[Congressional Record Volume 145, Number 134 (Wednesday, October 6, 1999)]
[House]
[Pages H9431-H9474]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




               QUALITY CARE FOR THE UNINSURED ACT OF 1999

  Mr. BLILEY. Mr. Speaker, pursuant to House Resolution 323, I call up 
the bill (H.R. 2990) to amend the Internal Revenue Code of 1986 to 
allow individuals greater access to health insurance through a health 
care tax deduction, a long-term care deduction, and other health-
related tax incentives, to amend the Employee Retirement Income 
Security Act of 1974 to provide access to and choice in health care 
through association health plans, to amend the Public Health Service 
Act to create new pooling opportunities for small employers to obtain 
greater access to health coverage through HealthMarts, and for other 
purposes, and ask for its immediate consideration in the House.
  The Clerk read the title of the bill.
  The text of H.R. 2990 is as follows:

                               H.R. 2990

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Quality 
     Care for the Uninsured Act of 1999''.
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

Sec. 1. Short title; table of contents.
Sec. 2. Purposes.
Sec. 3. Findings relating to health care choice.

              TITLE I--TAX-RELATED HEALTH CARE PROVISIONS

Sec. 101. Deduction for health and long-term care insurance costs of 
              individuals not participating in employer-subsidized 
              health plans.
Sec. 102. Deduction for 100 percent of health insurance costs of self-
              employed individuals.
Sec. 103. Expansion of availability of medical savings accounts.
Sec. 104. Long-term care insurance permitted to be offered under 
              cafeteria plans and flexible spending arrangements.
Sec. 105. Additional personal exemption for taxpayer caring for elderly 
              family member in taxpayer's home.
Sec. 106. Expanded human clinical trials qualifying for orphan drug 
              credit.
Sec. 107. Inclusion of certain vaccines against streptococcus 
              pneumoniae to list of taxable vaccines; reduction in per 
              dose tax rate.
Sec. 108. Credit for clinical testing research expenses attributable to 
              certain qualified academic institutions including 
              teaching hospitals.

  TITLE II--GREATER ACCESS AND CHOICE THROUGH ASSOCIATION HEALTH PLANS

Sec. 201. Rules.

           ``Part 8--Rules Governing Association Health Plans

``Sec. 801. Association health plans.
``Sec. 802. Certification of association health plans.
``Sec. 803. Requirements relating to sponsors and boards of trustees.
``Sec. 804. Participation and coverage requirements.
``Sec. 805. Other requirements relating to plan documents, contribution 
              rates, and benefit options.
``Sec. 806. Maintenance of reserves and provisions for solvency for 
              plans providing health benefits in addition to health 
              insurance coverage.
``Sec. 807. Requirements for application and related requirements.
``Sec. 808. Notice requirements for voluntary termination.
``Sec. 809. Corrective actions and mandatory termination.
``Sec. 810. Trusteeship by the Secretary of insolvent association 
              health plans providing health benefits in addition to 
              health insurance coverage.
``Sec. 811. State assessment authority.
``Sec. 812. Special rules for church plans.
``Sec. 813. Definitions and rules of construction.
Sec. 202. Clarification of treatment of single employer arrangements.
Sec. 203. Clarification of treatment of certain collectively bargained 
              arrangements.
Sec. 204. Enforcement provisions.
Sec. 205. Cooperation between Federal and State authorities.
Sec. 206. Effective date and transitional and other rules.

        TITLE III--GREATER ACCESS AND CHOICE THROUGH HEALTHMARTS

Sec. 301. Expansion of consumer choice through HealthMarts.

[[Page H9432]]

                      ``TITLE XXVIII--HEALTHMARTS

``Sec. 2801. Definition of HealthMart.
``Sec. 2802. Application of certain laws and requirements.
``Sec. 2803. Administration.
``Sec. 2804. Definitions.

                TITLE IV--COMMUNITY HEALTH ORGANIZATIONS

Sec. 401. Promotion of provision of insurance by community health 
              organizations.
       (c) Constitutional Authority To Enact This Legislation.--
     The constitutional authority upon which this Act rests is the 
     power of Congress to regulate commerce with foreign nations 
     and among the several States, set forth in article I, section 
     8 of the United States Constitution.

     SEC. 2. PURPOSES.

       The purposes of this Act are--
       (1) to make it possible for individuals, employees, and the 
     self-employed to purchase and own their own health insurance 
     without suffering any negative tax consequences;
       (2) to assist individuals in obtaining and in paying for 
     basic health care services;
       (3) to render patients and deliverers sensitive to the cost 
     of health care, giving them both the incentive and the 
     ability to restrain undesired increases in health care costs;
       (4) to foster the development of numerous, varied, and 
     innovative systems of providing health care which will 
     compete against each other in terms of price, service, and 
     quality, and thus allow the American people to benefit from 
     competitive forces which will reward efficient and effective 
     deliverers and eliminate those which provide unsatisfactory 
     quality of care or are inefficient; and
       (5) to encourage the development of systems of delivering 
     health care which are capable of supplying a broad range of 
     health care services in a comprehensive and systematic 
     manner.

     SEC. 3. FINDINGS RELATING TO HEALTH CARE CHOICE.

       (a) Congress finds that the majority of Americans are 
     receiving health care of a quality unmatched elsewhere in the 
     world but that 43 million Americans remain without private 
     health insurance. Congress further finds that small business 
     faces significant challenges in the purchase of health 
     insurance, including higher costs and lack of choice of 
     coverage. Congress further finds that such challenges lead to 
     fewer Americans who are able to take advantage of private 
     health insurance, leading to higher cost and lower quality 
     care.
       (b) Congress finds that reduction of the number of 
     uninsured Americans is an important public policy goal. 
     Congress further finds that the use of alternative pooling 
     mechanisms such as Association Health Plans, HealthMarts and 
     other innovative means could provide significant 
     opportunities for small business and individuals to purchase 
     health insurance. Congress further finds that the use of such 
     mechanisms could provide significant opportunities to expand 
     private health coverage for individuals who are employees of 
     small business, self-employed, or do not work for employers 
     who provide health insurance.
       (c) Congress finds that the current Tax Code provides 
     significant incentives for employers to provide health 
     insurance coverage for their employees by providing a 
     deduction for the employer for the cost of health insurance 
     coverage and an exclusion from income for the employee for 
     employer-provided health care. Congress further finds that 
     some individuals may prefer to decline coverage under their 
     employer's group health plan and obtain individual health 
     insurance coverage, and some employers may wish to give 
     employees the opportunity to do so. Congress further finds 
     that the Internal Revenue Service has ruled that this tax 
     treatment for the employer and employee for employer-provided 
     health care applies even if the employer pays for individual 
     health insurance polices for its employees. Therefore, the 
     Tax Code makes it possible for employers to provide employees 
     choice among health insurance coverage while retaining 
     favorable tax treatment. Congress further finds that the 
     present-law exclusion for employer-provided health care, 
     together with the tax provisions in the bill, will provide 
     more equitable tax treatment for health insurance 
     expenses, encourage uninsured individuals to purchase 
     insurance, expand health care options, and encourage 
     individuals to better manage their health care needs and 
     expenses.
       (d) Congress finds that continually increasing and complex 
     government regulation of the health care delivery system has 
     proven ineffective in restraining costs and is itself 
     expensive and counterproductive in fulfilling its purposes 
     and detrimental to the care of patients.

              TITLE I--TAX-RELATED HEALTH CARE PROVISIONS

     SEC. 101. DEDUCTION FOR HEALTH AND LONG-TERM CARE INSURANCE 
                   COSTS OF INDIVIDUALS NOT PARTICIPATING IN 
                   EMPLOYER-SUBSIDIZED HEALTH PLANS.

       (a) In General.--Part VII of subchapter B of chapter 1 of 
     the Internal Revenue Code of 1986 is amended by redesignating 
     section 222 as section 223 and by inserting after section 221 
     the following new section:

     ``SEC. 222. HEALTH AND LONG-TERM CARE INSURANCE COSTS.

       ``(a) In General.--In the case of an individual, there 
     shall be allowed as a deduction an amount equal to the 
     applicable percentage of the amount paid during the taxable 
     year for insurance which constitutes medical care for the 
     taxpayer and the taxpayer's spouse and dependents.
       ``(b) Applicable Percentage.--For purposes of subsection 
     (a), the applicable percentage shall be determined in 
     accordance with the following table:

``For taxable years beginning                            The applicable
  in calendar year--                                    percentage is--
  2002, 2003, and 2004.............................................25  
  2005.............................................................35  
  2006.............................................................65  
  2007 and thereafter............................................100.  
       ``(c) Limitation Based on Other Coverage.--
       ``(1) Coverage under certain subsidized employer plans.--
       ``(A) In general.--Subsection (a) shall not apply to any 
     taxpayer for any calendar month for which the taxpayer 
     participates in any health plan maintained by any employer of 
     the taxpayer or of the spouse of the taxpayer if 50 percent 
     or more of the cost of coverage under such plan (determined 
     under section 4980B and without regard to payments made with 
     respect to any coverage described in subsection (e)) is paid 
     or incurred by the employer.
       ``(B) Employer contributions to cafeteria plans, flexible 
     spending arrangements, and medical savings accounts.--
     Employer contributions to a cafeteria plan, a flexible 
     spending or similar arrangement, or a medical savings account 
     which are excluded from gross income under section 106 shall 
     be treated for purposes of subparagraph (A) as paid by the 
     employer.
       ``(C) Aggregation of plans of employer.--A health plan 
     which is not otherwise described in subparagraph (A) shall be 
     treated as described in such subparagraph if such plan would 
     be so described if all health plans of persons treated as a 
     single employer under subsection (b), (c), (m), or (o) of 
     section 414 were treated as one health plan.
       ``(D) Separate application to health insurance and long-
     term care insurance.--Subparagraphs (A) and (C) shall be 
     applied separately with respect to--
       ``(i) plans which include primarily coverage for qualified 
     long-term care services or are qualified long-term care 
     insurance contracts, and
       ``(ii) plans which do not include such coverage and are not 
     such contracts.
       ``(2) Coverage under certain federal programs.--
       ``(A) In general.--Subsection (a) shall not apply to any 
     amount paid for any coverage for an individual for any 
     calendar month if, as of the first day of such month, the 
     individual is covered under any medical care program 
     described in--
       ``(i) title XVIII, XIX, or XXI of the Social Security Act,
       ``(ii) chapter 55 of title 10, United States Code,
       ``(iii) chapter 17 of title 38, United States Code,
       ``(iv) chapter 89 of title 5, United States Code, or
       ``(v) the Indian Health Care Improvement Act.
       ``(B) Exceptions.--
       ``(i) Qualified long-term care.--Subparagraph (A) shall not 
     apply to amounts paid for coverage under a qualified long-
     term care insurance contract.
       ``(ii) Continuation coverage of fehbp.--Subparagraph 
     (A)(iv) shall not apply to coverage which is comparable to 
     continuation coverage under section 4980B.
       ``(d) Long-Term Care Deduction Limited to Qualified Long-
     Term Care Insurance Contracts.--In the case of a qualified 
     long-term care insurance contract, only eligible long-term 
     care premiums (as defined in section 213(d)(10)) may be taken 
     into account under subsection (a).
       ``(e) Deduction Not Available for Payment of Ancillary 
     Coverage Premiums.--Any amount paid as a premium for 
     insurance which provides for--
       ``(1) coverage for accidents, disability, dental care, 
     vision care, or a specified illness, or
       ``(2) making payments of a fixed amount per day (or other 
     period) by reason of being hospitalized,
     shall not be taken into account under subsection (a).
       ``(f) Special Rules.--
       ``(1) Coordination with deduction for health insurance 
     costs of self-employed individuals.--The amount taken into 
     account by the taxpayer in computing the deduction under 
     section 162(l) shall not be taken into account under this 
     section.
       ``(2) Coordination with medical expense deduction.--The 
     amount taken into account by the taxpayer in computing the 
     deduction under this section shall not be taken into account 
     under section 213.
       ``(g) Regulations.--The Secretary shall prescribe such 
     regulations as may be appropriate to carry out this section, 
     including regulations requiring employers to report to their 
     employees and the Secretary such information as the Secretary 
     determines to be appropriate.''.
       (b) Deduction Allowed Whether or Not Taxpayer Itemizes 
     Other Deductions.--Subsection (a) of section 62 of such Code 
     is amended by inserting after paragraph (17) the following 
     new item:
       ``(18) Health and long-term care insurance costs.--The 
     deduction allowed by section 222.''.
       (c) Clerical Amendment.--The table of sections for part VII 
     of subchapter B of chapter 1 of such Code is amended by 
     striking the last item and inserting the following new items:


[[Page H9433]]


``Sec. 222. Health and long-term care insurance costs.
``Sec. 223. Cross reference.''.

       (d) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2001.

     SEC. 102. DEDUCTION FOR 100 PERCENT OF HEALTH INSURANCE COSTS 
                   OF SELF-EMPLOYED INDIVIDUALS.

       (a) In General.--Paragraph (1) of section 162(l) of the 
     Internal Revenue Code of 1986 is amended to read as follows:
       ``(1) Allowance of deduction.--In the case of an individual 
     who is an employee within the meaning of section 401(c)(1), 
     there shall be allowed as a deduction under this section an 
     amount equal to 100 percent of the amount paid during the 
     taxable year for insurance which constitutes medical care for 
     the taxpayer and the taxpayer's spouse and dependents.''.
       (b) Clarification of Limitations on Other Coverage.--The 
     first sentence of section 162(l)(2)(B) of such Code is 
     amended to read as follows: ``Paragraph (1) shall not apply 
     to any taxpayer for any calendar month for which the taxpayer 
     participates in any subsidized health plan maintained by any 
     employer (other than an employer described in section 
     401(c)(4)) of the taxpayer or the spouse of the taxpayer.''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2000.

     SEC. 103. EXPANSION OF AVAILABILITY OF MEDICAL SAVINGS 
                   ACCOUNTS.

