[Congressional Record Volume 145, Number 8 (Tuesday, January 19, 1999)]
[Senate]
[Pages S406-S413]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. SPECTER:
  S. 24. A bill to provide improved access to health care, enhance 
informed individual choice regarding health care services, lower health 
care costs through the use of appropriate providers, improve the 
quality of health care, improve access to long term care, and for other 
purposes; to the Committee on Finance.


                 THE HEALTH CARE ASSURANCE ACT OF 1999

  Mr. SPECTER. Mr. President, as the 106th Congress commences, those of 
us in the Senate and the House have a new opportunity to make a real 
difference in the lives of the American people. It is a chance for us 
to learn from the past, determine how best to respond to the challenges 
that are before us, and forge important alliances which will enable us 
to pass legislation that is important to this nation. I believe it is 
clear that one of our first priorities must be additional incremental 
reforms of our health care system.
  Mr. President, there is no time to waste. Many of our nation's health 
care problems are getting worse, not better. In its December 1998 
report, the Employee Benefit Research Institute (EBRI) analyzed the 
March 1998 Current Population Survey, a document generated yearly by 
the U.S. Census Bureau. EBRI's analysis tells us that in 1997, about 
193 million working-age Americans derived their health insurance 
coverage as follows: approximately 64.2 percent from employer plans; 
13.0 percent from Medicare and Medicaid within a total of 14.8 percent 
from public sources of coverage; and 6.7 percent from other private 
insurance. This survey also details another troubling statistic: 43.1 
million Americans, or 18.3 percent of Americans aged 18-64, were 
uninsured. This reflects an increase of 7 percent, or 2.8 million 
uninsured working-age people, since 1995. Among the elderly, the 
outlook is a bit brighter, with only 1 percent uninsured, and 96.4 
percent deriving coverage from public sources.
  As I have said many times, we can fix the problems felt by this 
growing number of uninsured Americans without resorting to big 
government and without completely overhauling our current system, one 
that works well for most Americans--serving 81.7 percent of our non-
elderly citizens. We must enact reforms that improve upon our current 
market-based health care system, as it is clearly the best health care 
system in the world.
  Accordingly, today I am introducing the Health Care Assurance Act of 
1999, which, if enacted, will take us further down the path of the 
incremental reforms started by the Health Insurance Portability and 
Accountability Act of 1996 (Kassebaum-Kennedy) and various health care 
provisions enacted during the 105th Congress. I would note that the 
final version of Kassebaum-Kennedy contained many elements which were 
in S. 18, the incremental health care reform bill I introduced when the 
104th Congress began on January 4, 1995.
  I would note that the bill I am introducing today is distinct from my 
recent efforts regarding managed care reform. During the 105th 
Congress, I joined a bipartisan group of Senators to introduce the 
Promoting Responsible Managed Care Act of 1998, a balanced proposal 
which would ensure that patients receive the benefits and services to 
which they are entitled, without compromising the savings and 
coordination of care that can be achieved through managed care. I look 
forward to working again with my colleagues to enact responsible 
managed care legislation.
  The Health Care Assurance Act of 1999 is intended to initiate and 
stimulate new discussion, so we may move the health care reform debate 
forward. I welcome any suggestions my colleagues may have concerning 
how this bill can be improved, as long as such suggestions are 
consistent with the incremental approach to reform that has proven to 
be the only way to achieve successful health care reform.
  Given the importance of enacting this type of legislation, it is 
worth reviewing recent history which has taught us that bipartisanship 
is crucial in accomplishing these goals for the American people. In 
particular, the debate over President Clinton's Health Security Act 
during the 103rd Congress

[[Page S407]]

is replete with lessons concerning the pitfalls and obstacles that 
inevitably lead to legislative failure. Several times during the 103rd 
Congress, I spoke on the Senate floor to address what seemed to be the 
wisest course--to pass incremental health care reforms with which we 
could all agree. Unfortunately, what seemed obvious to me, based on 
comments and suggestions by a majority of Senators who favored a 
moderate approach, was not obvious at the time to the Senate's 
Democratic leadership.
  This failure to understand the merits of an incremental approach was 
demonstrated during April 1993 during my attempts to offer a health 
care reform amendment based on the text of S. 631, an incremental 
reform bill I had introduced earlier in the session. This bill 
incorporated moderate, consensus principles in a reasonable reform 
package. First, I attempted to offer the bill as an amendment to 
legislation dealing with debt ceilings. Subsequently, I was informed 
that the consideration of this bill would be structured in a way that 
precluded my offering an amendment. Therefore, I prepared to offer my 
health care bill as an amendment to the fiscal year 1993 Emergency 
Supplemental Appropriations bill. To my dismay, Senator Mitchell, then 
Majority Leader, and Senator Byrd, then Chairman of the Appropriations 
Committee, worked together to ensure that I could not offer my 
amendment by keeping the Senate in a quorum call, a parliamentary 
tactic used to delay and obstruct. I was unable to obtain unanimous 
consent to end the quorum call, and thus could not proceed with my 
amendment.
  Three years later, well after the behemoth Clinton health care reform 
bill was derailed, the Senate once again endured a lengthy political 
battle concerning the Kassebaum-Kennedy bill, which I was pleased to 
cosponsor. We achieved a breakthrough in August 1996, when enough 
Senators sensed the growing frustration of the American people to 
finally pass Kassebaum-Kennedy and its vital health insurance market 
reforms, such as increased portability of health insurance coverage. 
There is no question that Kassebaum-Kennedy made significant steps 
forward in addressing troubling issues in health care, although I 
recognize that there is much more to be done. The bill's incremental 
approach to health care reform is what allowed it to generate 
bipartisan, consensus support in the Senate. We knew that it did not 
address every single problem in the health care delivery system, but it 
would make life better for millions of American men, women, and 
children.
  In retrospect, I urge my colleagues to note a most important fact--
the Kassebaum-Kennedy bill was enacted only after Democrats abandoned 
their hopes for passing a nationalized, big government health care 
scheme, and Republicans abandoned their position that access to health 
care is not really a major problem in the United States which demands 
Federal action.
  Perhaps the greatest recent example of the power of bipartisanship 
took place during the 105th Congress, with the passage of the Balanced 
Budget Act of 1997. This historic bipartisan agreement between Congress 
and the White House to balance the budget by 2002 extended the life of 
the vital Medicare hospital trust fund by ten years, while expanding 
needed benefits for seniors. The new law created a National Bipartisan 
Commission on the Future of Medicare to address the implications of the 
retirement of the Baby Boom generation, and marked the first balanced 
Federal budget in thirty years. This landmark accomplishment clearly 
would not have occurred without all members of Congress and the 
Administration crossing party lines, compromising, and doing what was 
right for the American people regardless of political affiliations.
  We must realize that if we are to continue to be successful in 
meeting the nation's health care needs, the solutions to the system's 
problems must come from the political center, not from the extremes.
  I have advocated health care reform in one form or another throughout 
my 18 years in the Senate. My strong interest in health care dates back 
to my first term, when I sponsored S. 811, the Health Care for 
Displaced Workers Act of 1983, and S. 2051, the Health Care Cost 
Containment Act of 1983, which would have granted a limited antitrust 
exemption to health insurers, permitting them to engage in certain 
joint activities such as acquiring or processing information, and 
collecting and distributing insurance claims for health care services 
aimed at curtailing then escalating health care costs. In 1985, I 
introduced the Community Based Disease Prevention and Health Promotion 
Projects Act of 1985, S. 1873, directed at reducing the human tragedy 
of low birth weight babies and infant mortality. Since 1983, I have 
introduced and cosponsored numerous other bills concerning health care 
in our country. A complete list of the 26 health care bills that I have 
sponsored since 1983 is included for the Record.

