[Congressional Record Volume 142, Number 1 (Wednesday, January 3, 1996)]
[Senate]
[Pages S24-S26]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                                MEDICAID

  Mr. DeWINE. Mr. President, we all hope that agreement can be reached 
very shortly on the budget. I would like to take a few minutes of the 
Senate's time this afternoon to talk about one particular part of that 
budget controversy and that is Medicaid. I would like to caution the 
negotiators, caution all of us on both sides of the aisle, that as we 
debate and negotiate on Medicaid, we really need to stay focused on the 
fact that this is not just a question of money. The argument is not 
over just money. It is not just a question of finding a dollar amount 
that we can all agree on, a dollar amount that we can compromise. There 
are also very important policy issues that we simply must deal with. 
The policy issues are, in a very real sense, even more important than 
the dollars that are involved.
  If we merely reduce the Federal contribution to the States to furnish 
Medicaid but at the same time do nothing to structurally fix Medicaid, 
then I believe we will have failed, and that failure will have 
devastating consequences. Instead, I believe we must seize this 
opportunity to fix Medicaid by removing the wasteful, inefficient, and 
administratively burdensome parts of the current program. If we do 
that, then we will improve Medicaid but, more important, we will 
improve poor people's health care.
  So this debate is not just about money. It is not just about 
federalism. It is not just about State sovereignty. It is about the 
poor and how best to serve them, how best to develop constructive and 
viable alternatives that will meet their health care needs. Because the 
reality is, if given the flexibility, if given the freedom, the States 
can devise programs that cost less and at the same time provide better 
health care for the poor.

  I would like this afternoon, therefore, to review for just a few 
moments where we are currently on Medicaid, where our proposal and the 
President's proposal would take us. Today, under the status quo, under 
what has become an open-ended entitlement program, the Federal 
Government can give States an unlimited amount of money to look after 
the health of their poor so long as States do two things. First, States 
have to provide the poor within their boundaries with a Federally-
prescribed set of services. That is, States are told what health care 
to give their poor and how to give it to them, how to deliver the 
services. Second, States have to contribute to the costs of Medicaid 
from their budgets based on a Federal formula.
  The fact that unlimited funds have been made available to this 
program has also meant that there has been no incentive to remove the 
inefficiencies that exist, nor to come up with new or better ways to 
serve the health care needs of the poor. This has resulted, in turn, in 
ever-increasing expenditures on Medicaid by both the Federal Government 
and by the States. Between 1988 and 1994, 6 years, State spending on 
Medicaid has increased by 160 percent. During the same years, Federal 
spending on Medicaid has increased 170 percent. Or, to look at it 
another way, in 1987 States spent on the average 10 percent of their 
own budgets on Medicaid. Last year, they spent almost 20 percent.
  In a conversation I had this morning with my Governor, the Governor 
of the State of Ohio, George Voinovich, he told me that in just a few 
years, unless changes are made, Ohio will be spending 40 percent of its 
total budget for the cost of Medicaid.
  Federal Medicaid spending has grown from 2.7 percent of total Federal 
outlays to 5.6 percent during this same period of time. So, today, we 
have a Medicaid Program that is growing too fast and does not provide 
the best health care for the buck. So we have set out to change this, 
to cut Federal spending growth--not Federal spending, but to cut the 
rate of growth, and to cut it in half; and, at the same time, to 
improve the delivery of health care services to the poor. We proposed a 
reduction in the current Federal contribution to Medicaid. But, under 
our plan, we also gave States more flexibility than ever before in 
determining how health care services should be provided to poor people.
  These two changes, fewer dollars from Washington, slower rate of 
growth, but more flexibility for the States, those two have to go hand-
in-hand. You cannot have one without the other, because States cannot 
deliver health care with fewer dollars if they must do so under the 
current bureaucracy-laden, expensive system. On the other hand, if we 
let States be creative, they can spend less and at the same time 
provide better services.
  Allowing States the flexibility to reform and redefine Medicaid means 
that our proposal is not just a proposal about money. While it is a 
proposal that sometimes tells the States what services to provide, for 
the most part it leaves the States to find innovative ways to provide 
these services. It leaves it up to the States. States are given this 
flexibility because we believe the States can devise better and 