       (a) Repeal of Limitations on Number of Medical Savings 
     Accounts.--
       (1) In general.--Subsections (i) and (j) of section 220 of 
     the Internal Revenue Code of 1986 are hereby repealed.
       (2) Conforming amendments.--
       (A) Paragraph (1) of section 220(c) of such Code is amended 
     by striking subparagraph (D).
       (B) Section 138 of such Code is amended by striking 
     subsection (f).
       (b) Availability Not Limited to Accounts For Employees of 
     Small Employers and Self-employed Individuals.--
       (1) In general.--Section 220(c)(1)(A) of such Code 
     (relating to eligible individual) is amended to read as 
     follows:
       ``(A) In general.--The term `eligible individual' means, 
     with respect to any month, any individual if--
       ``(i) such individual is covered under a high deductible 
     health plan as of the 1st day of such month, and
       ``(ii) such individual is not, while covered under a high 
     deductible health plan, covered under any health plan--

       ``(I) which is not a high deductible health plan, and
       ``(II) which provides coverage for any benefit which is 
     covered under the high deductible health plan.''.

       (2) Conforming amendments.--
       (A) Section 220(c)(1) of such Code is amended by striking 
     subparagraph (C).
       (B) Section 220(c) of such Code is amended by striking 
     paragraph (4) (defining small employer) and by redesignating 
     paragraph (5) as paragraph (4).
       (C) Section 220(b) of such Code is amended by striking 
     paragraph (4) (relating to deduction limited by compensation) 
     and by redesignating paragraphs (5), (6), and (7) as 
     paragraphs (4), (5), and (6), respectively.
       (c) Increase in Amount of Deduction Allowed for 
     Contributions to Medical Savings Accounts.--
       (1) In general.--Paragraph (2) of section 220(b) of such 
     Code is amended to read as follows:
       ``(2) Monthly limitation.--The monthly limitation for any 
     month is the amount equal to \1/12\ of the annual deductible 
     (as of the first day of such month) of the individual's 
     coverage under the high deductible health plan.''.
       (2) Conforming amendment.--Clause (ii) of section 
     220(d)(1)(A) of such Code is amended by striking ``75 percent 
     of''.
       (d) Both Employers and Employees May Contribute to Medical 
     Savings Accounts.--Paragraph (5) of section 220(b) of such 
     Code is amended to read as follows:
       ``(5) Coordination with exclusion for employer 
     contributions.--The limitation which would (but for this 
     paragraph) apply under this subsection to the taxpayer for 
     any taxable year shall be reduced (but not below zero) by the 
     amount which would (but for section 106(b)) be includible 
     in the taxpayer's gross income for such taxable year.''.
       (e) Reduction of Permitted Deductibles Under High 
     Deductible Health Plans.--
       (1) In general.--Subparagraph (A) of section 220(c)(2) of 
     such Code (defining high deductible health plan) is amended--
       (A) by striking ``$1,500'' in clause (i) and inserting 
     ``$1,000'', and
       (B) by striking ``$3,000'' in clause (ii) and inserting 
     ``$2,000''.
       (2) Conforming amendment.--Subsection (g) of section 220 of 
     such Code is amended to read as follows:
       ``(g) Cost-of-Living Adjustment.--
       ``(1) In general.--In the case of any taxable year 
     beginning in a calendar year after 1998, each dollar amount 
     in subsection (c)(2) shall be increased by an amount equal 
     to--
       ``(A) such dollar amount, multiplied by
       ``(B) the cost-of-living adjustment determined under 
     section 1(f)(3) for the calendar year in which such taxable 
     year begins by substituting `calendar year 1997' for 
     `calendar year 1992' in subparagraph (B) thereof.
       ``(2) Special rules.--In the case of the $1,000 amount in 
     subsection (c)(2)(A)(i) and the $2,000 amount in subsection 
     (c)(2)(A)(ii), paragraph (1)(B) shall be applied by 
     substituting `calendar year 1999' for `calendar year 1997'.
       ``(3) Rounding.--If any increase under paragraph (1) or (2) 
     is not a multiple of $50, such increase shall be rounded to 
     the nearest multiple of $50.
       (f) Medical Savings Accounts May Be Offered Under Cafeteria 
     Plans.--Subsection (f) of section 125 of such Code is amended 
     by striking ``106(b),''.
       (g) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2000.

     SEC. 104. LONG-TERM CARE INSURANCE PERMITTED TO BE OFFERED 
                   UNDER CAFETERIA PLANS AND FLEXIBLE SPENDING 
                   ARRANGEMENTS.

       (a) Cafeteria Plans.--
       (1) In general.--Subsection (f ) of section 125 of the 
     Internal Revenue Code of 1986 (defining qualified benefits) 
     is amended by inserting before the period at the end ``; 
     except that such term shall include the payment of premiums 
     for any qualified long-term care insurance contract (as 
     defined in section 7702B) to the extent the amount of such 
     payment does not exceed the eligible long-term care premiums 
     (as defined in section 213(d)(10)) for such contract''.
       (b) Flexible Spending Arrangements.--Section 106 of such 
     Code (relating to contributions by employer to accident and 
     health plans) is amended by striking subsection (c).
       (c) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2001.

     SEC. 105. ADDITIONAL PERSONAL EXEMPTION FOR TAXPAYER CARING 
                   FOR ELDERLY FAMILY MEMBER IN TAXPAYER'S HOME.

       (a) In General.--Section 151 of the Internal Revenue Code 
     of 1986 (relating to allowance of deductions for personal 
     exemptions) is amended by redesignating subsection (e) as 
     subsection (f ) and by inserting after subsection (d) the 
     following new subsection:
       ``(e) Additional Exemption for Certain Elderly Family 
     Members Residing With Taxpayer.--
       ``(1) In general.--An exemption of the exemption amount for 
     each qualified family member of the taxpayer.
       ``(2) Qualified family member.--For purposes of this 
     subsection, the term `qualified family member' means, with 
     respect to any taxable year, any individual--
       ``(A) who is an ancestor of the taxpayer or of the 
     taxpayer's spouse or who is the spouse of any such ancestor,
       ``(B) who is a member for the entire taxable year of a 
     household maintained by the taxpayer, and
       ``(C) who has been certified, before the due date for 
     filing the return of tax for the taxable year (without 
     extensions), by a physician (as defined in section 1861(r)(1) 
     of the Social Security Act) as being an individual with long-
     term care needs described in paragraph (3) for a period--
       ``(i) which is at least 180 consecutive days, and
       ``(ii) a portion of which occurs within the taxable year.
     Such term shall not include any individual otherwise meeting 
     the requirements of the preceding sentence unless within the 
     39\1/2\ month period ending on such due date (or such other 
     period as the Secretary prescribes) a physician (as so 
     defined) has certified that such individual meets such 
     requirements.
       ``(3) Individuals with long-term care needs.--An individual 
     is described in this paragraph if the individual--
       ``(A) is unable to perform (without substantial assistance 
     from another individual) at least two activities of daily 
     living (as defined in section 7702B(c)(2)(B)) due to a loss 
     of functional capacity, or
       ``(B) requires substantial supervision to protect such 
     individual from threats to health and safety due to severe 
     cognitive impairment and is unable to perform, without 
     reminding or cuing assistance, at least one activity of daily 
     living (as so defined) or to the extent provided in 
     regulations prescribed by the Secretary (in consultation with 
     the Secretary of Health and Human Services), is unable to 
     engage in age appropriate activities.
       ``(4) Special rules.--Rules similar to the rules of 
     paragraphs (1), (2), (3), (4), and (5) of section 21(e) shall 
     apply for purposes of this subsection.''.
       (b) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2000.

     SEC. 106. EXPANDED HUMAN CLINICAL TRIALS QUALIFYING FOR 
                   ORPHAN DRUG CREDIT.

       (a) In General.--Subclause (I) of section 45C(b)(2)(A)(ii) 
     of the Internal Revenue Code of 1986 is amended to read as 
     follows:

       ``(I) after the date that the application is filed for 
     designation under such section 526, and''.

       (b) Conforming Amendment.--Clause (i) of section 
     45C(b)(2)(A) of such Code is amended by inserting ``which 
     is'' before ``being'' and by inserting before the comma at 
     the end ``and which is designated under section 526 of such 
     Act''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to amounts paid or incurred after December 31, 
     2000.

     SEC. 107. INCLUSION OF CERTAIN VACCINES AGAINST STREPTOCOCCUS 
                   PNEUMONIAE TO LIST OF TAXABLE VACCINES; 
                   REDUCTION IN PER DOSE TAX RATE.

       (a) Inclusion of Vaccines.--

[[Page H9434]]

       (1) In general.--Section 4132(a)(1) of the Internal Revenue 
     Code of 1986 (defining taxable vaccine) is amended by adding 
     at the end the following new subparagraph:
       ``(L) Any conjugate vaccine against streptococcus 
     pneumoniae.''.
       (2) Effective date.--
       (A) Sales.--The amendment made by this subsection shall 
     apply to vaccine sales beginning on the day after the date on 
     which the Centers for Disease Control makes a final 
     recommendation for routine administration to children of any 
     conjugate vaccine against streptococcus pneumoniae, but shall 
     not take effect if subsection (c) does not take effect.
       (B) Deliveries.--For purposes of subparagraph (A), in the 
     case of sales on or before the date described in such 
     subparagraph for which delivery is made after such date, the 
     delivery date shall be considered the sale date.
       (b) Reduction in Per Dose Tax Rate.--
       (1) In general.--Section 4131(b)(1) of such Code (relating 
     to amount of tax) is amended by striking ``75 cents'' and 
     inserting ``50 cents''.
       (2) Effective date.--
       (A) Sales.--The amendment made by this subsection shall 
     apply to vaccine sales after December 31, 2004, but shall not 
     take effect if subsection (c) does not take effect.
       (B) Deliveries.--For purposes of subparagraph (A), in the 
     case of sales on or before the date described in such 
     subparagraph for which delivery is made after such date, the 
     delivery date shall be considered the sale date.
       (3) Limitation on certain credits or refunds.--For purposes 
     of applying section 4132(b) of the Internal Revenue Code of 
     1986 with respect to any claim for credit or refund filed 
     after August 31, 2004, the amount of tax taken into account 
     shall not exceed the tax computed under the rate in effect on 
     January 1, 2005.
       (c) Vaccine Tax and Trust Fund Amendments.--
       (1) Sections 1503 and 1504 of the Vaccine Injury 
     Compensation Program Modification Act (and the amendments 
     made by such sections) are hereby repealed.
       (2) Subparagraph (A) of section 9510(c)(1) of such Code is 
     amended by striking ``August 5, 1997'' and inserting 
     ``October 21, 1998''.
       (3) The amendments made by this subsection shall take 
     effect as if included in the provisions of the Tax and Trade 
     Relief Extension Act of 1998 to which they relate.
       (d) Report.--Not later than December 31, 1999, the 
     Comptroller General of the United States shall prepare and 
     submit a report to the Committee on Ways and Means of the 
     House of Representatives and the Committee on Finance of the 
     Senate on the operation of the Vaccine Injury Compensation 
     Trust Fund and on the adequacy of such Fund to meet future 
     claims made under the Vaccine Injury Compensation Program.

     SEC. 108. CREDIT FOR CLINICAL TESTING RESEARCH EXPENSES 
                   ATTRIBUTABLE TO CERTAIN QUALIFIED ACADEMIC 
                   INSTITUTIONS INCLUDING TEACHING HOSPITALS.

       (a) In General.--Subpart D of part IV of subchapter A of 
     chapter 1 of the Internal Revenue Code of 1986 (relating to 
     business related credits) is amended by inserting after 
     section 41 the following:

     ``SEC. 41A. CREDIT FOR MEDICAL INNOVATION EXPENSES.