  During the 102nd Congress, I pressed the Senate to take action on 
this issue. On July 29, 1992, I offered a health care amendment to 
legislation then pending on the Senate floor. This amendment included 
provisions from legislation introduced by Senator Chafee, which I 
cosponsored and which was previously proposed by Senators Bentsen and 
Durenberger. The amendment included a change from 25 percent to 100 
percent deductibility for health insurance purchased by self-employed 
persons, and small business insurance market reforms to make health 
coverage more affordable for small businesses. When then-Majority 
Leader George Mitchell argued that the health care amendment I was 
proposing did not belong on that bill, I offered to withdraw the 
amendment if he would set a date certain to take up health care, just 
as product liability legislation had been placed on the calendar for 
September 8, 1992. The Majority Leader rejected that suggestion and the 
Senate did not consider comprehensive health care legislation during 
the balance of the 102nd Congress. My July 29, 1992 amendment was 
defeated on a procedural motion by a vote of 35 to 60, along party 
lines.
  The substance of that amendment, however, was adopted later by the 
Senate on September 23, 1992 when it was included in an amendment to 
broader tax legislation (H.R. 11), offered by Senators Bentsen and 
Durenberger and which I cosponsored. This amendment, which included 
essentially the same self-employed tax deductibility and small group 
reforms that I had proposed on July 29th of that year, passed the 
Senate by voice vote. Unfortunately, these provisions were later 
dropped from H.R. 11 in the House-Senate conference.
  On August 12, 1992, I introduced legislation entitled the Health Care 
Affordability and Quality Improvement Act of 1992, S. 3176, that would 
have enhanced informed individual choice regarding health care services 
by providing certain information to health care recipients, would have 
lowered the cost of health care through use of the most appropriate 
provider, and would have improved the quality of health care.
  On January 21, 1993, the first day of the 103rd Congress, I 
introduced the Comprehensive Health Care Act of 1993, S. 18. This 
legislation was comprised of reforms that our health care system could 
have adopted immediately. These initiatives would have both improved 
access and affordability of insurance coverage and would have 
implemented systemic changes to lower the escalating cost of care in 
this country. S. 18 is the principal basis of the legislation I 
introduced in the 104th (S. 18) and 105th Congresses (S. 24), and the 
Health Care Assurance Act of 1999, which I am introducing today.
  On March 23, 1993, I introduced the Comprehensive Access and 
Affordability Health Care Act of 1993, S. 631, which was a composite of 
health care legislation introduced by Senators Cohen, Kassebaum, Bond, 
and McCain, and included pieces of my bill, S. 18. I introduced this 
legislation in an attempt to move ahead on the consideration of health 
care legislation and provide a starting point for debate. As I noted 
earlier, I was precluded by Majority Leader Mitchell from obtaining 
Senate consideration of my legislation as a floor amendment on several 
occasions. Finally, on April 28, 1993, I offered the text of S. 631 as 
an amendment to the pending Department of Environment Act (S. 171) in 
an attempt to urge the Senate to act on health care reform. My 
amendment was defeated 65 to 33 on a procedural motion, but the Senate 
had finally been forced to contemplate action on health care reform.
  On the first day of the 104th Congress, January 4, 1995, I introduced 
a

[[Page S408]]

slightly modified version of S. 18, the Health Care Assurance Act of 
1995 (also S. 18), which contained provisions similar to those 
ultimately enacted in the Kassebaum-Kennedy legislation, including 
insurance market reforms, an extension of the tax deductibility of 
health insurance for the self employed, and deductibility of long term 
care insurance for employers.
  I continued these efforts in the 105th Congress, with the 
introduction of Health Care Assurance Act of 1997 (S. 24), which 
included market reforms similar to my previous proposals with the 
addition of a new Title I, an innovative program to provide vouchers to 
States to cover children who lack health insurance coverage. I also 
introduced Title I of this legislation as a stand-alone bill, the 
Healthy Children's Pilot Program of 1997 (S. 435) on March 13, 1997. 
This proposal targeted the approximately 4.2 million children of the 
working poor who lacked health insurance. These are children whose 
parents earn too much to be eligible for Medicaid, but do not earn 
enough to afford private health care coverage for their families. This 
legislation would have established a $10 billion/5 year discretionary 
pilot program to cover these uninsured children by providing grants to 
States. Modeled after Pennsylvania's extraordinarily successful Caring 
and BlueCHIP programs, this legislation was the first Republican-
sponsored child health insurance bill during the 105th Congress.
  I was encouraged that the Balanced Budget Act of 1997, signed into 
law on August 5, 1997, included a combination of the best provisions 
from many of child health insurance proposals throughout this Congress. 
The new legislation allocated $24 billion for the next five years to 
establish State Child Health Insurance Programs, funded in part by a 
slight increase in the cigarette tax. The bill I am introducing today, 
the Health Care Assurance Act of 1999, would further augment this new 
State Child Health Insurance Program and would enable States to cover 
even more children, and includes new provisions to assist individuals 
with disabilities to maintain quality health care coverage.
  My commitment to the issue of health care reform across all 
populations has been consistently evident during my tenure in the 
Senate, as I have taken to this floor and offered health care reform 
bills and amendments on countless occasions. I will continue to urge 
the Senate to address this vital issue and to stress the importance of 
the Federal government's investment in and attention to the system's 
future.
  As my colleagues are aware, I can personally report on the miracles 
of modern medicine. Five years ago, an MRI detected a benign tumor 
(meningioma) at the outer edge of my brain. It was removed by 
conventional surgery, with five days of hospitalization and five more 
weeks of recuperation.
  When a small regrowth was detected by a follow-up MRI in June 1996, 
it was treated with high powered radiation from the ``Gamma Knife.'' I 
entered the hospital in the morning of October 11, 1996, and left the 
same afternoon, ready to resume my regular schedule. Like the MRI, the 
Gamma Knife is a recent invention, coming into widespread use in the 
past decade.
  In July 1998, I was pleased to return to the Senate after a 
relatively brief period of convalescence following heart bypass 
surgery. This experience again led me to marvel at our health care 
system and made me more determined than ever to support Federal funding 
for biomedical research and to support legislation which will 
incrementally make health care available to all Americans.
  My concern about health care has long pre-dated my own personal 
benefits from the MRI and other diagnostic and curative procedures. As 
I have previously discussed, my concern about health care began many 
years ago and been intensified by my service on the Appropriations 
Subcommittee on Labor, Health and Human Services, and Education, which 
I now have the honor to chair.

