mr. BUYER. Mr. Speaker, I thank the Chair.
  Mr. McDERMOTT. Mr. Speaker, it is pretty clear that the advocates of 
incremental reform will be back next year trying to convince the 
American people that we can do health reform without universal 
coverage.
  Well, I am here to tell you that those people are wrong. The reason 
incremental reform did not pass this year is because no one could 
figure out a way to do affordable insurance reform without universal 
coverage.
  Every proposal for insurance reform alone without universal coverage 
would have caused private health insurance premiums to increase. The 
truth is that universal coverage is the foundation of affordable health 
care.
  By the year 2000, health insurance premiums are expected to double. 
And as premiums go up, more and more people will lose coverage because 
their employers won't be able to provide it--and people simply will not 
be able to purchase it by themselves.
  The inability of incremental reform to solve these problems is not 
going to change. So we have to start over, we have to return to the 
basics, and do this right in the next session of Congress.
  So let's return to the basics.
  When we started the reform process almost 2 years ago, we shared a 
vision--of a health care system financed by everyone and covering 
everyone.
  We had a vision of a health care system that was fair and ended the 
cost-shifting that business and those with health insurance no longer 
can sustain.
  We envisioned providing our people with health coverage so secure 
that they could devote themselves without distraction to their families 
and their jobs.
  We envisioned a health care system that would grow at a predictable 
rate so that the rest of our economy could flourish.
  The question is: Has anything happened since we began this process to 
justify abandoning health reform goals of universality, affordability, 
security, and choice?
  Are more people insured today? Are more employers providing 
insurance? Are health care costs declining? Are citizens enjoying 
increased choice of providers and receiving better continuity of care? 
Are administrative costs declining? The resounding answer to these 
questions is ``no.''
  In fact, more people have lost insurance since 1992, bringing the 
total of uninsured to almost 40 million. More employers are dropping 
insurance and when people change jobs, their new employers are less 
likely to provide comparable health benefits.
  Health care costs continue to rise, assuring that health insurance 
will be unaffordable to Americans who do not receive it through their 
employment. Those Americans who do have insurance are increasingly 
unable to choose their doctors and hospitals.
  Involuntarily forced into managed care plans selected by their 
employers, more Americans lose their doctor every time their employers 
change plans--a source of increasing anxiety and frustration.
  This trend continues against the backdrop of soaring administrative 
cost within the insurance industry. The nation's largest managed care 
companies now devote nearly 30 percent of premium dollars to 
administrative overhead and profit.
  The question is: will incremental reform do anything to address these 
fundamental problems or will it make things worse?
  Having examined the existing proposals, I have concluded that they 
not only will make things much worse--reducing coverage, increasing 
costs, further eroding choice for our citizens--but that in fundamental 
ways they will set back the course of health reform 30 years.
  I want to make clear why insurance reform as currently conceived will 
represent a giant step backward.
  The element of incremental reform that has attracted a great deal of 
attention is the effort to make sure that people who have medical 
problems will not continue to be prevented from buying insurance. The 
phrase used to describe this is limiting exclusions due to preexisting 
medical conditions.
  The problem is that this approach will only work if it is applied in 
a system in which there is universal coverage.
  Universal coverage is the foundation of successful health care 
reform. We cannot construct any reasonable shelter unless it is built 
on that foundation. Put another way, universal coverage is the big 
tent.
  With universal coverage, everyone can fit into the tent. People with 
preexisting conditions are in the tent and have health insurance 
coverage. With universal coverage, your health insurance moves with you 
when you change jobs, so you stay in the tent.
  With universal coverage, you can get cost-containment and insurance 
premiums become more affordable because insured people are no longer 
paying for someone else's bad debt--and everyone can stay in the tent.
  But if you try to eliminate preexisting condition exclusions without 
universal coverage, insurance premiums will increase. People with 
preexisting conditions may no longer be technically excluded--they 
simply will not be able to afford the price of the insurance policy.
  Without universal coverage, there is no way to keep healthy people in 
the insurance system. The tent gets smaller. As a result, when people 
with preexisting conditions finally buy insurance and healthy people 
leave the insurance pool, the risk pools worsen, premiums rise, fewer 
individuals and employers can afford the price of buying health 
insurance and people lose coverage--they have been forced out of the 
tent.