       ``(a) General Rule.--For purposes of section 38, the 
     medical innovation credit determined under this section for 
     the taxable year shall be an amount equal to 40 percent of 
     the excess (if any) of--
       ``(1) the qualified medical innovation expenses for the 
     taxable year, over
       ``(2) the medical innovation base period amount.
       ``(b) Qualified Medical Innovation Expenses.--For purposes 
     of this section--
       ``(1) In general.--The term `qualified medical innovation 
     expenses' means the amounts which are paid or incurred by the 
     taxpayer during the taxable year directly or indirectly to 
     any qualified academic institution for clinical testing 
     research activities.
       ``(2) Clinical testing research activities.--
       ``(A) In general.--The term `clinical testing research 
     activities' means human clinical testing conducted at any 
     qualified academic institution in the development of any 
     product, which occurs before--
       ``(i) the date on which an application with respect to such 
     product is approved under section 505(b), 506, or 507 of the 
     Federal Food, Drug, and Cosmetic Act (as in effect on the 
     date of the enactment of this section),
       ``(ii) the date on which a license for such product is 
     issued under section 351 of the Public Health Service Act (as 
     so in effect), or
       ``(iii) the date classification or approval of such product 
     which is a device intended for human use is given under 
     section 513, 514, or 515 of the Federal Food, Drug, and 
     Cosmetic Act (as so in effect).
       ``(B) Product.--The term `product' means any drug, 
     biologic, or medical device.
       ``(3) Qualified academic institution.--The term `qualified 
     academic institution' means any of the following 
     institutions:
       ``(A) Educational institution.--A qualified organization 
     described in section 170(b)(1)(A)(iii) which is owned by, or 
     affiliated with, an institution of higher education (as 
     defined in section 3304(f )).
       ``(B) Teaching hospital.--A teaching hospital which--
       ``(i) is publicly supported or owned by an organization 
     described in section 501(c)(3), and
       ``(ii) is affiliated with an organization meeting the 
     requirements of subparagraph (A).
       ``(C) Foundation.--A medical research organization 
     described in section 501(c)(3) (other than a private 
     foundation) which is affiliated with, or owned by--
       ``(i) an organization meeting the requirements of 
     subparagraph (A), or
       ``(ii) a teaching hospital meeting the requirements of 
     subparagraph (B).
       ``(D) Charitable research hospital.--A hospital that is 
     designated as a cancer center by the National Cancer 
     Institute.
       ``(4) Exclusion for amounts funded by grants, etc.--The 
     term `qualified medical innovation expenses' shall not 
     include any amount to the extent such amount is funded by any 
     grant, contract, or otherwise by another person (or any 
     governmental entity).
       ``(c) Medical Innovation Base Period Amount.--For purposes 
     of this section, the term `medical innovation base period 
     amount' means the average annual qualified medical innovation 
     expenses paid by the taxpayer during the 3-taxable year 
     period ending with the taxable year immediately preceding the 
     first taxable year of the taxpayer beginning after December 
     31, 2000.
       ``(d) Special Rules.--
       ``(1) Limitation on foreign testing.--No credit shall be 
     allowed under this section with respect to any clinical 
     testing research activities conducted outside the United 
     States.
       ``(2) Certain rules made applicable.--Rules similar to the 
     rules of subsections (f ) and (g) of section 41 shall apply 
     for purposes of this section.
       ``(3) Election.--This section shall apply to any taxpayer 
     for any taxable year only if such taxpayer elects to have 
     this section apply for such taxable year.
       ``(4) Coordination with credit for increasing research 
     expenditures and with credit for clinical testing expenses 
     for certain drugs for rare diseases.--Any qualified medical 
     innovation expense for a taxable year to which an election 
     under this section applies shall not be taken into account 
     for purposes of determining the credit allowable under 
     section 41 or 45C for such taxable year.''.
       (b) Credit To Be Part of General Business Credit.--
       (1) In general.--Section 38(b) of such Code (relating to 
     current year business credits) is amended by striking 
     ``plus'' at the end of paragraph (11), by striking the period 
     at the end of paragraph (12) and inserting ``, plus'', and by 
     adding at the end the following:
       ``(13) the medical innovation expenses credit determined 
     under section 41A(a).''.
       (2) Transition rule.--Section 39(d) of such Code is amended 
     by adding at the end the following new paragraph:
       ``(9) No carryback of section 41a credit before 
     enactment.--No portion of the unused business credit for any 
     taxable year which is attributable to the medical innovation 
     credit determined under section 41A may be carried back to a 
     taxable year beginning before January 1, 2001.''.
       (c) Denial of Double Benefit.--Section 280C of such Code is 
     amended by adding at the end the following new subsection:
       ``(d) Credit for Increasing Medical Innovation Expenses.--
       ``(1) In general.--No deduction shall be allowed for that 
     portion of the qualified medical innovation expenses (as 
     defined in section 41A(b)) otherwise allowable as a deduction 
     for the taxable year which is equal to the amount of the 
     credit determined for such taxable year under section 41A(a).
       ``(2) Certain rules to apply.--Rules similar to the rules 
     of paragraphs (2), (3), and (4) of subsection (c) shall apply 
     for purposes of this subsection.''.
       (d) Deduction for Unused Portion of Credit.--Section 196(c) 
     of such Code (defining qualified business credits) is amended 
     by redesignating paragraphs (5) through (8) as paragraphs (6) 
     through (9), respectively, and by inserting after paragraph 
     (4) the following new paragraph:
       ``(5) the medical innovation expenses credit determined 
     under section 41A(a) (other than such credit determined under 
     the rules of section 280C(d)(2)),''.
       (e) Clerical Amendment.--The table of sections for subpart 
     D of part IV of subchapter A of chapter 1 of such Code is 
     amended by adding after the item relating to section 41 
     the following:

``Sec. 41A. Credit for medical innovation expenses.''.

       (f) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2000.

  TITLE II--GREATER ACCESS AND CHOICE THROUGH ASSOCIATION HEALTH PLANS

     SEC. 201. RULES.

       (a) In General.--Subtitle B of title I of the Employee 
     Retirement Income Security Act of 1974 is amended by adding 
     after part 7 the following new part:

           ``Part 8--Rules Governing Association Health Plans

     ``SEC. 801. ASSOCIATION HEALTH PLANS.

       ``(a) In General.--For purposes of this part, the term 
     `association health plan' means a group health plan--
       ``(1) whose sponsor is (or is deemed under this part to be) 
     described in subsection (b); and
       ``(2) under which at least one option of health insurance 
     coverage offered by a health insurance issuer (which may 
     include,

[[Page H9435]]

     among other options, managed care options, point of service 
     options, and preferred provider options) is provided to 
     participants and beneficiaries, unless, for any plan year, 
     such coverage remains unavailable to the plan despite good 
     faith efforts exercised by the plan to secure such coverage.
       ``(b) Sponsorship.--The sponsor of a group health plan is 
     described in this subsection if such sponsor--
       ``(1) is organized and maintained in good faith, with a 
     constitution and bylaws specifically stating its purpose and 
     providing for periodic meetings on at least an annual basis, 
     as a bona fide trade association, a bona fide industry 
     association (including a rural electric cooperative 
     association or a rural telephone cooperative association), a 
     bona fide professional association, or a bona fide chamber of 
     commerce (or similar bona fide business association, 
     including a corporation or similar organization that operates 
     on a cooperative basis (within the meaning of section 1381 of 
     the Internal Revenue Code of 1986)), for substantial purposes 
     other than that of obtaining or providing medical care;
       ``(2) is established as a permanent entity which receives 
     the active support of its members and collects from its 
     members on a periodic basis dues or payments necessary to 
     maintain eligibility for membership in the sponsor; and
       ``(3) does not condition membership, such dues or payments, 
     or coverage under the plan on the basis of health status-
     related factors with respect to the employees of its members 
     (or affiliated members), or the dependents of such employees, 
     and does not condition such dues or payments on the basis of 
     group health plan participation.

     Any sponsor consisting of an association of entities which 
     meet the requirements of paragraphs (1), (2), and (3) shall 
     be deemed to be a sponsor described in this subsection.

     ``SEC. 802. CERTIFICATION OF ASSOCIATION HEALTH PLANS.

       ``(a) In General.--The applicable authority shall prescribe 
     by regulation, through negotiated rulemaking, a procedure 
     under which, subject to subsection (b), the applicable 
     authority shall certify association health plans which apply 
     for certification as meeting the requirements of this part.
       ``(b) Standards.--Under the procedure prescribed pursuant 
     to subsection (a), in the case of an association health plan 
     that provides at least one benefit option which does not 
     consist of health insurance coverage, the applicable 
     authority shall certify such plan as meeting the requirements 
     of this part only if the applicable authority is satisfied 
     that--
       ``(1) such certification--
       ``(A) is administratively feasible;
       ``(B) is not adverse to the interests of the individuals 
     covered under the plan; and
       ``(C) is protective of the rights and benefits of the 
     individuals covered under the plan; and
       ``(2) the applicable requirements of this part are met (or, 
     upon the date on which the plan is to commence operations, 
     will be met) with respect to the plan.
       ``(c) Requirements Applicable to Certified Plans.--An 
     association health plan with respect to which certification 
     under this part is in effect shall meet the applicable 
     requirements of this part, effective on the date of 
     certification (or, if later, on the date on which the plan is 
     to commence operations).
       ``(d) Requirements for Continued Certification.--The 
     applicable authority may provide by regulation, through 
     negotiated rulemaking, for continued certification of 
     association health plans under this part.
       ``(e) Class Certification for Fully Insured Plans.--The 
     applicable authority shall establish a class certification 
     procedure for association health plans under which all 
     benefits consist of health insurance coverage. Under such 
     procedure, the applicable authority shall provide for the 
     granting of certification under this part to the plans in 
     each class of such association health plans upon appropriate 
     filing under such procedure in connection with plans in such 
     class and payment of the prescribed fee under section 807(a).
       ``(f) Certification of Self-Insured Association Health 
     Plans.--An association health plan which offers one or more 
     benefit options which do not consist of health insurance 
     coverage may be certified under this part only if such plan 
     consists of any of the following:
       ``(1) a plan which offered such coverage on the date of the 
     enactment of the Quality Care for the Uninsured Act of 1999,
       ``(2) a plan under which the sponsor does not restrict 
     membership to one or more trades and businesses or industries 
     and whose eligible participating employers represent a broad 
     cross-section of trades and businesses or industries, or
       ``(3) a plan whose eligible participating employers 
     represent one or more trades or businesses, or one or more 
     industries, which have been indicated as having average or 
     above-average health insurance risk or health claims 
     experience by reason of State rate filings, denials of 
     coverage, proposed premium rate levels, and other means 
     demonstrated by such plan in accordance with regulations 
     which the Secretary shall prescribe through negotiated 
     rulemaking, including (but not limited to) the following: 
     agriculture; automobile dealerships; barbering and 
     cosmetology; child care; construction; dance, theatrical, and 
     orchestra productions; disinfecting and pest control; eating 
     and drinking establishments; fishing; hospitals; labor 
     organizations; logging; manufacturing (metals); mining; 
     medical and dental practices; medical laboratories; sanitary 
     services; transportation (local and freight); and 
     warehousing.

     ``SEC. 803. REQUIREMENTS RELATING TO SPONSORS AND BOARDS OF 
                   TRUSTEES.

       ``(a) Sponsor.--The requirements of this subsection are met 
     with respect to an association health plan if the sponsor has 
     met (or is deemed under this part to have met) the 
     requirements of section 801(b) for a continuous period of not 
     less than 3 years ending with the date of the application for 
     certification under this part.
       ``(b) Board of Trustees.--The requirements of this 
     subsection are met with respect to an association health plan 
     if the following requirements are met:
       ``(1) Fiscal control.--The plan is operated, pursuant to a 
     trust agreement, by a board of trustees which has complete 
     fiscal control over the plan and which is responsible for all 
     operations of the plan.
       ``(2) Rules of operation and financial controls.--The board 
     of trustees has in effect rules of operation and financial 
     controls, based on a 3-year plan of operation, adequate to 
     carry out the terms of the plan and to meet all requirements 
     of this title applicable to the plan.
       ``(3) Rules governing relationship to participating 
     employers and to contractors.--
       ``(A) In general.--Except as provided in subparagraphs (B) 
     and (C), the members of the board of trustees are individuals 
     selected from individuals who are the owners, officers, 
     directors, or employees of the participating employers or who 
     are partners in the participating employers and actively 
     participate in the business.
       ``(B) Limitation.--
       ``(i) General rule.--Except as provided in clauses (ii) and 
     (iii), no such member is an owner, officer, director, or 
     employee of, or partner in, a contract administrator or other 
     service provider to the plan.
       ``(ii) Limited exception for providers of services solely 
     on behalf of the sponsor.--Officers or employees of a sponsor 
     which is a service provider (other than a contract 
     administrator) to the plan may be members of the board if 
     they constitute not more than 25 percent of the membership of 
     the board and they do not provide services to the plan other 
     than on behalf of the sponsor.
       ``(iii) Treatment of providers of medical care.--In the 
     case of a sponsor which is an association whose membership 
     consists primarily of providers of medical care, clause (i) 
     shall not apply in the case of any service provider described 
     in subparagraph (A) who is a provider of medical care under 
     the plan.
       ``(C) Certain plans excluded.--Subparagraph (A) shall not 
     apply to an association health plan which is in existence on 
     the date of the enactment of the Quality Care for the 
     Uninsured Act of 1999.
       ``(D) Sole authority.--The board has sole authority under 
     the plan to approve applications for participation in the 
     plan and to contract with a service provider to administer 
     the day-to-day affairs of the plan.
       ``(c) Treatment of Franchise Networks.--In the case of a 
     group health plan which is established and maintained by a 
     franchiser for a franchise network consisting of its 
     franchisees--
       ``(1) the requirements of subsection (a) and section 
     801(a)(1) shall be deemed met if such requirements would 
     otherwise be met if the franchiser were deemed to be the 
     sponsor referred to in section 801(b), such network were 
     deemed to be an association described in section 801(b), and 
     each franchisee were deemed to be a member (of the 
     association and the sponsor) referred to in section 801(b); 
     and
       ``(2) the requirements of section 804(a)(1) shall be deemed 
     met.
     The Secretary may by regulation, through negotiated 
     rulemaking, define for purposes of this subsection the terms 
     `franchiser', `franchise network', and `franchisee'.
       ``(d) Certain Collectively Bargained Plans.--
       ``(1) In general.--In the case of a group health plan 
     described in paragraph (2)--
       ``(A) the requirements of subsection (a) and section 
     801(a)(1) shall be deemed met;
       ``(B) the joint board of trustees shall be deemed a board 
     of trustees with respect to which the requirements of 
     subsection (b) are met; and
       ``(C) the requirements of section 804 shall be deemed met.
       ``(2) Requirements.--A group health plan is described in 
     this paragraph if--
       ``(A) the plan is a multiemployer plan; or
       ``(B) the plan is in existence on April 1, 1997, and would 
     be described in section 3(40)(A)(i) but solely for the 
     failure to meet the requirements of section 3(40)(C)(ii).

     ``SEC. 804. PARTICIPATION AND COVERAGE REQUIREMENTS.