  My own experience as a patient has given me deeper insights into the 
American health care system beyond my perspective from the U.S. Senate. 
I have learned: (1) our health care system, the best in the world, is 
worth every cent we pay for it; (2) patients sometimes have to press 
their own cases beyond the doctors' standard advice; (3) greater 
flexibility must be provided on testing and treatment; (4) our system 
has the resources to treat the 43.1 million Americans currently 
uninsured, but we must find the way to pay for it; and (5) all 
Americans deserve the access to health care from which I and others 
with coverage have benefitted.
  I have long been convinced that our Federal budget of 
$1,700,000,000,000, could provide sufficient funding for America's 
needs if we establish our real priorities. The real question has been 
whether we have enough doctors, hospitals, medical personnel, etc. to 
take care of Americans in need of medical attention. I am convinced 
that we do. The part which has yet to be accomplished is to work out 
the financing for the delivery of such health care. As specified in the 
legislation which I have introduced, I am convinced that sufficient 
savings are possible within the current system to provide health care 
for all Americans within the current expenditures.
  I share the American people's frustration with government and their 
desire to have their problems addressed. Over the past six years, I 
believe we have learned a great deal about our health care system and 
what the American people are willing to accept from the Federal 
government. The message we heard loudest was that Americans did not 
want a massive overhaul of the health care system. Instead, our 
constituents want Congress to proceed more slowly and to target what 
isn't working in the health care system while leaving in place what is 
working.
  As I have said both publicly and privately, I am willing to cooperate 
with the Administration in solving the health care problems facing our 
country. However, in the past I have found many important areas where I 
differed with President Clinton's approach to solutions and I did so 
because I believed that the proposals would have been deleterious to my 
fellow Pennsylvanians, to the American people, and to our health care 
system. Most important, I did not support creating a large new 
government bureaucracy because I believe that savings should go to 
health care services and not bureaucracies.
  On this latter issue, I first became concerned about the potential 
growth in bureaucracy in September 1993 after reading the President's 
239-page preliminary health care reform proposal. I was surprised by 
the number of new boards, agencies, and commissions, so I asked my 
legislative assistant, Sharon Helfant, to make me a list of all of 
them. Instead, she decided to make a chart. The initial chart depicted 
77 new entities and 54 existing entities with new or additional 
responsibilities.
  When the President's 1,342-page Health Security Act was transmitted 
to Congress on October 27, 1993, my staff reviewed it and found an 
increase to 105 new agencies, boards, and commissions and 47 existing 
departments, programs and agencies with new or expanded jobs. This 
chart received national attention after being used by Senator Bob Dole 
in his response to the President's State of the Union address on 
January 24, 1994.
  The response to the chart was tremendous, with more than 12,000 
people from across the country contacting my office for a copy; I still 
receive requests for the chart. Groups and associations, such as United 
We Stand America, the American Small Business Association, the National 
Federation of Republican Women, and the Christian Coalition, reprinted 
the chart in their publications--amounting to hundreds of thousands 
more in distribution. Bob Woodward of the Washington Post later stated 
that he thought the chart was the single biggest factor contributing to 
the demise of the Clinton health care plan. And, as recently as the 
November 1996 election, my chart was used by Senator Dole in his 
presidential campaign to illustrate the need for incremental health 
care reform as opposed to a big government solution.
  With the history of the health care reform debate in mind, I have 
drafted an incremental bill which would provide quality health care 
without adversely affecting the many positive aspects of our health 
care system, which works for 81.7 percent of working-age Americans. It 
is more prudent to implement targeted reforms and then act later to 
improve upon what we have

[[Page S409]]

done. I call this trial and modification. We must be careful not to 
damage the positive aspects of our health care system upon which more 
than 193 million Americans justifiably rely.
  The legislation I am introducing today has three objectives: (1) to 
provide affordable health insurance for the 43.1 million working-age 
Americans now not covered; (2) to reduce health care costs for all 
Americans; and (3) to improve coverage for underinsured individuals, 
families, and children. This legislation is comprised of initiatives 
that our health care system can readily adopt in order to meet these 
objectives, and it does not create an enormous new bureaucracy to meet 
them.
  This bill includes provisions to encourage the formation of small 
group purchasing arrangements, to expand access to health insurance for 
children, to improve health coverage for individuals with disabilities, 
to strengthen preventive health benefits under the Medicare program, to 
increase access to prenatal care and outreach for the prevention of low 
birth weight babies, to facilitate the implementation of patients' 
rights regarding medical care at the end of life, to improve health 
education, to place greater emphasis on and to expand access to primary 
and preventive health services, to utilize non-physician providers, to 
reform the COBRA law to extend the time period for employees who leave 
their jobs to maintain their health benefits until alternative coverage 
becomes available, to increase the availability and use of consumer 
information and outcomes research, and to establish a national fund for 
health research within the Department of Treasury.
  Taken together, I believe the reforms proposed in the Health Care 
Assurance Act of 1999 will both improve the quality of health care 
delivery and will bring down the escalating costs of health care in 
this country. These initiatives represent a blueprint which can be 
modified, improved and expanded. In total, I believe this bill can 
significantly reduce the number of uninsured Americans, improve the 
affordability of care, ensure the portability and security of coverage 
between jobs, and yield cost savings of billions of dollars to the 
Federal Government, which can be used to cover the remaining uninsured 
and underinsured Americans.


                                TITLE I

  As I mentioned previously, Title I of the bill builds on the State 
Child Health Insurance Program (S-CHIP), the new program established in 
the Balanced Budget Act of 1997, which allocated $24 billion/five years 
to increase health insurance coverage for children. The S-CHIP program 
gives States the option to use federally funded grants to provide 
vouchers to eligible families to purchase health insurance for their 
children, or to expand Medicaid coverage for those uninsured children, 
or a combination of both. This title would increase the income 
eligibility to families with incomes at or below 235 percent of the 
Federal poverty level ($38,658 annually for a family of four), and 
would strengthen the States' ability to conduct Medicaid outreach to 
eligible children. The S-CHIP program anticipates enrolling 2.3 million 
uninsured children by the end of 2000. This provision would allow 
eligibility for approximately another 876,000 uninsured children, 
representing a 38 percent increase over current law.