[[Page S25]]
more cost-effective ways in which to deliver health care services. If I 
could, let me give the Members of the Senate an example, an example I 
think is very instructive.
  Let us take a child on Medicaid who has severe asthma, and who is 
hospitalized on an average of every 2 to 3 weeks every summer, usually 
for 3 to 4 days at a time. Medicaid pays for this child to be in the 
hospital at a cost, tremendous cost, per day. But Medicaid does not--
let me repeat--does not allow a State to send a case worker over to 
that child's home and install an air-conditioner in that child's 
bedroom to prevent these recurring asthma attacks. An air-conditioner 
could well save the child from what are very scary breathing problems. 
I will say my wife, Fran, and I have experienced this with our own 
children. There is nothing scarier than to have a child who cannot get 
her breath. A simple thing such as an air-conditioner could save that 
child from that agony and that family from that agony and, at the same 
time, save taxpayers thousands and thousands of dollars. Yet, under the 
current law, this sort of preventive measure is not permitted. This 
sort of preventive measure is not permitted under current Medicaid law.
  Giving the States more flexibility will allow them to be innovative, 
bold, imaginative, and will provide people with real services that 
matter--and that in many cases will be cheaper.
  Let me give another example, Mr. President. Under today's Medicaid 
Program Medicaid beneficiaries who suffer traumatic brain injuries are 
required to be institutionalized in nursing homes, if they want the 
money, and if they want the help. So if an 18-year-old is involved in a 
car accident and is left comatose, he or she may be treated in a 
rehabilitation center until the car insurance is exhausted. But then 
that 18-year-old would be placed under current law in a nursing home. 
Imagine if instead this 18-year-old could be treated at home with 
services specific to his or her needs with community-based services 
aimed specifically at brain injuries. He may well recover, return to 
school, get a job, and live a full life. And, Mr. President, it would 
cost a lot less.
  Mr. President, I ask unanimous consent that my time be extended by 10 
minutes.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. DeWINE. Mr. President, let us consider another example, a 15-
month-old baby girl born with short bowel syndrome. The teenage parents 
can find child care an overwhelming prospect. Under Medicaid today that 
infant would almost inevitably be sent to an institution. What if 
nursing services could instead be provided for that baby at home along 
with training and support for the young parents? That little girl could 
grow up with parents in a more stable home environment, and live the 
sort of life that children are meant to live. And again, Mr. President, 
it would cost less.
  Here is another example. If today an 85-year-old woman has 
osteoperosis, cancer, psoriasis, she would likely end up in a nursing 
home. But what if the States could instead establish full health 
programs that include monthly nursing visits and weekly physical 
therapy? She could be mobile, hopefully keep her condition from 
deteriorating, and stay at home.
  Another example: As we all know, under the current Medicaid system 
many, many poor children get ordinary care in emergency rooms. That is 
where they go for that type of care. But that really is not the place 
for building long-term doctor-patient relationships. Let us give States 
the flexibility, and they will develop their own managed care plans for 
the poor. So these children could go to their own primary care 
physicians where the doctors will know them, their names, and their 
medical history. That will certainly ensure better health care. But 
some may say, but cannot States really do all of these things now? 
Well, in any one of these scenarios a State could go hat in hand to 
Washington and maybe, just maybe, get permission, get a waiver, to help 
their citizens in these alternative innovative, and, yes, responsive 
ways. But States do not have the ability to address these local 
situations in their own communities without permission from Washington. 
That is the law today. They have to go to Washington hat in hand. They 
have to beg for permission to do it. Why should we have a system in 
which we must waive the rules in order to simply do what is right?