       ``(a) Covered Employers and Individuals.--The requirements 
     of this subsection are met with respect to an association 
     health plan if, under the terms of the plan--
       ``(1) each participating employer must be--
       ``(A) a member of the sponsor,
       ``(B) the sponsor, or
       ``(C) an affiliated member of the sponsor with respect to 
     which the requirements of subsection (b) are met,

     except that, in the case of a sponsor which is a professional 
     association or other individual-based association, if at 
     least one of the officers, directors, or employees of an

[[Page H9436]]

     employer, or at least one of the individuals who are partners 
     in an employer and who actively participates in the business, 
     is a member or such an affiliated member of the sponsor, 
     participating employers may also include such employer; and
       ``(2) all individuals commencing coverage under the plan 
     after certification under this part must be--
       ``(A) active or retired owners (including self-employed 
     individuals), officers, directors, or employees of, or 
     partners in, participating employers; or
       ``(B) the beneficiaries of individuals described in 
     subparagraph (A).
       ``(b) Coverage of Previously Uninsured Employees.--In the 
     case of an association health plan in existence on the date 
     of the enactment of the Quality Care for the Uninsured Act of 
     1999, an affiliated member of the sponsor of the plan may be 
     offered coverage under the plan as a participating employer 
     only if--
       ``(1) the affiliated member was an affiliated member on the 
     date of certification under this part; or
       ``(2) during the 12-month period preceding the date of the 
     offering of such coverage, the affiliated member has not 
     maintained or contributed to a group health plan with respect 
     to any of its employees who would otherwise be eligible to 
     participate in such association health plan.
       ``(c) Individual Market Unaffected.--The requirements of 
     this subsection are met with respect to an association health 
     plan if, under the terms of the plan, no participating 
     employer may provide health insurance coverage in the 
     individual market for any employee not covered under the plan 
     which is similar to the coverage contemporaneously provided 
     to employees of the employer under the plan, if such 
     exclusion of the employee from coverage under the plan is 
     based on a health status-related factor with respect to the 
     employee and such employee would, but for such exclusion on 
     such basis, be eligible for coverage under the plan.
       ``(d) Prohibition of Discrimination Against Employers and 
     Employees Eligible To Participate.--The requirements of this 
     subsection are met with respect to an association health plan 
     if--
       ``(1) under the terms of the plan, all employers meeting 
     the preceding requirements of this section are eligible to 
     qualify as participating employers for all geographically 
     available coverage options, unless, in the case of any such 
     employer, participation or contribution requirements of the 
     type referred to in section 2711 of the Public Health Service 
     Act are not met;
       ``(2) upon request, any employer eligible to participate is 
     furnished information regarding all coverage options 
     available under the plan; and
       ``(3) the applicable requirements of sections 701, 702, and 
     703 are met with respect to the plan.

     ``SEC. 805. OTHER REQUIREMENTS RELATING TO PLAN DOCUMENTS, 
                   CONTRIBUTION RATES, AND BENEFIT OPTIONS.

       ``(a) In General.--The requirements of this section are met 
     with respect to an association health plan if the following 
     requirements are met:
       ``(1) Contents of governing instruments.--The instruments 
     governing the plan include a written instrument, meeting the 
     requirements of an instrument required under section 
     402(a)(1), which--
       ``(A) provides that the board of trustees serves as the 
     named fiduciary required for plans under section 402(a)(1) 
     and serves in the capacity of a plan administrator (referred 
     to in section 3(16)(A));
       ``(B) provides that the sponsor of the plan is to serve as 
     plan sponsor (referred to in section 3(16)(B)); and
       ``(C) incorporates the requirements of section 806.
       ``(2) Contribution rates must be nondiscriminatory.--
       ``(A) The contribution rates for any participating small 
     employer do not vary on the basis of the claims experience of 
     such employer and do not vary on the basis of the type of 
     business or industry in which such employer is engaged.
       ``(B) Nothing in this title or any other provision of law 
     shall be construed to preclude an association health plan, or 
     a health insurance issuer offering health insurance coverage 
     in connection with an association health plan, from--
       ``(i) setting contribution rates based on the claims 
     experience of the plan; or
       ``(ii) varying contribution rates for small employers in a 
     State to the extent that such rates could vary using the same 
     methodology employed in such State for regulating premium 
     rates in the small group market with respect to health 
     insurance coverage offered in connection with bona fide 
     associations (within the meaning of section 2791(d)(3) of the 
     Public Health Service Act),

     subject to the requirements of section 702(b) relating to 
     contribution rates.
       ``(3) Floor for number of covered individuals with respect 
     to certain plans.--If any benefit option under the plan does 
     not consist of health insurance coverage, the plan has as of 
     the beginning of the plan year not fewer than 1,000 
     participants and beneficiaries.
       ``(4) Marketing requirements.--
       ``(A) In general.--If a benefit option which consists of 
     health insurance coverage is offered under the plan, State-
     licensed insurance agents shall be used to distribute to 
     small employers coverage which does not consist of health 
     insurance coverage in a manner comparable to the manner in 
     which such agents are used to distribute health insurance 
     coverage.
       ``(B) State-licensed insurance agents.--For purposes of 
     subparagraph (A), the term `State-licensed insurance agents' 
     means one or more agents who are licensed in a State and are 
     subject to the laws of such State relating to licensure, 
     qualification, testing, examination, and continuing education 
     of persons authorized to offer, sell, or solicit health 
     insurance coverage in such State.
       ``(5) Regulatory requirements.--Such other requirements as 
     the applicable authority determines are necessary to carry 
     out the purposes of this part, which shall be prescribed by 
     the applicable authority by regulation through negotiated 
     rulemaking.
       ``(b) Ability of Association Health Plans To Design Benefit 
     Options.--Subject to section 514(d), nothing in this part or 
     any provision of State law (as defined in section 514(c)(1)) 
     shall be construed to preclude an association health plan, or 
     a health insurance issuer offering health insurance coverage 
     in connection with an association health plan, from 
     exercising its sole discretion in selecting the specific 
     items and services consisting of medical care to be included 
     as benefits under such plan or coverage, except (subject to 
     section 514) in the case of any law to the extent that it (1) 
     prohibits an exclusion of a specific disease from such 
     coverage, or (2) is not preempted under section 731(a)(1) 
     with respect to matters governed by section 711 or 712.

     ``SEC. 806. MAINTENANCE OF RESERVES AND PROVISIONS FOR 
                   SOLVENCY FOR PLANS PROVIDING HEALTH BENEFITS IN 
                   ADDITION TO HEALTH INSURANCE COVERAGE.

       ``(a) In General.--The requirements of this section are met 
     with respect to an association health plan if--
       ``(1) the benefits under the plan consist solely of health 
     insurance coverage; or
       ``(2) if the plan provides any additional benefit options 
     which do not consist of health insurance coverage, the plan--
       ``(A) establishes and maintains reserves with respect to 
     such additional benefit options, in amounts recommended by 
     the qualified actuary, consisting of--
       ``(i) a reserve sufficient for unearned contributions;
       ``(ii) a reserve sufficient for benefit liabilities which 
     have been incurred, which have not been satisfied, and for 
     which risk of loss has not yet been transferred, and for 
     expected administrative costs with respect to such benefit 
     liabilities;
       ``(iii) a reserve sufficient for any other obligations of 
     the plan; and
       ``(iv) a reserve sufficient for a margin of error and other 
     fluctuations, taking into account the specific circumstances 
     of the plan; and
       ``(B) establishes and maintains aggregate and specific 
     excess /stop loss insurance and solvency indemnification, 
     with respect to such additional benefit options for which 
     risk of loss has not yet been transferred, as follows:
       ``(i) The plan shall secure aggregate excess /stop loss 
     insurance for the plan with an attachment point which is not 
     greater than 125 percent of expected gross annual claims. The 
     applicable authority may by regulation, through negotiated 
     rulemaking, provide for upward adjustments in the amount of 
     such percentage in specified circumstances in which the plan 
     specifically provides for and maintains reserves in excess of 
     the amounts required under subparagraph (A).
       ``(ii) The plan shall secure specific excess /stop loss 
     insurance for the plan with an attachment point which is at 
     least equal to an amount recommended by the plan's qualified 
     actuary (but not more than $175,000). The applicable 
     authority may by regulation, through negotiated rulemaking, 
     provide for adjustments in the amount of such insurance in 
     specified circumstances in which the plan specifically 
     provides for and maintains reserves in excess of the amounts 
     required under subparagraph (A).
       ``(iii) The plan shall secure indemnification insurance for 
     any claims which the plan is unable to satisfy by reason of a 
     plan termination.

     Any regulations prescribed by the applicable authority 
     pursuant to clause (i) or (ii) of subparagraph (B) may allow 
     for such adjustments in the required levels of excess /stop 
     loss insurance as the qualified actuary may recommend, taking 
     into account the specific circumstances of the plan.
       ``(b) Minimum Surplus in Addition to Claims Reserves.--In 
     the case of any association health plan described in 
     subsection (a)(2), the requirements of this subsection are 
     met if the plan establishes and maintains surplus in an 
     amount at least equal to--
       ``(1) $500,000, or
       ``(2) such greater amount (but not greater than $2,000,000) 
     as may be set forth in regulations prescribed by the 
     applicable authority through negotiated rulemaking, based on 
     the level of aggregate and specific excess /stop loss 
     insurance provided with respect to such plan.
       ``(c) Additional Requirements.--In the case of any 
     association health plan described in subsection (a)(2), the 
     applicable authority may provide such additional requirements 
     relating to reserves and excess /stop loss insurance as the 
     applicable authority considers appropriate. Such requirements 
     may be provided by regulation, through negotiated rulemaking, 
     with respect to any such plan or any class of such plans.

[[Page H9437]]

       ``(d) Adjustments for Excess /Stop Loss Insurance.--The 
     applicable authority may provide for adjustments to the 
     levels of reserves otherwise required under subsections (a) 
     and (b) with respect to any plan or class of plans to take 
     into account excess /stop loss insurance provided with 
     respect to such plan or plans.
       ``(e) Alternative Means of Compliance.--The applicable 
     authority may permit an association health plan described in 
     subsection (a)(2) to substitute, for all or part of the 
     requirements of this section (except subsection 
     (a)(2)(B)(iii)), such security, guarantee, hold-harmless 
     arrangement, or other financial arrangement as the applicable 
     authority determines to be adequate to enable the plan to 
     fully meet all its financial obligations on a timely basis 
     and is otherwise no less protective of the interests of 
     participants and beneficiaries than the requirements for 
     which it is substituted. The applicable authority may take 
     into account, for purposes of this subsection, evidence 
     provided by the plan or sponsor which demonstrates an 
     assumption of liability with respect to the plan. Such 
     evidence may be in the form of a contract of indemnification, 
     lien, bonding, insurance, letter of credit, recourse under 
     applicable terms of the plan in the form of assessments of 
     participating employers, security, or other financial 
     arrangement.
       ``(f) Measures To Ensure Continued Payment of Benefits by 
     Certain Plans in Distress.--
       ``(1) Payments by certain plans to association health plan 
     fund.--
       ``(A) In general.--In the case of an association health 
     plan described in subsection (a)(2), the requirements of this 
     subsection are met if the plan makes payments into the 
     Association Health Plan Fund under this subparagraph when 
     they are due. Such payments shall consist of annual payments 
     in the amount of $5,000, except that the Secretary shall 
     reduce part or all of such annual payments, or shall 
     provide a rebate of part or all of such a payment, to the 
     extent that the Secretary determines that the balance in 
     such Fund is sufficient (taking into account such a 
     reduction or rebate) to meet all reasonable actuarial 
     requirements. Such determination shall occur not less than 
     once annually. In addition to any such annual payments, 
     such payments may include such supplemental payments as 
     the Secretary may determine to be necessary to meet 
     reasonable actuarial requirements to carry out paragraph 
     (2). Payments under this paragraph are payable to the Fund 
     at the time determined by the Secretary. Initial payments 
     are due in advance of certification under this part. 
     Payments shall continue to accrue until a plan's assets 
     are distributed pursuant to a termination procedure.
       ``(B) Penalties for failure to make payments.--If any 
     payment is not made by a plan when it is due, a late payment 
     charge of not more than 100 percent of the payment which was 
     not timely paid shall be payable by the plan to the Fund.
       ``(C) Continued duty of the secretary.--The Secretary shall 
     not cease to carry out the provisions of paragraph (2) on 
     account of the failure of a plan to pay any payment when due.
       ``(2) Payments by secretary to continue excess /stop loss 
     insurance coverage and indemnification insurance coverage for 
     certain plans.--In any case in which the applicable authority 
     determines that there is, or that there is reason to believe 
     that there will be: (A) a failure to take necessary 
     corrective actions under section 809(a) with respect to an 
     association health plan described in subsection (a)(2); or 
     (B) a termination of such a plan under section 809(b) or 
     810(b)(8) (and, if the applicable authority is not the 
     Secretary, certifies such determination to the Secretary), 
     the Secretary shall determine the amounts necessary to make 
     payments to an insurer (designated by the Secretary) to 
     maintain in force excess /stop loss insurance coverage or 
     indemnification insurance coverage for such plan, if the 
     Secretary determines that there is a reasonable expectation 
     that, without such payments, claims would not be satisfied by 
     reason of termination of such coverage. The Secretary shall, 
     to the extent provided in advance in appropriation Acts, pay 
     such amounts so determined to the insurer designated by the 
     Secretary.
       ``(3) Association health plan fund.--
       ``(A) In general.--There is established on the books of the 
     Treasury a fund to be known as the `Association Health Plan 
     Fund'. The Fund shall be available for making payments 
     pursuant to paragraph (2). The Fund shall be credited with 
     payments received pursuant to paragraph (1)(A), penalties 
     received pursuant to paragraph (1)(B); and earnings on 
     investments of amounts of the Fund under subparagraph (B).
       ``(B) Investment.--Whenever the Secretary determines that 
     the moneys of the fund are in excess of current needs, the 
     Secretary may request the investment of such amounts as the 
     Secretary determines advisable by the Secretary of the 
     Treasury in obligations issued or guaranteed by the United 
     States.
       ``(g) Excess /Stop Loss Insurance.--For purposes of this 
     section--
       ``(1) Aggregate excess /stop loss insurance.--The term 
     `aggregate excess /stop loss insurance' means, in connection 
     with an association health plan, a contract--
       ``(A) under which an insurer (meeting such minimum 
     standards as the applicable authority may prescribe by 
     regulation through negotiated rulemaking) provides for 
     payment to the plan with respect to aggregate claims under 
     the plan in excess of an amount or amounts specified in such 
     contract;
       ``(B) which is guaranteed renewable; and
       ``(C) which allows for payment of premiums by any third 
     party on behalf of the insured plan.
       ``(2) Specific excess /stop loss insurance.--The term 
     `specific excess /stop loss insurance' means, in connection 
     with an association health plan, a contract--
       ``(A) under which an insurer (meeting such minimum 
     standards as the applicable authority may prescribe by 
     regulation through negotiated rulemaking) provides for 
     payment to the plan with respect to claims under the plan in 
     connection with a covered individual in excess of an amount 
     or amounts specified in such contract in connection with such 
     covered individual;
       ``(B) which is guaranteed renewable; and
       ``(C) which allows for payment of premiums by any third 
     party on behalf of the insured plan.
       ``(h) Indemnification Insurance.--For purposes of this 
     section, the term `indemnification insurance' means, in 
     connection with an association health plan, a contract--
       ``(1) under which an insurer (meeting such minimum 
     standards as the applicable authority may prescribe through 
     negotiated rulemaking) provides for payment to the plan with 
     respect to claims under the plan which the plan is unable to 
     satisfy by reason of a termination pursuant to section 809(b) 
     (relating to mandatory termination);
       ``(2) which is guaranteed renewable and noncancellable for 
     any reason (except as the applicable authority may prescribe 
     by regulation through negotiated rulemaking); and
       ``(3) which allows for payment of premiums by any third 
     party on behalf of the insured plan.
       ``(i) Reserves.--For purposes of this section, the term 
     `reserves' means, in connection with an association health 
     plan, plan assets which meet the fiduciary standards under 
     part 4 and such additional requirements regarding liquidity 
     as the applicable authority may prescribe through negotiated 
     rulemaking.
       ``(j) Solvency Standards Working Group.--
       ``(1) In general.--Within 90 days after the date of the 
     enactment of the Quality Care for the Uninsured Act of 1999, 
     the applicable authority shall establish a Solvency Standards 
     Working Group. In prescribing the initial regulations under 
     this section, the applicable authority shall take into 
     account the recommendations of such Working Group.
       ``(2) Membership.--The Working Group shall consist of 18 
     members appointed by the applicable authority as follows:
       ``(A) 3 representatives of the National Association of 
     Insurance Commissioners;
       ``(B) 3 representatives of the American Academy of 
     Actuaries;
       ``(C) 3 representatives of the State governments, or their 
     interests;
       ``(D) 3 representatives of existing self-insured 
     arrangements, or their interests;
       ``(E) 3 representatives of associations of the type 
     referred to in section 801(b)(1), or their interests; and
       ``(F) 3 representatives of multiemployer plans that are 
     group health plans, or their interests.