                                TITLE II

  Title II assists another of our Nation's most vulnerable populations, 
persons with disabilities. This title would expand health services for 
disabled individuals in two ways. Currently, disabled individuals, or 
recipients of Social Security Disability Income (SSDI), may receive 
health insurance coverage under the Medicare program for a short time 
after returning to work. One provision of my bill would extend to 24 
months the period during which the individual may continue to receive 
Medicare benefits after returning to work, and allow the individual to 
purchase Medicare coverage at a reduced rate, subject to yearly review.

  In an effort to improve the delivery of care and the comfort of those 
with long-term disabilities, the second provision would allow for 
reimbursement for community-based attendant care services, instead of 
institutionalization, for eligible individuals who require such 
services based on functional need, without regard to the individual's 
age or the nature of the disability. The most recent data available 
tell us that 5.9 million individuals receive care for disabilities 
under the Medicaid program. The number of disabled who are not 
currently enrolled in the program who would apply for this improved 
benefit is not easily counted, but would likely be substantial given 
the preference of home and community-based care over institutional 
care.


                               TITLE III

  The next title contains provisions to make it easier for small 
businesses to buy health insurance for their workers by establishing 
voluntary purchasing groups. It also obligates employers to offer, but 
not pay for, at least two health insurance plans that protect 
individual freedom of choice and that meet a standard minimum benefits 
package. It extends COBRA benefits and coverage options to provide 
portability and security of affordable coverage between jobs.
  Specifically, Title III extends the COBRA benefit option from 18 
months to 24 months. COBRA refers to a measure which was enacted in 
1985 as part of the Consolidated Omnibus Budget Reconciliation Act 
(COBRA '85) to allow employees who leave their job, either through a 
lay-off or by choice, to continue receiving their health care benefits 
by paying the full cost of such coverage. By extending this option, 
such unemployed persons will have enhanced coverage options.
  In addition, options under COBRA are expanded to include plans with 
lower premiums and higher deductibles of either $1,000 or $3,000. This 
provision is incorporated from legislation introduced in the 103rd 
Congress by Senator Phil Gramm and will provide an extra cushion of 
coverage options for people in transition. According to Senator Gramm, 
with these options, the typical monthly premium paid for a family of 
four would drop by as much as 20 percent when switching to a $1,000 
deductible and as much as 52 percent when switching to a $3,000 
deductible.
  This year I have also included a provision which would extend to 36 
months the time period for COBRA coverage for a child who is no longer 
a dependent under a parent's health insurance policy. Again, EBRI 
statistics indicate that young adults between the ages of 18 and 24 are 
more likely than any other age to be uninsured; 30.1% were without 
coverage in 1997. This provision would allow those who are no longer 
dependents on their parents' plan to have a more secure safety net.
  With respect to the uninsured and underinsured, my bill would permit 
individuals and families to purchase guaranteed, comprehensive health 
coverage through purchasing groups. Health insurance plans offered 
through the purchasing groups would be required to meet basic, 
comprehensive standards with respect to benefits. Such benefits must 
include a variation of benefits permitted among actuarially equivalent 
plans to be developed by the National Association of Insurance 
Commissioners. The standard plan would consist of the following 
services when medically necessary or appropriate: (1) medical and 
surgical devices; (2) medical equipment; (3) preventive services; and 
(4) emergency transportation in frontier areas.
  My bill would also create individual health insurance purchasing 
groups for individuals wishing to purchase health insurance on their 
own. In today's market, such individuals often face a market where 
coverage options are not affordable. Purchasing groups will allow small 
businesses and individuals to buy coverage by pooling together within 
purchasing groups, and choose from among insurance plans that provide 
comprehensive benefits, with guaranteed enrollment and renewability, 
and equal pricing through community rating adjusted by age and family 
size. Community rating will assure that no one small business or 
individual will be singularly priced out of being able to buy 
comprehensive health coverage because of health status. With community 
rating, a small group of individuals and businesses can join together, 
spread the risk, and have the same purchasing power that larger 
companies have today.
  For example, Pennsylvania has the ninth lowest rate of uninsured in 
the nation, with 90 percent of all Pennsylvanians enrolled in some form 
of health coverage. Lewin and Associates found that one of the factors 
enabling Pennsylvania to achieve this low rate

[[Page S410]]

of uninsured persons is that Pennsylvania's Blue Cross/Blue Shield 
plans provide guaranteed enrollment and renewability, an open 
enrollment period, community rating, and coverage for persons with pre-
existing conditions. My legislation seeks to enact reforms to provide 
for more of these types of practices. The purchasing groups, as 
developed and administered on a local level, will provide small 
businesses and all individuals with affordable health coverage options.
  Title III of my bill also includes an important provision to give the 
self employed 100 percent deductibility of their health insurance 
premiums. The Kassebaum-Kennedy bill extended the deductibility of 
health insurance for the self employed to 80 percent by 2006. The 
Balanced Budget Act of 1997 and the Omnibus Appropriations Act for 
Fiscal Year 1999 both contained new phase-in scales for health 
insurance deductibility for the self-employed. Currently, self-employed 
persons may deduct 60 percent of their health insurance costs through 
2002, to be fully deductible in 2003. My bill would speed up the phase-
in to allow self-employed individuals and their families to deduct 100 
percent of their health insurance costs beginning in 2001, thereby 
giving the currently 2.9 million self-employed Americans who are 
uninsured a better incentive to purchase coverage.
  The provisions contained in this portion of my bill are vital, as 
EBRI statistics tell us that 48 percent of all uninsured workers in 
1997 were either self-employed or were working in private-sector firms 
with fewer than 25 employees. The disparity is further demonstrated by 
this telling statistic: 35 percent of workers in private-sector firms 
with fewer than 10 employees were uninsured, compared with only 12.3 
percent of workers in private-sector firms with 1000 or more employees.
  It is anticipated that the increased costs to employers electing to 
cover their employees as provided under Title III in my bill would be 
offset by the administrative savings generated by development of the 
small employer purchasing groups. Such savings have been estimated at 
levels as high as $9 billion annually. In addition, by addressing some 
of the areas within the health care system that have exacerbated costs, 
significant savings can be achieved and then redirected toward direct 
health care services.