  We instead free States so that they could respond compassionately to 
their poor, and in the long run provide them with better care while 
cutting the inefficient and duplicative cost of Medicaid.
  So, Mr. President, I believe it is a mistake to look only at the 
money side of the Medicaid question. The President proposes to cut the 
rate of growth of Federal contributions but make no structural 
changes--let me repeat, make no structural changes--and require States 
to make up the monetary difference. It does not increase State 
flexibility, and it ties the hands of Governors and State legislators 
so that States are left paying more toward Medicaid but given an 
insufficient voice in determining how those funds are spent.
  Mr. President, it will take more than this to achieve what I am sure 
both President Clinton and I ultimately want, and what we all want for 
the poor of this Nation: Better affordable health care for the poor. 
Unfortunately, the President's proposal has shifted the debate away 
from substantive Medicaid reforms to simply a numbers debate.
  It must be reiterated again and again that we are not just debating 
how large or small the Federal contribution to Medicaid should be. To 
characterize the debate in this way emphasizes a fundamental 
misunderstanding of Medicaid, and a fundamental misunderstanding of 
what this debate is all about. We cannot sit down to the negotiating 
table to simply split the differences on the Federal contribution level 
and call it a day. We cannot just sit down and say Republicans are at 
this figure, Democrats are at this figure, let us split the difference 
and all go away happily. That is not going to solve the problem. And in 
fact, Mr. President, as I think I have outlined to demonstrate this 
afternoon, that may be the worst of all possible worlds. If we end up 
splitting the difference between the two sides but yet make no change 
in policy and keep the policy the way it is today, it simply will not 
work. The States cannot make it work. We will be dealing the States a 
hand that they simply cannot play. And the people who are going to 
suffer are not just going to be the Governors, the State legislatures, 
and the taxpayers of each State. The people who are going to suffer are 
the poor who depend on Medicaid for their health care. That is who is 
going to suffer.

  Mr. President, to approach it in this simplistic way, to make this 
just a numbers debate, would be, I believe, to take the easy way out 
and leave unaddressed the problems currently facing Medicaid today--the 
inefficiencies, the exorbitant costs. Given the flexibility, States 
could begin to address. In fact, to split the difference and call it a 
day would leave the States with a devastating bill to meet these legal 
obligations. As I stated earlier, my State of Ohio would have to spend 
40 percent of its total budget on Medicaid--40 percent. Ohio already 
devotes 30 percent of its budget to Medicaid today, and this increase 
would come in just the first 10 years. That is huge, and this 
percentage will continue to grow.
  Mr. President, in conclusion, let me say that States will be forced 
to pull money away from other programs if this path is followed. Which 
State programs would we have our Governors cut? Education? Public 
health and safety? I think not. This runaway proposal would squeeze out 
all else, and it simply cannot be tolerated.
  Mr. President, the only solution would be bankruptcy for the States 
or increase State taxes to raise money to pay for the ever-increasing 
legal obligations of the States under Medicaid. This would certainly be 
one back-door way of increasing taxes that I do not think anyone in 
this Chamber would approve of. We cannot reduce the Federal 
contribution to Medicaid while at the same time keep the costly, 
inefficient, and counterproductive requirements of Medicaid and then 
simply walk away.
  We cannot walk away from the 18-year-old accident victim, nor walk 
away from the 15-month-old infant of the overwhelmed teenage parents. 
We 

[[Page S26]]
cannot walk away from an 85-year-old woman with osteoporosis and 
cancer. Mr. President, we do not believe in simply abandoning people. 
Any Medicaid Program that comes out of these negotiations that we 
negotiate or vote for should not do that either.
  I thank the Chair. I yield the floor, and I suggest the absence of a 
quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The bill clerk proceeded to call the roll.
  Mr. BOND. Mr. President, I ask unanimous consent that the order for 
the quorum call be rescinded.
  The PRESIDING OFFICER (Mr. DeWine). Without objection, it is so 
ordered.
  (Mr. STEVENS assumed the Chair.)

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