     ``SEC. 807. REQUIREMENTS FOR APPLICATION AND RELATED 
                   REQUIREMENTS.

       ``(a) Filing Fee.--Under the procedure prescribed pursuant 
     to section 802(a), an association health plan shall pay to 
     the applicable authority at the time of filing an application 
     for certification under this part a filing fee in the amount 
     of $5,000, which shall be available in the case of the 
     Secretary, to the extent provided in appropriation Acts, for 
     the sole purpose of administering the certification 
     procedures applicable with respect to association health 
     plans.
       ``(b) Information To Be Included in Application for 
     Certification.--An application for certification under this 
     part meets the requirements of this section only if it 
     includes, in a manner and form which shall be prescribed by 
     the applicable authority through negotiated rulemaking, at 
     least the following information:
       ``(1) Identifying information.--The names and addresses 
     of--
       ``(A) the sponsor; and
       ``(B) the members of the board of trustees of the plan.
       ``(2) States in which plan intends to do business.--The 
     States in which participants and beneficiaries under the plan 
     are to be located and the number of them expected to be 
     located in each such State.
       ``(3) Bonding requirements.--Evidence provided by the board 
     of trustees that the bonding requirements of section 412 will 
     be met as of the date of the application or (if later) 
     commencement of operations.
       ``(4) Plan documents.--A copy of the documents governing 
     the plan (including any bylaws and trust agreements), the 
     summary plan description, and other material describing the 
     benefits that will be provided to participants and 
     beneficiaries under the plan.
       ``(5) Agreements with service providers.--A copy of any 
     agreements between the plan and contract administrators and 
     other service providers.
       ``(6) Funding report.--In the case of association health 
     plans providing benefits options in addition to health 
     insurance coverage, a report setting forth information with 
     respect to such additional benefit options determined as of a 
     date within the 120-day period ending with the date of the 
     application, including the following:

[[Page H9438]]

       ``(A) Reserves.--A statement, certified by the board of 
     trustees of the plan, and a statement of actuarial opinion, 
     signed by a qualified actuary, that all applicable 
     requirements of section 806 are or will be met in accordance 
     with regulations which the applicable authority shall 
     prescribe through negotiated rulemaking.
       ``(B) Adequacy of contribution rates.--A statement of 
     actuarial opinion, signed by a qualified actuary, which sets 
     forth a description of the extent to which contribution rates 
     are adequate to provide for the payment of all obligations 
     and the maintenance of required reserves under the plan for 
     the 12-month period beginning with such date within such 120-
     day period, taking into account the expected coverage and 
     experience of the plan. If the contribution rates are not 
     fully adequate, the statement of actuarial opinion shall 
     indicate the extent to which the rates are inadequate and the 
     changes needed to ensure adequacy.
       ``(C) Current and projected value of assets and 
     liabilities.--A statement of actuarial opinion signed by a 
     qualified actuary, which sets forth the current value of the 
     assets and liabilities accumulated under the plan and a 
     projection of the assets, liabilities, income, and expenses 
     of the plan for the 12-month period referred to in 
     subparagraph (B). The income statement shall identify 
     separately the plan's administrative expenses and claims.
       ``(D) Costs of coverage to be charged and other expenses.--
     A statement of the costs of coverage to be charged, including 
     an itemization of amounts for administration, reserves, and 
     other expenses associated with the operation of the plan.
       ``(E) Other information.--Any other information as may be 
     determined by the applicable authority, by regulation through 
     negotiated rulemaking, as necessary to carry out the purposes 
     of this part.
       ``(c) Filing Notice of Certification With States.--A 
     certification granted under this part to an association 
     health plan shall not be effective unless written notice of 
     such certification is filed with the applicable State 
     authority of each State in which at least 25 percent of the 
     participants and beneficiaries under the plan are located. 
     For purposes of this subsection, an individual shall be 
     considered to be located in the State in which a known 
     address of such individual is located or in which such 
     individual is employed.
       ``(d) Notice of Material Changes.--In the case of any 
     association health plan certified under this part, 
     descriptions of material changes in any information which was 
     required to be submitted with the application for the 
     certification under this part shall be filed in such form and 
     manner as shall be prescribed by the applicable authority by 
     regulation through negotiated rulemaking. The applicable 
     authority may require by regulation, through negotiated 
     rulemaking, prior notice of material changes with respect to 
     specified matters which might serve as the basis for 
     suspension or revocation of the certification.
       ``(e) Reporting Requirements for Certain Association Health 
     Plans.--An association health plan certified under this part 
     which provides benefit options in addition to health 
     insurance coverage for such plan year shall meet the 
     requirements of section 103 by filing an annual report under 
     such section which shall include information described in 
     subsection (b)(6) with respect to the plan year and, 
     notwithstanding section 104(a)(1)(A), shall be filed with the 
     applicable authority not later than 90 days after the close 
     of the plan year (or on such later date as may be prescribed 
     by the applicable authority). The applicable authority may 
     require by regulation through negotiated rulemaking such 
     interim reports as it considers appropriate.
       ``(f) Engagement of Qualified Actuary.--The board of 
     trustees of each association health plan which provides 
     benefits options in addition to health insurance coverage and 
     which is applying for certification under this part or is 
     certified under this part shall engage, on behalf of all 
     participants and beneficiaries, a qualified actuary who shall 
     be responsible for the preparation of the materials 
     comprising information necessary to be submitted by a 
     qualified actuary under this part. The qualified actuary 
     shall utilize such assumptions and techniques as are 
     necessary to enable such actuary to form an opinion as to 
     whether the contents of the matters reported under this 
     part--
       ``(1) are in the aggregate reasonably related to the 
     experience of the plan and to reasonable expectations; and
       ``(2) represent such actuary's best estimate of anticipated 
     experience under the plan.

     The opinion by the qualified actuary shall be made with 
     respect to, and shall be made a part of, the annual report.

     ``SEC. 808. NOTICE REQUIREMENTS FOR VOLUNTARY TERMINATION.

       ``Except as provided in section 809(b), an association 
     health plan which is or has been certified under this part 
     may terminate (upon or at any time after cessation of 
     accruals in benefit liabilities) only if the board of 
     trustees--
       ``(1) not less than 60 days before the proposed termination 
     date, provides to the participants and beneficiaries a 
     written notice of intent to terminate stating that such 
     termination is intended and the proposed termination date;
       ``(2) develops a plan for winding up the affairs of the 
     plan in connection with such termination in a manner which 
     will result in timely payment of all benefits for which the 
     plan is obligated; and
       ``(3) submits such plan in writing to the applicable 
     authority.

     Actions required under this section shall be taken in such 
     form and manner as may be prescribed by the applicable 
     authority by regulation through negotiated rulemaking.

     ``SEC. 809. CORRECTIVE ACTIONS AND MANDATORY TERMINATION.

       ``(a) Actions To Avoid Depletion of Reserves.--An 
     association health plan which is certified under this part 
     and which provides benefits other than health insurance 
     coverage shall continue to meet the requirements of section 
     806, irrespective of whether such certification continues in 
     effect. The board of trustees of such plan shall determine 
     quarterly whether the requirements of section 806 are met. In 
     any case in which the board determines that there is reason 
     to believe that there is or will be a failure to meet such 
     requirements, or the applicable authority makes such a 
     determination and so notifies the board, the board shall 
     immediately notify the qualified actuary engaged by the plan, 
     and such actuary shall, not later than the end of the next 
     following month, make such recommendations to the board for 
     corrective action as the actuary determines necessary to 
     ensure compliance with section 806. Not later than 30 days 
     after receiving from the actuary recommendations for 
     corrective actions, the board shall notify the applicable 
     authority (in such form and manner as the applicable 
     authority may prescribe by regulation through negotiated 
     rulemaking) of such recommendations of the actuary for 
     corrective action, together with a description of the actions 
     (if any) that the board has taken or plans to take in 
     response to such recommendations. The board shall thereafter 
     report to the applicable authority, in such form and 
     frequency as the applicable authority may specify to the 
     board, regarding corrective action taken by the board until 
     the requirements of section 806 are met.
       ``(b) Mandatory Termination.--In any case in which--
       ``(1) the applicable authority has been notified under 
     subsection (a) of a failure of an association health plan 
     which is or has been certified under this part and is 
     described in section 806(a)(2) to meet the requirements of 
     section 806 and has not been notified by the board of 
     trustees of the plan that corrective action has restored 
     compliance with such requirements; and
       ``(2) the applicable authority determines that there is a 
     reasonable expectation that the plan will continue to fail to 
     meet the requirements of section 806,

     the board of trustees of the plan shall, at the direction of 
     the applicable authority, terminate the plan and, in the 
     course of the termination, take such actions as the 
     applicable authority may require, including satisfying any 
     claims referred to in section 806(a)(2)(B)(iii) and 
     recovering for the plan any liability under subsection 
     (a)(2)(B)(iii) or (e) of section 806, as necessary to ensure 
     that the affairs of the plan will be, to the maximum extent 
     possible, wound up in a manner which will result in timely 
     provision of all benefits for which the plan is obligated.

     ``SEC. 810. TRUSTEESHIP BY THE SECRETARY OF INSOLVENT 
                   ASSOCIATION HEALTH PLANS PROVIDING HEALTH 
                   BENEFITS IN ADDITION TO HEALTH INSURANCE 
                   COVERAGE.

       ``(a) Appointment of Secretary as Trustee for Insolvent 
     Plans.--Whenever the Secretary determines that an association 
     health plan which is or has been certified under this part 
     and which is described in section 806(a)(2) will be unable to 
     provide benefits when due or is otherwise in a financially 
     hazardous condition, as shall be defined by the Secretary by 
     regulation through negotiated rulemaking, the Secretary 
     shall, upon notice to the plan, apply to the appropriate 
     United States district court for appointment of the Secretary 
     as trustee to administer the plan for the duration of the 
     insolvency. The plan may appear as a party and other 
     interested persons may intervene in the proceedings at the 
     discretion of the court. The court shall appoint such 
     Secretary trustee if the court determines that the 
     trusteeship is necessary to protect the interests of the 
     participants and beneficiaries or providers of medical care 
     or to avoid any unreasonable deterioration of the financial 
     condition of the plan. The trusteeship of such Secretary 
     shall continue until the conditions described in the first 
     sentence of this subsection are remedied or the plan is 
     terminated.
       ``(b) Powers as Trustee.--The Secretary, upon appointment 
     as trustee under subsection (a), shall have the power--
       ``(1) to do any act authorized by the plan, this title, or 
     other applicable provisions of law to be done by the plan 
     administrator or any trustee of the plan;
       ``(2) to require the transfer of all (or any part) of the 
     assets and records of the plan to the Secretary as trustee;
       ``(3) to invest any assets of the plan which the Secretary 
     holds in accordance with the provisions of the plan, 
     regulations prescribed by the Secretary through negotiated 
     rulemaking, and applicable provisions of law;
       ``(4) to require the sponsor, the plan administrator, any 
     participating employer, and any employee organization 
     representing plan participants to furnish any information 
     with respect to the plan which the Secretary as trustee may 
     reasonably need in order to administer the plan;

[[Page H9439]]