                                TITLE IV

   Although our existing health care system suffers from very serious 
structural problems, common sense steps can be taken to head off the 
remaining problems before they reach crisis proportions. Title IV of my 
bill includes initiatives which will enhance primary and preventive 
care services aimed at preventing disease and ill-health.
  Each year about 7 percent of babies born in the United States are 
born with a low birth weight, multiplying their risk of death and 
disability. Most of the deaths which do occur are preventable. Although 
the infant mortality rate in the United States fell to an all-time low 
in 1989, an increasing percentage of babies continue to be born of low 
birth weight. The Executive Director of the National Commission To 
Prevent Infant Mortality put it this way: ``More babies are being born 
at risk and all we are doing is saving them with expensive 
technology.''
  It is a human tragedy for a child to be born weighing 16 ounces with 
attendant problems which last a lifetime. I first saw one pound babies 
in 1984 when I was astounded to learn that Pittsburgh, PA had the 
highest infant mortality rate of African-American babies of any city in 
the United States. I wondered how that could be true of Pittsburgh, 
which has such enormous medical resources. It was an amazing thing for 
me to see a one pound baby, about as big as my hand. However, I am 
pleased to report that as a result of successful prevention 
initiatives, Pittsburgh's infant mortality has decreased 20% (currently 
14.9 deaths per 1000 births, according to the 1997 statistics).
  My legislation also focuses attention on women at-risk for delivering 
low birth weight babies. The Department of Health and Human Services 
has estimated that between $1.1 billion and $2.5 billion per year could 
be saved if the number of low birth weight children were reduced by 
82,000 births. We know that in most instances, prenatal care is 
effective in preventing low birth weight babies. Numerous studies have 
demonstrated that low birth weight that does not have a genetic link is 
most often associated with inadequate prenatal care or the lack of 
prenatal care. The short and long-term costs of saving and caring for 
infants of low birth weight is staggering. In the most recent available 
study on the costs of low birth weight babies, the Office of Technology 
Assessment in 1988 concluded that $8 billion was expended in 1987 for 
the care of 262,000 low birth weight infants in excess of that which 
would have been spent on an equivalent number of babies born of normal 
birth weight, averted by earlier or more frequent prenatal care. If 
adequate prenatal care had been provided, especially to women at-risk 
for delivering low birth weight babies, the U.S. health care system 
could have saved between $14,000 and $30,000 per child in the first 
year in addition to the projected savings over the lifetime of each 
child.
  To improve pregnancy outcomes for women at risk of delivering babies 
of low birth weight, my legislation would strengthen the Healthy Start 
program to reduce infant mortality and the incidence of low birth 
weight births, as well as to improve the health and well-being of 
mothers and their families, pregnant women and infants. Funds are 
awarded under this program with the goal of developing and coordinating 
effective health care and social support services for women and their 
babies.
  I initiated action that led to the creation of the Healthy Start 
program in 1991, working with the Bush Administration and Senator 
Harkin. As Chairman of the Appropriations Subcommittee with 
jurisdiction over the Department of Health and Human Services, I have 
worked with my colleagues to ensure the continued growth of this 
important program. In 1991, we allocated $25 million for the 
development of 15 demonstration projects. This number grew to 22 in 
1994, to 75 projects in 1998, and the Health Resources and Services 
Administration expects this number to continue to increase. For fiscal 
year 1999, we secured $105 million for this vital program.
  Title IV also provides increased support to local educational 
agencies to develop and strengthen comprehensive health education 
programs, and to Head Start resource centers to support health 
education training programs for teachers and other day care workers. 
Many studies indicate that poor health and social habits are carried 
into adulthood and often passed on to the next generation. To interrupt 
this tragic cycle, our nation must invest in proven preventive health 
education programs.
  Title IV further expands the authorization of a variety of public 
health programs, such as breast and cervical cancer prevention, 
childhood immunizations, family planning, and community health centers. 
These existing programs are designed to improve the public health and 
prevent disease through primary and secondary prevention initiatives. 
It is essential that we invest more resources in these programs now if 
we are to make any substantial progress in reducing the costs of acute 
care in this country.
  As Chairman of the Appropriations Subcommittee with jurisdiction over 
the Department of Health and Human Services, I have greatly encouraged 
the development of prevention programs which are essential to keeping 
people healthy and lowering the cost of health care in this country. In 
my view, no aspect of health care policy is more important. 
Accordingly, my prevention efforts have been widespread. Specifically, 
I joined my colleagues in efforts to ensure that funding for the 
Centers for Disease Control and Prevention (CDC) increased $1.6 billion 
or 160 percent since 1989; fiscal year 1999 funding for the CDC totals 
$2.6 billion. We have also worked to elevate funding for CDC's breast 
and cervical cancer early detection program to $159 million in fiscal 
year 1999, a 123 percent increase since 1993. In addition, I have 
supported providing funding to CDC to improve the detection and 
treatment of re-emerging infectious diseases.
  I have also supported programs at CDC which help children. CDC's 
childhood immunization program seeks to eliminate preventable diseases 
through immunization and to ensure that at least 90 percent of 2 year 
olds are vaccinated. The CDC also continues to educate parents and 
caregivers on the importance of immunization for children under two 
years. Along with my

[[Page S411]]

colleagues on the Appropriations Committee, I have helped to ensure 
that funding for this important program totaled $421.5 million for 
fiscal year 1999. The CDC's lead poisoning prevention program annually 
identifies about 50,000 children with elevated blood levels and places 
those children under medical management. The program prevents the 
amount of lead in children's blood from reaching dangerous levels and 
is currently funded at about $38 million.
  In recent years, we have also strengthened funding for Community 
Health Centers, which provide immunizations, health advice, and health 
professions training. These Centers, administered by the Health 
Resources and Services Administration, provide a critical primary care 
safety net to rural and medically underserved communities, as well as 
uninsured individuals, migrant workers, the homeless, residents of 
public housing, and Medicaid recipients. In 1996, 940 Health Centers 
provided comprehensive health care to 10 million children and adults 
across the United States. For fiscal year 1999, these Centers received 
$925 million, a $100 million increase over fiscal year 1998.
  As Chairman of the Select Committee on Intelligence and Chairman of 
the Appropriations Subcommittee with jurisdiction over the Department 
of Health and Human Services, I have worked to transfer CIA imaging 
technology to the fight against breast cancer. Through the Office of 
Women's Health within the Department of Health and Human Services, I 
secured a $2 million contract in fiscal year 1996 for the University of 
Pennsylvania and a consortium to perform the first clinical trials 
testing the use of intelligence community technology for breast cancer 
detection. My Appropriations Subcommittee has continued to provide 
funds to continue the clinical trials.
  I have also been a strong supporter of funding for AIDS research, 
education, and prevention programs. Funding for Ryan White AIDS 
programs has increased from $757.4 million in 1996 to $1.41 billion for 
fiscal year 1999. Within the fiscal year 1999 funding, $46 million was 
included for pediatric AIDS programs and $461 million for the AIDS Drug 
Assistance Program (ADAP). AIDS research at the NIH totaled $742.4 
million in 1989, and has increased to $1.85 billion in fiscal year 
1999. AIDS funding across the Department of Health and Human Services 
has steadily increased to over $3.9 billion for fiscal year 1999.
  The health care community continues to recognize the importance of 
prevention in improving health status and reducing health care costs. 
In this bill, I have also included provisions which refine and 
strengthen preventive benefits within the Medicare program, including 
coverage of yearly pap smears, pelvic exams, and mammography screening 
for women, with no copayment or Part B deductible; and coverage of 
insulin pumps for certain Type I Diabetics.
  The proposed expansions in preventive health services included in 
Title IV of my bill are conservatively projected to save approximately 
$2.5 billion per year or $12.5 billion over five years. However, I 
believe the savings will be higher. It is clearly difficult to quantify 
today the savings that will surely be achieved tomorrow from future 
generations of children that are truly educated in a range of health-
related subjects including hygiene, nutrition, physical and emotional 
health, drug and alcohol abuse, and accident prevention and safety.