  Whatever we do in health care reform, we must assure that health care 
becomes more affordable or it is inevitable that people will lose 
coverage.
  Only universal coverage makes insurance affordable. Without it, we 
will never be able to spread the risk of insurance to keep costs low 
and we will never be able to control cost-shifting--the means by which 
the insured patient pays for the debt of the uninsured patient.
  And unless we stop cost shifting, cost containment throughout the 
entire system is a pipe dream.
  Without universal coverage, someone is uninsured. And providing care 
to the uninsured is terribly expensive because they are simply too sick 
by the time they seek care.
  The uninsured patient is like the leak in the dike. Either you fix 
the dike or you face the flood, and without universal coverage the 
flood is uncontrollable health care costs.
  The element of incremental reform that is supposed to at least get 
the Nation on the road to universal coverage is the subsidy program 
that would give people vouchers to help them buy private insurance. But 
the way the incremental proposals pay for those subsidies will cause 
many Americans to lose coverage they already have.
  How would these proposals pay for the subsidies to help people buy 
insurance? They would cut the Medicare Program, our national health 
insurance program for senior citizens and the Medicaid Program, our 
national/state health insurance program primarily for mothers and 
children.
  This is just robbing Peter to pay Paul, except at the end of the day, 
fewer people will have insurance coverage and the robbery will create 
great disruption in our health care system.
  Assuming that you could overcome the enormous hurdle of administering 
voucher subsidies on an individual basis to well over 100 million 
Americans--a task that is completely unnecessary in a single-payer 
system--a subsidy program could work to expand coverage if: the level 
of the subsidy were sufficient to assure that the voucher actually 
could pay for an adequate insurance policy and people knew they could 
count on the vouchers if they needed them.
  None of the proposals for incremental reform designs a voucher system 
that will actually pay for insurance policies or be there when you need 
them. They all tie the funds available for subsidies to deficit 
reduction, resulting in an inadequate and unstable subsidy program.
  The George Washington University Center for Health Policy Research 
determined that under incremental subsidy proposals, a family earning a 
total of $23,780 per year still would need to spend more than 16 
percent of its gross income on health insurance.
  The linkage between financing and subsidies in the incremental 
proposals are particularly destructive. The incremental proposal in the 
House proposal terminates the Medicaid Program removing the guaranteed 
safety net of medical care in this country.
  It is replaced only with a conditional subsidy program that will 
fluctuate from year to year: People may be eligible in 1 year but not 
the next or may have a voucher that will actually purchase an adequate 
policy--or may not. Literally millions of people--mostly mothers and 
children--who have some protection now will be placed at risk.
  Because these proposals are more concerned with reducing the deficit 
than expanding coverage, the subsidies are financed with cuts in the 
Medicare and Medicaid Programs. Contrary to the widespread claims, 
these cuts are not just reductions in payments to doctors and 
hospitals, but include real cuts in services.
  For example, under the financing package which forms the basis for 
the financing discussions by the minority Members in the other body, 
the Early and Periodic Screening, Diagnosis and Treatment Program for 
children--the foundation of child health care in this country for 30 
years--would be terminated while the House proposal ends the early 
childhood immunization program.
  The proposed cuts will affect directly more than 1 million infants, 
toddlers, and school-aged children who suffer from chronic diseases and 
physical and developmental disabilities and require health care 
programs to succeed in school. The cuts in programs serving disabled 
adults will affect hundreds of thousands of adults who rely on health 
care services to remain employed.
  It is important to understand that the cuts affect more than the 
patients these programs are designed to serve. Major health care 
institutions and community-based providers rely on Medicaid and 
Medicare for their survival.
  Children's hospitals rely on Medicaid and Medicare payments for 
between 40 and 70 percent of their revenues. It is doubtful that one 
children's hospital in the country would survive this disruption in its 
financing.
  Rural health clinics and public health agencies offering primary care 
services as well as the Nation's teaching hospitals all depend to a 
great degree on Medicaid and Medicare.
  Yet, under the financing package proposed in the Senate by opponents 
of universal coverage, Medicaid coverage of rural health clinics and 
federally qualified community health centers would be eliminated, 
costing these clinics an enormous proportion of their operating 
revenues.
  The combined effect of these financing provisions cuts into the heart 
and soul of the entire pediatric health care system in this country. 
Even the wealthy will not have access to care if major providers cease 
to exist.