       ``(5) to collect for the plan any amounts due the plan and 
     to recover reasonable expenses of the trusteeship;
       ``(6) to commence, prosecute, or defend on behalf of the 
     plan any suit or proceeding involving the plan;
       ``(7) to issue, publish, or file such notices, statements, 
     and reports as may be required by the Secretary by regulation 
     through negotiated rulemaking or required by any order of the 
     court;
       ``(8) to terminate the plan (or provide for its termination 
     accordance with section 809(b)) and liquidate the plan 
     assets, to restore the plan to the responsibility of the 
     sponsor, or to continue the trusteeship;
       ``(9) to provide for the enrollment of plan participants 
     and beneficiaries under appropriate coverage options; and
       ``(10) to do such other acts as may be necessary to comply 
     with this title or any order of the court and to protect the 
     interests of plan participants and beneficiaries and 
     providers of medical care.
       ``(c) Notice of Appointment.--As soon as practicable after 
     the Secretary's appointment as trustee, the Secretary shall 
     give notice of such appointment to--
       ``(1) the sponsor and plan administrator;
       ``(2) each participant;
       ``(3) each participating employer; and
       ``(4) if applicable, each employee organization which, for 
     purposes of collective bargaining, represents plan 
     participants.
       ``(d) Additional Duties.--Except to the extent inconsistent 
     with the provisions of this title, or as may be otherwise 
     ordered by the court, the Secretary, upon appointment as 
     trustee under this section, shall be subject to the same 
     duties as those of a trustee under section 704 of title 11, 
     United States Code, and shall have the duties of a fiduciary 
     for purposes of this title.
       ``(e) Other Proceedings.--An application by the Secretary 
     under this subsection may be filed notwithstanding the 
     pendency in the same or any other court of any bankruptcy, 
     mortgage foreclosure, or equity receivership proceeding, or 
     any proceeding to reorganize, conserve, or liquidate such 
     plan or its property, or any proceeding to enforce a lien 
     against property of the plan.
       ``(f) Jurisdiction of Court.--
       ``(1) In general.--Upon the filing of an application for 
     the appointment as trustee or the issuance of a decree under 
     this section, the court to which the application is made 
     shall have exclusive jurisdiction of the plan involved and 
     its property wherever located with the powers, to the extent 
     consistent with the purposes of this section, of a court of 
     the United States having jurisdiction over cases under 
     chapter 11 of title 11, United States Code. Pending an 
     adjudication under this section such court shall stay, and 
     upon appointment by it of the Secretary as trustee, such 
     court shall continue the stay of, any pending mortgage 
     foreclosure, equity receivership, or other proceeding to 
     reorganize, conserve, or liquidate the plan, the sponsor, or 
     property of such plan or sponsor, and any other suit against 
     any receiver, conservator, or trustee of the plan, the 
     sponsor, or property of the plan or sponsor. Pending such 
     adjudication and upon the appointment by it of the Secretary 
     as trustee, the court may stay any proceeding to enforce a 
     lien against property of the plan or the sponsor or any other 
     suit against the plan or the sponsor.
       ``(2) Venue.--An action under this section may be brought 
     in the judicial district where the sponsor or the plan 
     administrator resides or does business or where any asset of 
     the plan is situated. A district court in which such action 
     is brought may issue process with respect to such action in 
     any other judicial district.
       ``(g) Personnel.--In accordance with regulations which 
     shall be prescribed by the Secretary through negotiated 
     rulemaking, the Secretary shall appoint, retain, and 
     compensate accountants, actuaries, and other professional 
     service personnel as may be necessary in connection with the 
     Secretary's service as trustee under this section.

     ``SEC. 811. STATE ASSESSMENT AUTHORITY.

       ``(a) In General.--Notwithstanding section 514, a State may 
     impose by law a contribution tax on an association health 
     plan described in section 806(a)(2), if the plan commenced 
     operations in such State after the date of the enactment of 
     the Quality Care for the Uninsured Act of 1999.
       ``(b) Contribution Tax.--For purposes of this section, the 
     term `contribution tax' imposed by a State on an association 
     health plan means any tax imposed by such State if--
       ``(1) such tax is computed by applying a rate to the amount 
     of premiums or contributions, with respect to individuals 
     covered under the plan who are residents of such State, which 
     are received by the plan from participating employers located 
     in such State or from such individuals;
       ``(2) the rate of such tax does not exceed the rate of any 
     tax imposed by such State on premiums or contributions 
     received by insurers or health maintenance organizations for 
     health insurance coverage offered in such State in connection 
     with a group health plan;
       ``(3) such tax is otherwise nondiscriminatory; and
       ``(4) the amount of any such tax assessed on the plan is 
     reduced by the amount of any tax or assessment otherwise 
     imposed by the State on premiums, contributions, or both 
     received by insurers or health maintenance organizations for 
     health insurance coverage, aggregate excess /stop loss 
     insurance (as defined in section 806(g)(1)), specific excess 
     /stop loss insurance (as defined in section 806(g)(2)), other 
     insurance related to the provision of medical care under the 
     plan, or any combination thereof provided by such insurers or 
     health maintenance organizations in such State in connection 
     with such plan.

     ``SEC. 812. SPECIAL RULES FOR CHURCH PLANS.

       ``(a) Election for Church Plans.--Notwithstanding section 
     4(b)(2), if a church, a convention or association 
     of churches, or an organization described in section 
     3(33)(C)(i) maintains a church plan which is a group 
     health plan (as defined in section 733(a)(1)), and such 
     church, convention, association, or organization makes an 
     election with respect to such plan under this subsection 
     (in such form and manner as the Secretary may by 
     regulation prescribe), then the provisions of this section 
     shall apply to such plan, with respect to benefits 
     provided under such plan consisting of medical care, as if 
     section 4(b)(2) did not contain an exclusion for church 
     plans. Nothing in this subsection shall be construed to 
     render any other section of this title applicable to 
     church plans, except to the extent that such other section 
     is incorporated by reference in this section.
       ``(b) Effect of Election.--
       ``(1) Preemption of state insurance laws regulating covered 
     church plans.--Subject to paragraphs (2) and (3), this 
     section shall supersede any and all State laws which regulate 
     insurance insofar as they may now or hereafter regulate 
     church plans to which this section applies or trusts 
     established under such church plans.
       ``(2) General state insurance regulation unaffected.--
       ``(A) In general.--Except as provided in subparagraph (B) 
     and paragraph (3), nothing in this section shall be construed 
     to exempt or relieve any person from any provision of State 
     law which regulates insurance.
       ``(B) Church plans not to be deemed insurance companies or 
     insurers.--Neither a church plan to which this section 
     applies, nor any trust established under such a church plan, 
     shall be deemed to be an insurance company or other insurer 
     or to be engaged in the business of insurance for purposes of 
     any State law purporting to regulate insurance companies or 
     insurance contracts.
       ``(3) Preemption of certain state laws relating to premium 
     rate regulation and benefit mandates.--The provisions of 
     subsections (a)(2)(B) and (b) of section 805 shall apply with 
     respect to a church plan to which this section applies in the 
     same manner and to the same extent as such provisions apply 
     with respect to association health plans.
       ``(4) Definitions.--For purposes of this subsection--
       ``(A) State law.--The term `State law' includes all laws, 
     decisions, rules, regulations, or other State action having 
     the effect of law, of any State. A law of the United States 
     applicable only to the District of Columbia shall be treated 
     as a State law rather than a law of the United States.
       ``(B) State.--The term `State' includes a State, any 
     political subdivision thereof, or any agency or 
     instrumentality of either, which purports to regulate, 
     directly or indirectly, the terms and conditions of church 
     plans covered by this section.
       ``(c) Requirements for Covered Church Plans.--
       ``(1) Fiduciary rules and exclusive purpose.--A fiduciary 
     shall discharge his duties with respect to a church plan to 
     which this section applies--
       ``(A) for the exclusive purpose of:
       ``(i) providing benefits to participants and their 
     beneficiaries; and
       ``(ii) defraying reasonable expenses of administering the 
     plan;
       ``(B) with the care, skill, prudence and diligence under 
     the circumstances then prevailing that a prudent man acting 
     in a like capacity and familiar with such matters would use 
     in the conduct of an enterprise of a like character and with 
     like aims; and
       ``(C) in accordance with the documents and instruments 
     governing the plan.
     The requirements of this paragraph shall not be treated as 
     not satisfied solely because the plan assets are commingled 
     with other church assets, to the extent that such plan assets 
     are separately accounted for.
       ``(2) Claims procedure.--In accordance with regulations of 
     the Secretary, every church plan to which this section 
     applies shall--
       ``(A) provide adequate notice in writing to any participant 
     or beneficiary whose claim for benefits under the plan has 
     been denied, setting forth the specific reasons for such 
     denial, written in a manner calculated to be understood by 
     the participant;
       ``(B) afford a reasonable opportunity to any participant 
     whose claim for benefits has been denied for a full and fair 
     review by the appropriate fiduciary of the decision denying 
     the claim; and
       ``(C) provide a written statement to each participant 
     describing the procedures established pursuant to this 
     paragraph.
       ``(3) Annual statements.--In accordance with regulations of 
     the Secretary, every church plan to which this section 
     applies shall file with the Secretary an annual statement--
       ``(A) stating the names and addresses of the plan and of 
     the church, convention, or association maintaining the plan 
     (and its principal place of business);
       ``(B) certifying that it is a church plan to which this 
     section applies and that it complies with the requirements of 
     paragraphs (1) and (2);
       ``(C) identifying the States in which participants and 
     beneficiaries under the plan

[[Page H9440]]

     are or likely will be located during the 1-year period 
     covered by the statement; and
       ``(D) containing a copy of a statement of actuarial opinion 
     signed by a qualified actuary that the plan maintains 
     capital, reserves, insurance, other financial arrangements, 
     or any combination thereof adequate to enable the plan to 
     fully meet all of its financial obligations on a timely 
     basis.
       ``(4) Disclosure.--At the time that the annual statement is 
     filed by a church plan with the Secretary pursuant to 
     paragraph (3), a copy of such statement shall be made 
     available by the Secretary to the State insurance 
     commissioner (or similar official) of any State. The name of 
     each church plan and sponsoring organization filing an annual 
     statement in compliance with paragraph (3) shall be published 
     annually in the Federal Register.
       ``(c) Enforcement.--The Secretary may enforce the 
     provisions of this section in a manner consistent with 
     section 502, to the extent applicable with respect to actions 
     under section 502(a)(5), and with section 3(33)(D), except 
     that, other than for the purpose of seeking a temporary 
     restraining order, a civil action may be brought with respect 
     to the plan's failure to meet any requirement of this section 
     only if the plan fails to correct its failure within the 
     correction period described in section 3(33)(D). The other 
     provisions of part 5 (except sections 501(a), 503, 512, 514, 
     and 515) shall apply with respect to the enforcement and 
     administration of this section.
       ``(d) Definitions and Other Rules.--For purposes of this 
     section--
       ``(1) In general.--Except as otherwise provided in this 
     section, any term used in this section which is defined in 
     any provision of this title shall have the definition 
     provided such term by such provision.
       ``(2) Seminary students.--Seminary students who are 
     enrolled in an institution of higher learning described in 
     section 3(33)(C)(iv) and who are treated as participants 
     under the terms of a church plan to which this section 
     applies shall be deemed to be employees as defined in section 
     3(6) if the number of such students constitutes an 
     insignificant portion of the total number of individuals who 
     are treated as participants under the terms of the plan.

     ``SEC. 813. DEFINITIONS AND RULES OF CONSTRUCTION.

       ``(a) Definitions.--For purposes of this part--
       ``(1) Group health plan.--The term `group health plan' has 
     the meaning provided in section 733(a)(1) (after applying 
     subsection (b) of this section).
       ``(2) Medical care.--The term `medical care' has the 
     meaning provided in section 733(a)(2).
       ``(3) Health insurance coverage.--The term `health 
     insurance coverage' has the meaning provided in section 
     733(b)(1).
       ``(4) Health insurance issuer.--The term `health insurance 
     issuer' has the meaning provided in section 733(b)(2).
       ``(5) Applicable authority.--
       ``(A) In general.--Except as provided in subparagraph (B), 
     the term `applicable authority' means, in connection with an 
     association health plan--
       ``(i) the State recognized pursuant to subsection (c) of 
     section 506 as the State to which authority has been 
     delegated in connection with such plan; or
       ``(ii) if there is no State referred to in clause (i), the 
     Secretary.
       ``(B) Exceptions.--
       ``(i) Joint authorities.--Where such term appears in 
     section 808(3), section 807(e) (in the first instance), 
     section 809(a) (in the second instance), section 809(a) (in 
     the fourth instance), and section 809(b)(1), such term means, 
     in connection with an association health plan, the Secretary 
     and the State referred to in subparagraph (A)(i) (if any) in 
     connection with such plan.
       ``(ii) Regulatory authorities.--Where such term appears in 
     section 802(a) (in the first instance), section 802(d), 
     section 802(e), section 803(d), section 805(a)(5), section 
     806(a)(2), section 806(b), section 806(c), section 806(d), 
     paragraphs (1)(A) and (2)(A) of section 806(g), section 
     806(h), section 806(i), section 806(j), section 807(a) (in 
     the second instance), section 807(b), section 807(d), section 
     807(e) (in the second instance), section 808 (in the matter 
     after paragraph (3)), and section 809(a) (in the third 
     instance), such term means, in connection with an association 
     health plan, the Secretary.
       ``(6) Health status-related factor.--The term `health 
     status-related factor' has the meaning provided in section 
     733(d)(2).
       ``(7) Individual market.--
       ``(A) In general.--The term `individual market' means the 
     market for health insurance coverage offered to individuals 
     other than in connection with a group health plan.
       ``(B) Treatment of very small groups.--
       ``(i) In general.--Subject to clause (ii), such term 
     includes coverage offered in connection with a group health 
     plan that has fewer than 2 participants as current employees 
     or participants described in section 732(d)(3) on the first 
     day of the plan year.
       ``(ii) State exception.--Clause (i) shall not apply in the 
     case of health insurance coverage offered in a State if such 
     State regulates the coverage described in such clause in the 
     same manner and to the same extent as coverage in the small 
     group market (as defined in section 2791(e)(5) of the Public 
     Health Service Act) is regulated by such State.
       ``(8) Participating employer.--The term `participating 
     employer' means, in connection with an association health 
     plan, any employer, if any individual who is an employee of 
     such employer, a partner in such employer, or a self-employed 
     individual who is such employer (or any dependent, as defined 
     under the terms of the plan, of such individual) is or was 
     covered under such plan in connection with the status of such 
     individual as such an employee, partner, or self-employed 
     individual in relation to the plan.
       ``(9) Applicable state authority.--The term `applicable 
     State authority' means, with respect to a health insurance 
     issuer in a State, the State insurance commissioner or 
     official or officials designated by the State to enforce the 
     requirements of title XXVII of the Public Health Service Act 
     for the State involved with respect to such issuer.
       ``(10) Qualified actuary.--The term `qualified actuary' 
     means an individual who is a member of the American Academy 
     of Actuaries or meets such reasonable standards and 
     qualifications as the Secretary may provide by regulation 
     through negotiated rulemaking.
       ``(11) Affiliated member.--The term `affiliated member' 
     means, in connection with a sponsor--
       ``(A) a person who is otherwise eligible to be a member of 
     the sponsor but who elects an affiliated status with the 
     sponsor,
       ``(B) in the case of a sponsor with members which consist 
     of associations, a person who is a member of any such 
     association and elects an affiliated status with the sponsor, 
     or
       ``(C) in the case of an association health plan in 
     existence on the date of the enactment of the Quality Care 
     for the Uninsured Act of 1999, a person eligible to be a 
     member of the sponsor or one of its member associations.
       ``(12) Large employer.--The term `large employer' means, in 
     connection with a group health plan with respect to a plan 
     year, an employer who employed an average of at least 51 
     employees on business days during the preceding calendar year 
     and who employs at least 2 employees on the first day of the 
     plan year.
       ``(13) Small employer.--The term `small employer' means, in 
     connection with a group health plan with respect to a plan 
     year, an employer who is not a large employer.
       ``(b) Rules of Construction.--
       ``(1) Employers and employees.--For purposes of determining 
     whether a plan, fund, or program is an employee welfare 
     benefit plan which is an association health plan, and for 
     purposes of applying this title in connection with such plan, 
     fund, or program so determined to be such an employee welfare 
     benefit plan--
       ``(A) in the case of a partnership, the term `employer' (as 
     defined in section (3)(5)) includes the partnership in 
     relation to the partners, and the term `employee' (as defined 
     in section (3)(6)) includes any partner in relation to the 
     partnership; and
       ``(B) in the case of a self-employed individual, the term 
     `employer' (as defined in section 3(5)) and the term 
     `employee' (as defined in section 3(6)) shall include such 
     individual.
       ``(2) Plans, funds, and programs treated as employee 
     welfare benefit plans.--In the case of any plan, fund, or 
     program which was established or is maintained for the 
     purpose of providing medical care (through the purchase of 
     insurance or otherwise) for employees (or their dependents) 
     covered thereunder and which demonstrates to the Secretary 
     that all requirements for certification under this part would 
     be met with respect to such plan, fund, or program if such 
     plan, fund, or program were a group health plan, such plan, 
     fund, or program shall be treated for purposes of this title 
     as an employee welfare benefit plan on and after the date of 
     such demonstration.''.
       (b) Conforming Amendments to Preemption Rules.--
       (1) Section 514(b)(6) of such Act (29 U.S.C. 1144(b)(6)) is 
     amended by adding at the end the following new subparagraph:
       ``(E) The preceding subparagraphs of this paragraph do not 
     apply with respect to any State law in the case of an 
     association health plan which is certified under part 8.''.
       (2) Section 514 of such Act (29 U.S.C. 1144) is amended--
       (A) in subsection (b)(4), by striking ``Subsection (a)'' 
     and inserting ``Subsections (a) and (d)'';
       (B) in subsection (b)(5), by striking ``subsection (a)'' in 
     subparagraph (A) and inserting ``subsection (a) of this 
     section and subsections (a)(2)(B) and (b) of section 805'', 
     and by striking ``subsection (a)'' in subparagraph (B) and 
     inserting ``subsection (a) of this section or subsection 
     (a)(2)(B) or (b) of section 805'';
       (C) by redesignating subsection (d) as subsection (e); and
       (D) by inserting after subsection (c) the following new 
     subsection:
       ``(d)(1) Except as provided in subsection (b)(4), the 
     provisions of this title shall supersede any and all State 
     laws insofar as they may now or hereafter preclude, or have 
     the effect of precluding, a health insurance issuer from 
     offering health insurance coverage in connection with an 
     association health plan which is certified under part 8.
       ``(2) Except as provided in paragraphs (4) and (5) of 
     subsection (b) of this section--
       ``(A) In any case in which health insurance coverage of any 
     policy type is offered under an association health plan 
     certified under part 8 to a participating employer operating