                                TITLE V

  Title V of my bill would establish a federal standard and create 
uniform national forms concerning a patient's right to decline medical 
treatment. Nothing in my bill mandates the use of uniform forms. 
Rather, the purpose of this provision is to make it easier for 
individuals to make their own choices and determination regarding their 
treatment during this vulnerable and highly personal time. Studies have 
also indicated that advance directives do not increase health care 
costs. Data indicate that end-of-life costs account for 10 percent of 
total health expenditures and 28 percent of total Medicare 
expenditures. Loose projections indicate that a 10 percent savings made 
in the final days of life would result in approximately $10 billion of 
savings in medical costs per year, and about $4.7 billion in savings 
for Medicare alone.
  However, economic considerations are not and should not be the 
primary reasons for using advance directives. They provide a means for 
patients to exercise their autonomy over end-of-life decisions. A study 
done at the Thomas Jefferson University Medical College in Philadelphia 
cited research which found that about 90 percent of the American 
population has expressed interest in discussing advance directives. 
However, even more recent studies indicate that living wills would be 
used by many more Americans if they were better understood. My bill 
would provide information on an individual's rights regarding living 
wills and advanced directives, and would make it easier for people to 
have their wishes known and honored. In my view, no one has the right 
to decide for anyone else what constitutes appropriate medical 
treatment to prolong a person's life. Encouraging the use of advance 
directives will ensure that patients are not needlessly and unlawfully 
treated against their will. No health care provider would be permitted 
to treat an adult contrary to the adult's wishes as outlined in an 
advance directive. However, in no way would the use of advance 
directives condone assisted suicide or any affirmative act to end human 
life.


                                TITLE VI

  The next title addresses the unique barriers to coverage which exist 
in both rural and urban medically underserved areas. Within my State of 
Pennsylvania, such barriers result from a lack of health care providers 
in rural areas, and other problems associated with the lack of coverage 
for indigent populations living in inner cities. Title VI of my bill 
improves access to health care services for these populations by: (1) 
expanding Public Health Service programs and training more primary care 
providers to serve in such areas; (2) increasing the utilization of 
non-physician providers, including nurse practitioners, clinical nurse 
specialists and physician assistants, through direct reimbursements 
under the Medicare and Medicaid programs; and (3) increasing support 
for education and outreach.
  I believe these provisions will also yield substantial savings. A 
study of the Canadian health system utilizing nurse practitioners 
projected savings of 10 to 15 percent of all medical costs. While our 
system is dramatically different from that of Canada, it may not be 
unreasonable to project annual savings of five percent, or $55 billion, 
from an increased number of primary care providers in our system. 
Again, experience will raise or lower this projection. Assuming these 
savings, based on an average expenditure for health care of $3,821 per 
person in 1995, it seems reasonable that we could cover over 10 million 
uninsured persons with these savings.


                               TITLE VII

  Outcomes research, included in title VII of my bill, is another area 
where we can achieve considerable long term health care savings while 
also improving the quality of care. According to most outcomes 
management experts, it is estimated that about 25 to 30 percent of 
medical care is inappropriate or unnecessary. Dr. Marcia Angell, former 
editor-in-chief of the New England Journal of Medicine, also stated 
that 20 to 30 percent of health care procedures are either 
inappropriate, ineffective or unnecessary. In 1997, health care 
expenditures totaled $1.1 trillion annually.
  A well-funded program for outcomes research is therefore essential, 
and is supported by Dr. C. Everett Koop, former Surgeon General of the 
United States. Title VII of my bill would establish such a program by 
imposing a one-tenth of one cent surcharge on all health insurance 
premiums. Based on the Health Care Financing Administration's 1995 
health spending review, private health insurance premiums totaled 
$325.4 billion. As provided in my bill, a surcharge would generate 
$325.4 million for an outcomes research fund.
  Title VII also authorizes the Secretary of Health and Human Services 
to award grants to States to establish or improve a health care data 
information system. Currently, 38 States have a mandate to establish 
such a system, and 22 States are in various stages of implementation. 
In my own State, the Pennsylvania Health Care Cost Containment Council 
has received national

[[Page S412]]

recognition for the work it has done to help control health care costs 
through the promotion of competition in the collection, analysis and 
distribution of uniform cost and quality data for all hospitals and 
physicians in the Commonwealth. Consumers, businesses, labor, insurance 
companies, health maintenance organizations, and hospitals have 
utilized this important information. Specifically, hospitals have used 
this information to become more competitive in the marketplace; 
businesses and labor have used this data to lower their health care 
expenditures; health plans have used this information when contracting 
with providers; and consumers have used this information to compare 
costs and outcomes of health care providers and procedures.


                               TITLE VIII

   Nursing home care is another significant issue which must be 
addressed. The cost of this care is exorbitant, averaging in excess of 
$40,000 annually. Public expenditures on nursing home care, largely 
through the Medicaid program, were over $33 billion in 1995. Despite 
these large public expenditures, the elderly face significant uncovered 
liability for long term care. Title VIII of my bill therefore would 
provide a tax credit for premiums paid to purchase private long-term 
care insurance. It also proposes home and community-based care benefits 
as less costly alternatives to institutional care. Other tax incentives 
and reforms provided in my bill to make long term care insurance more 
affordable include: (1) allowing employees to select long-term care 
insurance as part of a cafeteria plan and allowing employers to deduct 
this expense; (2) excluding from income tax the life insurance savings 
used to pay for long term care; and (3) setting standards for long term 
care insurance that reduce the bias that currently favors institutional 
care over community and home-based alternatives.