  Public hospitals and many urban hospitals would be devastated by this 
reduction in funding. The only option for those hospitals that have a 
private patient base would be to shift costs onto the privately 
insured, causing health insurance premiums to skyrocket.
  Mr. Speaker, I cannot understand how anyone can defend an approach to 
health care reform that weakens what little security our system 
currently provides. Is this what health care reform was supposed to do?
  Is eliminating children's health care institutions, academic health 
centers, and the major providers of rural health care in this country a 
step forward?
  Of course not. These proposals take us 30 years back. What they fail 
to recognize is that we just cannot turn the clock back 30 years and 
pretend that nothing has happened in the interim.
  We simply cannot contain costs in the public health care system alone 
without creating huge distortions throughout the entire system.
  The effect will be massive disruption in the delivery system as a 
whole, significant increases in private health insurance premiums, 
particularly to small businesses, and dramatic and visible reductions 
in access to care.
  What insurance reform and a subsidy program as directed by the 
minority in the Senate and House offer the American people is subsidy 
programs that are illusory, unstable financing, the elimination of 
existing health coverage, narrow risk pools, and a health care system 
plunging further into chaos--all of which will lead to higher health 
insurance premiums.
  And in all of these proposals there is not one word that will protect 
the American people from the disruption in the patient/doctor 
relationships that people now experience at the hands of their changing 
health plans.
  These incremental proposals simply enable insurance companies to 
complete their takeover of the health care process.
  But more importantly, nominal incremental reform delays us--possibly 
for years--from confronting the real problems while we wait to see the 
clearly predictable consequences of incrementalism unfold.
  The cost of intervening later will be much, much higher and the toll 
taken in human suffering much greater.
  But Mr. Speaker, I want to be absolutely clear about what has 
happened to health care reform in this session of Congress.
  This is not the failure of comprehensive reform. This is the failure 
of incremental reform.
  We were tempted, Mr. Speaker, by the promise that universal coverage 
was not necessary right away, that we could do other things first.
  So we put comprehensive reform and universal coverage to one side 
while we tried these other things. And what happened, Mr. Speaker, is 
that no one could come up with a plan for incremental reform that did 
more good than harm.
  What happened, Mr. Speaker, is that we learned that we must have 
universal coverage before we can do anything else.
  What happened, Mr. Speaker, is that we learned that we took a false 
road in the hope of finding a shortcut and now we have to return to the 
right road.
  There are no shortcuts here. We learned that we have to come back and 
provide universal coverage or nothing else will work.
  Mr. Speaker, as difficult as the past 2 years have been for the 
American people and for the Members of this Congress as we truly 
struggled with this issue, I believe the 2 years were worth learning 
the lesson that halfway measures and shortcuts will not work.
  So when the advocates of incremental reform come back again to 
attempt to obstruct real solutions with promised shortcuts, the 
American people must be prepared to defend universal coverage by asking 
tough questions.
  To the opponents of universal coverage, we must ask:
  If I change jobs, how can I afford to take my health insurance with 
me if my employer does not contribute to the premium? I can pay $6,000 
for a health policy today on my own and get insurance. Isn't 
incremental reform just saying, ``Go buy insurance''? Why is that 
reform?
  Even if I can technically buy insurance with a preexisting condition, 
how will that help me if I can't afford the premium which will be 
$12,000 a year for a family by the year 2000?
  How can I keep my doctor if my employer changes health plans?
  Where will I go for health care if my rural health clinic or the 
children's hospital has closed?
  Where will I get my health care if providers won't accept Medicare 
patients anymore?
  The incremental proposals have no answers to these questions. And the 
reason is that universal coverage lies at the heart of the answers.
  Providing universal coverage in America is not Mount Everest. In 
fact, it is not even a hill. We already have the delivery system. We 
already conduct the research. And we already spend the money. We simply 
are trying to adjust our already oversized health care system to serve 
all of our citizens.
  To say that we are the only Nation in the industrialized world that 
cannot provide affordable universal health coverage is unworthy of the 
American people.
  Winston Churchill observed that ``you can always count on the 
Americans to do the right thing--but only after they have tried 
everything else.''
  When it comes to health care reform, we have tried everything else, 
and it now is time to do the right thing. We can do it, and I intend to 
come back again in the next session of Congress to do just that.

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