[[Page H9441]]

     in such State, the provisions of this title shall supersede 
     any and all laws of such State insofar as they may preclude a 
     health insurance issuer from offering health insurance 
     coverage of the same policy type to other employers operating 
     in the State which are eligible for coverage under such 
     association health plan, whether or not such other employers 
     are participating employers in such plan.
       ``(B) In any case in which health insurance coverage of any 
     policy type is offered under an association health plan in a 
     State and the filing, with the applicable State authority, of 
     the policy form in connection with such policy type is 
     approved by such State authority, the provisions of this 
     title shall supersede any and all laws of any other State in 
     which health insurance coverage of such type is offered, 
     insofar as they may preclude, upon the filing in the same 
     form and manner of such policy form with the applicable State 
     authority in such other State, the approval of the filing in 
     such other State.
       ``(3) For additional provisions relating to association 
     health plans, see subsections (a)(2)(B) and (b) of section 
     805.
       ``(4) For purposes of this subsection, the term 
     `association health plan' has the meaning provided in section 
     801(a), and the terms `health insurance coverage', 
     `participating employer', and `health insurance issuer' have 
     the meanings provided such terms in section 811, 
     respectively.''.
       (3) Section 514(b)(6)(A) of such Act (29 U.S.C. 
     1144(b)(6)(A)) is amended--
       (A) in clause (i)(II), by striking ``and'' at the end;
       (B) in clause (ii), by inserting ``and which does not 
     provide medical care (within the meaning of section 
     733(a)(2)),'' after ``arrangement,'', and by striking 
     ``title.'' and inserting ``title, and''; and
       (C) by adding at the end the following new clause:
       ``(iii) subject to subparagraph (E), in the case of any 
     other employee welfare benefit plan which is a multiple 
     employer welfare arrangement and which provides medical care 
     (within the meaning of section 733(a)(2)), any law of any 
     State which regulates insurance may apply.''.
       (4) Section 514(e) of such Act (as redesignated by 
     paragraph (2)(C)) is amended--
       (A) by striking ``Nothing'' and inserting ``(1) Except as 
     provided in paragraph (2), nothing''; and
       (B) by adding at the end the following new paragraph:
       ``(2) Nothing in any other provision of law enacted on or 
     after the date of the enactment of the Quality Care for the 
     Uninsured Act of 1999 shall be construed to alter, amend, 
     modify, invalidate, impair, or supersede any provision of 
     this title, except by specific cross-reference to the 
     affected section.''.
       (c) Plan Sponsor.--Section 3(16)(B) of such Act (29 U.S.C. 
     102(16)(B)) is amended by adding at the end the following new 
     sentence: ``Such term also includes a person serving as the 
     sponsor of an association health plan under part 8.''.
       (d) Disclosure of Solvency Protections Related to Self-
     Insured and Fully Insured Options Under Association Health 
     Plans.--Section 102(b) of such Act (29 U.S.C. 102(b)) is 
     amended by adding at the end the following: ``An association 
     health plan shall include in its summary plan description, in 
     connection with each benefit option, a description of the 
     form of solvency or guarantee fund protection secured 
     pursuant to this Act or applicable State law, if any.''.
       (e) Savings Clause.--Section 731(c) of such Act is amended 
     by inserting ``or part 8'' after ``this part''.
       (f) Report to the Congress Regarding Certification of Self-
     Insured Association Health Plans.--Not later than January 1, 
     2004, the Secretary of Labor shall report to the Committee on 
     Education and the Workforce of the House of Representatives 
     and the Committee on Health, Education, Labor, and Pensions 
     of the Senate the effect association health plans have had, 
     if any, on reducing the number of uninsured individuals.
       (g) Clerical Amendment.--The table of contents in section 1 
     of the Employee Retirement Income Security Act of 1974 is 
     amended by inserting after the item relating to section 734 
     the following new items:

           ``Part 8--Rules Governing Association Health Plans

``Sec. 801. Association health plans.
``Sec. 802. Certification of association health plans.
``Sec. 803. Requirements relating to sponsors and boards of trustees.
``Sec. 804. Participation and coverage requirements.
``Sec. 805. Other requirements relating to plan documents, contribution 
              rates, and benefit options.
``Sec. 806. Maintenance of reserves and provisions for solvency for 
              plans providing health benefits in addition to health 
              insurance coverage.
``Sec. 807. Requirements for application and related requirements.
``Sec. 808. Notice requirements for voluntary termination.
``Sec. 809. Corrective actions and mandatory termination.
``Sec. 810. Trusteeship by the Secretary of insolvent association 
              health plans providing health benefits in addition to 
              health insurance coverage.
``Sec. 811. State assessment authority.
``Sec. 812. Special rules for church plans.
``Sec. 813. Definitions and rules of construction.''.

     SEC. 202. CLARIFICATION OF TREATMENT OF SINGLE EMPLOYER 
                   ARRANGEMENTS.

       Section 3(40)(B) of the Employee Retirement Income Security 
     Act of 1974 (29 U.S.C. 1002(40)(B)) is amended--
       (1) in clause (i), by inserting ``for any plan year of any 
     such plan, or any fiscal year of any such other 
     arrangement;'' after ``single employer'', and by inserting 
     ``during such year or at any time during the preceding 1-year 
     period'' after ``control group'';
       (2) in clause (iii)--
       (A) by striking ``common control shall not be based on an 
     interest of less than 25 percent'' and inserting ``an 
     interest of greater than 25 percent may not be required as 
     the minimum interest necessary for common control''; and
       (B) by striking ``similar to'' and inserting ``consistent 
     and coextensive with'';
       (3) by redesignating clauses (iv) and (v) as clauses (v) 
     and (vi), respectively; and
       (4) by inserting after clause (iii) the following new 
     clause:
       ``(iv) in determining, after the application of clause (i), 
     whether benefits are provided to employees of two or more 
     employers, the arrangement shall be treated as having only 
     one participating employer if, after the application of 
     clause (i), the number of individuals who are employees and 
     former employees of any one participating employer and who 
     are covered under the arrangement is greater than 75 percent 
     of the aggregate number of all individuals who are employees 
     or former employees of participating employers and who are 
     covered under the arrangement;''.

     SEC. 203. CLARIFICATION OF TREATMENT OF CERTAIN COLLECTIVELY 
                   BARGAINED ARRANGEMENTS.

       (a) In General.--Section 3(40)(A)(i) of the Employee 
     Retirement Income Security Act of 1974 (29 U.S.C. 
     1002(40)(A)(i)) is amended to read as follows:
       ``(i)(I) under or pursuant to one or more collective 
     bargaining agreements which are reached pursuant to 
     collective bargaining described in section 8(d) of the 
     National Labor Relations Act (29 U.S.C. 158(d)) or paragraph 
     Fourth of section 2 of the Railway Labor Act (45 U.S.C. 152, 
     paragraph Fourth) or which are reached pursuant to labor-
     management negotiations under similar provisions of State 
     public employee relations laws, and (II) in accordance with 
     subparagraphs (C), (D), and (E);''.
       (b) Limitations.--Section 3(40) of such Act (29 U.S.C. 
     1002(40)) is amended by adding at the end the following new 
     subparagraphs:
       ``(C) For purposes of subparagraph (A)(i)(II), a plan or 
     other arrangement shall be treated as established or 
     maintained in accordance with this subparagraph only if the 
     following requirements are met:
       ``(i) The plan or other arrangement, and the employee 
     organization or any other entity sponsoring the plan or other 
     arrangement, do not--
       ``(I) utilize the services of any licensed insurance agent 
     or broker for soliciting or enrolling employers or 
     individuals as participating employers or covered individuals 
     under the plan or other arrangement; or
       ``(II) pay any type of compensation to a person, other than 
     a full time employee of the employee organization (or a 
     member of the organization to the extent provided in 
     regulations prescribed by the Secretary through negotiated 
     rulemaking), that is related either to the volume or number 
     of employers or individuals solicited or enrolled as 
     participating employers or covered individuals under the plan 
     or other arrangement, or to the dollar amount or size of the 
     contributions made by participating employers or covered 
     individuals to the plan or other arrangement;

     except to the extent that the services used by the plan, 
     arrangement, organization, or other entity consist solely of 
     preparation of documents necessary for compliance with the 
     reporting and disclosure requirements of part 1 or 
     administrative, investment, or consulting services unrelated 
     to solicitation or enrollment of covered individuals.
       ``(ii) As of the end of the preceding plan year, the number 
     of covered individuals under the plan or other arrangement 
     who are neither--
       ``(I) employed within a bargaining unit covered by any of 
     the collective bargaining agreements with a participating 
     employer (nor covered on the basis of an individual's 
     employment in such a bargaining unit); nor
       ``(II) present employees (or former employees who were 
     covered while employed) of the sponsoring employee 
     organization, of an employer who is or was a party to any of 
     the collective bargaining agreements, or of the plan or other 
     arrangement or a related plan or arrangement (nor covered on 
     the basis of such present or former employment);

     does not exceed 15 percent of the total number of individuals 
     who are covered under the plan or arrangement and who are 
     present or former employees who are or were covered under the 
     plan or arrangement pursuant to a collective bargaining 
     agreement with a participating employer. The requirements of 
     the preceding provisions of this clause shall be treated as 
     satisfied if, as of the end of the preceding plan year, such 
     covered individuals are comprised solely of individuals who 
     were covered individuals under the plan or other arrangement 
     as of the date of the enactment of the Quality Care for the 
     Uninsured Act of 1999 and, as of the end of the preceding 
     plan year, the number of such covered individuals does not 
     exceed 25 percent of

[[Page H9442]]

     the total number of present and former employees enrolled 
     under the plan or other arrangement.
       ``(iii) The employee organization or other entity 
     sponsoring the plan or other arrangement certifies to the 
     Secretary each year, in a form and manner which shall be 
     prescribed by the Secretary through negotiated 
     rulemaking that the plan or other arrangement meets the 
     requirements of clauses (i) and (ii).
       ``(D) For purposes of subparagraph (A)(i)(II), a plan or 
     arrangement shall be treated as established or maintained in 
     accordance with this subparagraph only if--
       ``(i) all of the benefits provided under the plan or 
     arrangement consist of health insurance coverage; or
       ``(ii)(I) the plan or arrangement is a multiemployer plan; 
     and
       ``(II) the requirements of clause (B) of the proviso to 
     clause (5) of section 302(c) of the Labor Management 
     Relations Act, 1947 (29 U.S.C. 186(c)) are met with respect 
     to such plan or other arrangement.
       ``(E) For purposes of subparagraph (A)(i)(II), a plan or 
     arrangement shall be treated as established or maintained in 
     accordance with this subparagraph only if--
       ``(i) the plan or arrangement is in effect as of the date 
     of the enactment of the Quality Care for the Uninsured Act of 
     1999; or
       ``(ii) the employee organization or other entity sponsoring 
     the plan or arrangement--
       ``(I) has been in existence for at least 3 years; or
       ``(II) demonstrates to the satisfaction of the Secretary 
     that the requirements of subparagraphs (C) and (D) are met 
     with respect to the plan or other arrangement.''.
       (c) Conforming Amendments to Definitions of Participant and 
     Beneficiary.--Section 3(7) of such Act (29 U.S.C. 1002(7)) is 
     amended by adding at the end the following new sentence: 
     ``Such term includes an individual who is a covered 
     individual described in paragraph (40)(C)(ii).''.