                                TITLE IX

  The final title of my bill would create a national fund for health 
research within the Department of the Treasury, to supplement the 
monies appropriated for the National Institutes of Health. To 
capitalize this fund, health insurance companies would be required to 
contribute 1 percent of all health insurance premiums received. This 
creative proposal was first developed by my distinguished colleagues, 
Senators Mark Hatfield and Tom Harkin. Their idea is a sound one and 
ought to be adopted. To this end, Senator Harkin and I introduced the 
National Fund for Health Research Act of 1997 (S. 441) on March 13, 
1997. I look forward to continuing to work together with Senator Harkin 
to enact a biomedical research fund this Congress.
  While precision is again impossible, it is reasonable to project that 
my proposal could achieve a net annual savings of between $90 and $100 
billion. I arrive at this sum by totaling the projected savings of $90 
to $100 billion annually--$9 billion in small employer market reforms 
coupled with employer purchasing groups; $2.5 billion for preventive 
health services; $22 to $33 billion for reducing inappropriate care 
through outcomes research; $10 billion from advanced directives; $55 
billion from increasing primary care providers; and $2.9 billion by 
reducing administrative costs and netting this against the $2.8 billion 
for long term care. Although these estimates are not exact, I propose 
this bill as a starting point to address the remaining problems with 
our health care system. Experience will require modification of these 
projections, and I am prepared to work with my colleagues to develop 
implementing legislation and to press for further action in the 
important area of health care reform.
  The provisions which I have outlined today contain the framework for 
providing affordable health care for all Americans. I am opposed to 
rationing health care. I do not want rationing for myself, for my 
family, or for America. In my judgment, we should not scrap, but rather 
we should build on our current health delivery system. We do not need 
the overwhelming bureaucracy that President Clinton and other 
Democratic leaders proposed in 1993 to accomplish this. I believe we 
can provide care for the 43.1 million Americans who are now not covered 
and reduce health care costs for those who are covered within the 
currently growing $1.1 trillion in health care spending.
  This bill is a significant next step forward in obtaining the 
objective of reforming our health care system, although that reform 
will not be achieved immediately or easily. Mr. President, the time has 
come for concerted action in this arena.
  I urge the Congressional leadership, including the appropriate 
committee chairmen, to move this legislation and other health care 
bills forward promptly.
  I ask unanimous consent that a summary of the bill and a list of the 
26 health care bills I have sponsored since 1983 be printed in the 
Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

        26 Health Care Bills Introduced by Senator Arlen Specter

       98th Congress 1/3/83 until 1/2/85:
       (1) S.811: The Health Care for Displaced Workers Act of 
     1983 (3/15/83)
       (2) S.2051: The Health Care Cost Containment Act of 1983 
     (11/4/83)
       99th Congress 1/3/85 until 1/2/87:
       (3) S.379: The Health Care Cost Containment Act of 1985 (2/
     5/85)
       (4) S.1873: The Community Based Disease Prevention and 
     Health Promotion Projects Act of 1985 (11/21/85)
       100th Congress 1/3/87 until 1/2/89:
       (5) S.281: The Aid to Families and Employment Transition 
     Act (1/6/87)
       (6) S.1871: The Pediatric Acquired Immunodeficiency 
     Syndrome (AIDS) Resource Centers Act (11/17/87)
       (7) S.1872: The Minority Acquired Immunodeficiency Syndrome 
     (AIDS) Awareness and Prevention Projects Act (11/17/87):
       101st Congress 1/3/89 until 1/2/91
       (8) S.896: The Pediatric AIDS Resource Centers Act (5/2/89)
       (9) S.1607: Authorization of the Office of Minority Health 
     (9/12/89):
       102nd Congress 1/3/91 until 1/5/93:
       (10) S.1122: The Long-Term Care Incentives Act of 1991 (5/
     22/91)
       (11) S.1214: The Change in Designation of Lancaster County, 
     PA, for Purposes of Medicare Services (6/4/91)
       (12) S.1864: The Children's Hospital of Philadelphia 
     Medical Research Facility Act (10/23/91)
       (13) S.1995: The Health Care Access and Affordabililty Act 
     of 1991 (11/20/91)
       (14) S.2028: The Women Veteran's Health Equity Act of 1991 
     (11/22/91)
       (15) S.2029: Self-Funding of Veteran's Administrative 
     Health Care Act (11/22/91)
       (16) S.2188: Rural Veterans Health Care Facilities Act (2/
     5/92)
       (17) S.3176: The Health Care Affordabililty and Quality 
     Improvement Act of 1992 (8/12/92)
       (18) S.3353: The Deferred Acquisition Cost Act (10/6/92)
       103rd Congress 1/5/93 until 12/11/94:
       (19) S.18: The Comprehensive Health Care Act of 1993 (1/21/
     93)
       (20) S.631: The Comprehensive Access and Affordabililty 
     Health Care (3/23/93):
       104th Congress 1/4/95 until 10/3/96:
       (21) S.18: The Health Care Assurance Act of 1995 (1/4/95)
       (22) S.1716: The Adolescent Family Life and Abstinence 
     Education Act of 1996 (4/29/96)
       105th Congress 1/7/97 to 10/21/98:
       (23) S.24: The Health Care Assurance Act of 1997 (1/21/97)
       (24) S.435: The Healthy Children's Pilot Program Act of 
     1997 (3/13/97)
       (25) S.934: The Adolescent Family Life and Abstinence 
     Education Act of 1997 (6/18/97)
       (26) S.999: Authorizing the Department of Veteran's Affairs 
     to Specify the Frequency of Screening Mammograms (7/9/97)
                                  ____


               Health Care assurance Act of 1999--Summary

       TITLE I: Expanded State Child Health Insurance Program--
     This title will expand upon the State Child Health Insurance 
     Program (S-CHIP), the new program established in the Balanced 
     Budget Act of 1997 which allocates $24 billion/five years to 
     increase health insurance coverage for children. The S-CHIP 
     program gives States the option to use federally funded 
     grants to provide vouchers to eligible families to purchase 
     health insurance for their children, or to expand Medicaid 
     coverage for those uninsured children, or a combination of 
     both. These grants are distributed to participating States 
     based on the number of uninsured children residing there. 
     This title would increase the income eligibility to families 
     with incomes at or below 235 percent of the Federal poverty 
     level ($38,658 annually for a family of four), and would 
     strengthen the States' ability to conduct Medicaid outreach 
     to eligible children.
       TITLE II: Expanded Health Services for Disabled 
     Individuals:--Extension of Medicare Eligibility for Disabled 
     Individuals Who Return to Work: Currently, disabled 
     individuals, or recipients of Social Security Disability 
     Income (SSDI), may receive health insurance coverage under 
     the Medicare program for a short time after returning to 
     work. This provision would extend to 24 months the period 
     during which the individual may continue to receive Medicare 
     benefits after returning to work, and allow the individual to 
     ``buy-into'' Medicare at a reduced rate, subject to yearly 
     review.
       Expansion of Community-Based Attendant Care Services--
     Medicaid currently covers the costs associated with 
     institutional care

[[Page S413]]

     for disabled individuals. In an effort to improve the 
     delivery of care and the comfort of those with long-term 
     disabilities, this section would allow for reimbursement for 
     community-based attendant care services, instead of 
     institutionalization, for eligible individuals who require 
     such services based on functional need, without regard to the 
     individual's age or the nature of the disability.
       TITLE III: General Health Insurance Coverage Provisions--
     Tax Equity for the Self-Employed: Under current law, self-
     employed persons may deduct 60 percent of their health 
     insurance costs through 2002, and those costs would be fully 
     deductible in 2003. However, all other employees may already 
     deduct 100 percent of such costs. Title III corrects this 
     inequity for the self-employed, 2.9 million of whom are 
     currently uninsured, by speeding up the phase-in to allow 
     self-employed individuals and their families to deduct 100 
     percent of their health insurance costs beginning in 2001.
       Small Employer and Individual Purchasing Groups: 
     Establishes voluntary small employer and individual 
     purchasing groups designed to provide affordable, 
     comprehensive health coverage options for such employers, 
     their employees, and other uninsured and underinsured 
     individuals and families. Health plans offering coverage 
     through such groups will: (1) provide a standard, actuarially 
     equivalent health benefits package; (2) adjust community 
     rated premiums by age and family size in order to spread risk 
     and provide price equity to all; and (3) meet certain other 
     guidelines involving marketing practices.
       Standard Benefits Package: The standard package of benefits 
     would include a variation of benefits permitted among 
     actuarially equivalent plans developed through the National 
     Association of Insurance Commissioners (NAIC). The standard 
     plan will consist of the following services when medically 
     necessary or appropriate: (1) medical and surgical services; 
     (2) medical equipment; (3) preventive services; and (4) 
     emergency transportation in frontier areas.
       COBRA Portability Reform: For those persons who are 
     uninsured between jobs and for insured persons who fear 
     losing coverage should they lose their jobs, Title III 
     reforms the existing COBRA law by: (1) extending to 24 months 
     the minimum time period in which COBRA may cover individuals 
     through their former employers' plan, and extending to 36 
     months the time period in which a child who is no longer a 
     dependent under a parent's health insurance policy may 
     receive COBRA coverage; (2) expanding coverage options to 
     include plans with a lower premium and a $1,000 deductible--
     saving a typical family of four 20 percent in monthly 
     premiums--and plans with a lower premium and a $3,000 
     deductible--saving a family of four 52 percent in monthly 
     premiums.
       TITLE IV: Primary and Preventive Care Services:
       New Medicare Preventive Care Services: The health care 
     community continues to recognize the importance of prevention 
     in improving health status and reducing health care costs. 
     This provision institutes new preventive benefits within the 
     Medicare program, and refines and strengthens existing ones. 
     Under this provision, Medicare would cover yearly pap smears, 
     pelvic exams, and mammography screening for women, with no 
     copayment or Part B deductible; and cover insulin pumps for 
     certain Type I Diabetics.
       Primary Health and Education Assistance Programs: The 
     Department of Health and Human Service administers many 
     programs designed to increase access to primary and 
     preventive care. This provision provides increased 
     authorization for several existing preventive health programs 
     such as breast and cervical cancer prevention, Healthy Start 
     project grants aimed at reducing infant mortality and low 
     weight births and to improve the health and well-being of 
     mothers and their families, pregnant women and infants, and 
     childhood immunizations. This section also authorizes a new 
     grant program for local education agencies and pre-school 
     programs to provide comprehensive health education, and 
     reauthorizes the Adolescent Family Life (AFL) program (Title 
     XX) for the first time since 1984. The AFL program provides 
     funding for initiatives focusing directly on abstinence 
     education.
       TITLE V: Patient's Right to Decline Medical Treatment: 
     Improves the effectiveness and portability of advance 
     directives by strengthening the federal law regarding patient 
     self-determination and establishing uniform federal forms 
     with regard to self-determination.
       TITLE VI: Primary and Preventive Care Providers: Encourages 
     use of non-physician providers such as nurse practitioners, 
     physician assistants, and clinical nurse specialists by 
     increasing direct reimbursement under Medicare and Medicaid 
     without regard to the setting where services are provided. 
     Title VI also seeks to encourage students early on in their 
     medical training to pursue a career in primary care and it 
     provides assistance to medical training programs to recruit 
     such students.
       TITLE VII: Cost Containment:
       Outcomes Research: Expands funding for outcomes research 
     necessary for the development of medical practice guidelines 
     and increasing consumers' access to information in order to 
     reduce the delivery of unnecessary and overpriced care.
       New Drug Clinical Trials Program: Authorizes a program at 
     the National Institutes of Health to expand support for 
     clinical trials on promising new drugs and disease treatments 
     with priority given to the most costly diseases impacting the 
     greatest number of people.
       Health Care Cost Containment and Quality Information 
     Project: Authorizes the Secretary of Health and Human 
     Services to award grants to States to establish a health care 
     cost and quality information system or to improve an existing 
     system. Currently, 38 States have State mandates to establish 
     an information system, approximately 22 States of which have 
     information systems in various stages of operation. 
     Information such as hospital charge data and patient 
     procedure outcomes data, which the State agency or council 
     collects is used by businesses, labor, health maintenance 
     organizations, hospitals, researchers, consumers, States, 
     etc. Such data has enabled hospitals to become more 
     competitive, businesses to save health care dollars, and 
     consumers to make informed choices regarding their care.
       TITLE VIII: Tax Incentives for Purchase of Qualified Long-
     Term Care Insurance: Increases access to long-term care by: 
     (1) establishing a tax credit for amounts paid toward long-
     term care services of family members; (2) excluding life 
     insurance savings used to pay for long-term care from income 
     tax; (3) allowing employees to select long-term care 
     insurance as part of a cafeteria plan and allowing employers 
     to deduct this expense; (4) setting standards that require 
     long-term care to eliminate the current bias that favors 
     institutional care over community and home-based 
     alternatives.
       TITLE IX: National Fund for Health Research: Authorizes the 
     establishment of a National Fund for Health Research to 
     supplement biomedical research through the contributions of 
     1% of premiums collected by health insurers. Funds will be 
     distributed to the National Institutes of Health's member 
     institutes and centers in the same proportion as the amount 
     of appropriations they receive for the fiscal year.
                                 ______