     SEC. 204. ENFORCEMENT PROVISIONS.

       (a) Criminal Penalties for Certain Willful 
     Misrepresentations.--Section 501 of the Employee Retirement 
     Income Security Act of 1974 (29 U.S.C. 1131) is amended--
       (1) by inserting ``(a)'' after ``Sec. 501.''; and
       (2) by adding at the end the following new subsection:
       ``(b) Any person who willfully falsely represents, to any 
     employee, any employee's beneficiary, any employer, the 
     Secretary, or any State, a plan or other arrangement 
     established or maintained for the purpose of offering or 
     providing any benefit described in section 3(1) to employees 
     or their beneficiaries as--
       ``(1) being an association health plan which has been 
     certified under part 8;
       ``(2) having been established or maintained under or 
     pursuant to one or more collective bargaining agreements 
     which are reached pursuant to collective bargaining described 
     in section 8(d) of the National Labor Relations Act (29 
     U.S.C. 158(d)) or paragraph Fourth of section 2 of the 
     Railway Labor Act (45 U.S.C. 152, paragraph Fourth) or which 
     are reached pursuant to labor-management negotiations under 
     similar provisions of State public employee relations laws; 
     or
       ``(3) being a plan or arrangement with respect to which the 
     requirements of subparagraph (C), (D), or (E) of section 
     3(40) are met;

     shall, upon conviction, be imprisoned not more than 5 years, 
     be fined under title 18, United States Code, or both.''.
       (b) Cease Activities Orders.--Section 502 of such Act (29 
     U.S.C. 1132) is amended by adding at the end the following 
     new subsection:
       ``(n)(1) Subject to paragraph (2), upon application by the 
     Secretary showing the operation, promotion, or marketing of 
     an association health plan (or similar arrangement providing 
     benefits consisting of medical care (as defined in section 
     733(a)(2))) that--
       ``(A) is not certified under part 8, is subject under 
     section 514(b)(6) to the insurance laws of any State in which 
     the plan or arrangement offers or provides benefits, and is 
     not licensed, registered, or otherwise approved under the 
     insurance laws of such State; or
       ``(B) is an association health plan certified under part 8 
     and is not operating in accordance with the requirements 
     under part 8 for such certification,
     a district court of the United States shall enter an order 
     requiring that the plan or arrangement cease activities.
       ``(2) Paragraph (1) shall not apply in the case of an 
     association health plan or other arrangement if the plan or 
     arrangement shows that--
       ``(A) all benefits under it referred to in paragraph (1) 
     consist of health insurance coverage; and
       ``(B) with respect to each State in which the plan or 
     arrangement offers or provides benefits, the plan or 
     arrangement is operating in accordance with applicable State 
     laws that are not superseded under section 514.
       ``(3) The court may grant such additional equitable relief, 
     including any relief available under this title, as it deems 
     necessary to protect the interests of the public and of 
     persons having claims for benefits against the plan.''.
       (c) Responsibility for Claims Procedure.--Section 503 of 
     such Act (29 U.S.C. 1133) (as amended by title I) is amended 
     by adding at the end the following new subsection:
       ``(c) Association Health Plans.--The terms of each 
     association health plan which is or has been certified under 
     part 8 shall require the board of trustees or the named 
     fiduciary (as applicable) to ensure that the requirements of 
     this section are met in connection with claims filed under 
     the plan.''.

     SEC. 205. COOPERATION BETWEEN FEDERAL AND STATE AUTHORITIES.

       Section 506 of the Employee Retirement Income Security Act 
     of 1974 (29 U.S.C. 1136) is amended by adding at the end the 
     following new subsection:
       ``(c) Responsibility of States With Respect to Association 
     Health Plans.--
       ``(1) Agreements with states.--A State may enter into an 
     agreement with the Secretary for delegation to the State of 
     some or all of--
       ``(A) the Secretary's authority under sections 502 and 504 
     to enforce the requirements for certification under part 8;
       ``(B) the Secretary's authority to certify association 
     health plans under part 8 in accordance with regulations of 
     the Secretary applicable to certification under part 8; or
       ``(C) any combination of the Secretary's authority 
     authorized to be delegated under subparagraphs (A) and (B).
       ``(2) Delegations.--Any department, agency, or 
     instrumentality of a State to which authority is delegated 
     pursuant to an agreement entered into under this paragraph 
     may, if authorized under State law and to the extent 
     consistent with such agreement, exercise the powers of the 
     Secretary under this title which relate to such authority.
       ``(3) Recognition of primary domicile state.--In entering 
     into any agreement with a State under subparagraph (A), the 
     Secretary shall ensure that, as a result of such agreement 
     and all other agreements entered into under subparagraph (A), 
     only one State will be recognized, with respect to any 
     particular association health plan, as the State to which all 
     authority has been delegated pursuant to such agreements in 
     connection with such plan. In carrying out this paragraph, 
     the Secretary shall take into account the places of residence 
     of the participants and beneficiaries under the plan and the 
     State in which the trust is maintained.''.

     SEC. 206. EFFECTIVE DATE AND TRANSITIONAL AND OTHER RULES.

       (a) Effective Date.--The amendments made by sections 201, 
     204, and 205 shall take effect on January 1, 2001. The 
     amendments made by sections 202 and 203 shall take effect on 
     the date of the enactment of this Act. The Secretary of Labor 
     shall first issue all regulations necessary to carry out the 
     amendments made by this title before January 1, 2001. Such 
     regulations shall be issued through negotiated rulemaking.
       (b) Exception.--Section 801(a)(2) of the Employee 
     Retirement Income Security Act of 1974 (added by section 201) 
     does not apply in connection with an association health plan 
     (certified under part 8 of subtitle B of title I of such Act) 
     existing on the date of the enactment of this Act, if no 
     benefits provided thereunder as of the date of the enactment 
     of this Act consist of health insurance coverage (as defined 
     in section 733(b)(1) of such Act).
       (c) Treatment of Certain Existing Health Benefits 
     Programs.--
       (1) In general.--In any case in which, as of the date of 
     the enactment of this Act, an arrangement is maintained in a 
     State for the purpose of providing benefits consisting of 
     medical care for the employees and beneficiaries of its 
     participating employers, at least 200 participating employers 
     make contributions to such arrangement, such arrangement has 
     been in existence for at least 10 years, and such arrangement 
     is licensed under the laws of one or more States to provide 
     such benefits to its participating employers, upon the filing 
     with the applicable authority (as defined in section 
     813(a)(5) of the Employee Retirement Income Security Act of 
     1974 (as amended by this Act)) by the arrangement of an 
     application for certification of the arrangement under part 8 
     of subtitle B of title I of such Act--
       (A) such arrangement shall be deemed to be a group health 
     plan for purposes of title I of such Act;
       (B) the requirements of sections 801(a)(1) and 803(a)(1) of 
     the Employee Retirement Income Security Act of 1974 shall be 
     deemed met with respect to such arrangement;
       (C) the requirements of section 803(b) of such Act shall be 
     deemed met, if the arrangement is operated by a board of 
     directors which--
       (i) is elected by the participating employers, with each 
     employer having one vote; and
       (ii) has complete fiscal control over the arrangement and 
     which is responsible for all operations of the arrangement;
       (D) the requirements of section 804(a) of such Act shall be 
     deemed met with respect to such arrangement; and
       (E) the arrangement may be certified by any applicable 
     authority with respect to its operations in any State only if 
     it operates in such State on the date of certification.

     The provisions of this subsection shall cease to apply with 
     respect to any such arrangement at such time after the date 
     of the enactment of this Act as the applicable requirements 
     of this subsection are not met with respect to such 
     arrangement.
       (2) Definitions.--For purposes of this subsection, the 
     terms ``group health plan'', ``medical care'', and 
     ``participating employer'' shall have the meanings provided 
     in section 813 of the Employee Retirement Income Security Act 
     of 1974, except that the reference in paragraph (7) of such 
     section to an ``association health plan'' shall be deemed a 
     reference to an arrangement referred to in this subsection.

[[Page H9443]]

       (d) Promoting Use of Certain Additional Associations in 
     Providing Individual Health Insurance Coverage.--Section 
     2742(b)(5) of the Public Health Service Act (42 U.S.C. 300gg-
     42(b)(5)) is amended--
       (1) by striking ``paragraph'' and inserting 
     ``subparagraph'';
       (2) by inserting ``(A)'' after ``.--''; and
       (3) by adding at the end the following new subparagraph:
       ``(B)(i) In the case of health insurance coverage that is 
     made available in the individual market only through one or 
     more associations described in clause (ii), the membership of 
     the individual in the association (on the basis of which the 
     coverage is provided) ceases but only if such coverage is 
     terminated under this subparagraph uniformly without regard 
     to any health status-related factor of covered individuals 
     and only if the individual is entitled, upon application and 
     without furnishing evidence of insurability, to health 
     insurance conversion coverage that meets and is subject to 
     all the rules and regulations of the State in which 
     application is made.
       ``(ii) An association described in this clause is an 
     organization that meets the requirements for a bona fide 
     organization described in subparagraphs (A), (B), (C), (E) 
     and (F) of section 2791(d)(3) and, except in the case of an 
     association that enrolls individual members who each pay 
     their own individual membership dues, which provides that all 
     members and dependents of members are eligible for coverage 
     offered through the association regardless of any health 
     status-related factor.''.

        TITLE III--GREATER ACCESS AND CHOICE THROUGH HEALTHMARTS

     SEC. 301. EXPANSION OF CONSUMER CHOICE THROUGH HEALTHMARTS.

       (a) In General.--The Public Health Service Act is amended 
     by adding at the end the following new title:

                      ``TITLE XXVIII--HEALTHMARTS

     ``SEC. 2801. DEFINITION OF HEALTHMART.

       ``(a) In General.--For purposes of this title, the term 
     `HealthMart' means a legal entity that meets the following 
     requirements:
       ``(1) Organization.--The HealthMart is a nonprofit 
     organization operated under the direction of a board of 
     directors which is composed of representatives of not fewer 
     than 2 and in equal numbers from each of the following:
       ``(A) Small employers.
       ``(B) Employees of small employers.
       ``(C) Health care providers, which may be physicians, other 
     health care professionals, health care facilities, or any 
     combination thereof.
       ``(D) Entities, such as insurance companies, health 
     maintenance organizations, and licensed provider-sponsored 
     organizations, that underwrite or administer health benefits 
     coverage.
       ``(2) Offering health benefits coverage.--
       ``(A) In general.--The HealthMart, in conjunction with 
     those health insurance issuers that offer health benefits 
     coverage through the HealthMart, makes available health 
     benefits coverage in the manner described in subsection (b) 
     to all small employers and eligible employees in the manner 
     described in subsection (c)(2) at rates (including employer's 
     and employee's share) that are established by the health 
     insurance issuer on a policy or product specific basis and 
     that may vary only as permissible under State law. A 
     HealthMart is deemed to be a group health plan for purposes 
     of applying section 702 of the Employee Retirement Income 
     Security Act of 1974, section 2702 of this Act, and section 
     9802(b) of the Internal Revenue Code of 1986 (which limit 
     variation among similarly situated individuals of required 
     premiums for health benefits coverage on the basis of health 
     status-related factors).
       ``(B) Nondiscrimination in coverage offered.--
       ``(i) In general.--Subject to clause (ii), the HealthMart 
     may not offer health benefits coverage to an eligible 
     employee in a geographic area (as specified under paragraph 
     (3)(A)) unless the same coverage is offered to all such 
     employees in the same geographic area. Section 2711(a)(1)(B) 
     of this Act limits denial of enrollment of certain eligible 
     individuals under health benefits coverage in the small group 
     market.
       ``(ii) Construction.--Nothing in this title shall be 
     construed as requiring or permitting a health insurance 
     issuer to provide coverage outside the service area of the 
     issuer, as approved under State law.
       ``(C) No financial underwriting.--The HealthMart provides 
     health benefits coverage only through contracts with health 
     insurance issuers and does not assume insurance risk with 
     respect to such coverage.
       (D) Minimum coverage.--By the end of the first year of its 
     operation and thereafter, the HealthMart maintains not fewer 
     than 10 purchasers and 100 members.
       ``(3) Geographic areas.--
       ``(A) Specification of geographic areas.--The HealthMart 
     shall specify the geographic area (or areas) in which it 
     makes available health benefits coverage offered by health 
     insurance issuers to small employers. Such an area shall 
     encompass at least one entire county or equivalent area.
       ``(B) Multistate areas.--In the case of a HealthMart that 
     serves more than one State, such geographic areas may be 
     areas that include portions of two or more contiguous States.
       ``(C) Multiple healthmarts permitted in single geographic 
     area.--Nothing in this title shall be construed as preventing 
     the establishment and operation of more than one HealthMart 
     in a geographic area or as limiting the number of HealthMarts 
     that may operate in any area.
       ``(4) Provision of administrative services to purchasers.--
       ``(A) In general.--The HealthMart provides administrative 
     services for purchasers. Such services may include 
     accounting, billing, enrollment information, and employee 
     coverage status reports.
       ``(B) Construction.--Nothing in this subsection shall be 
     construed as preventing a HealthMart from serving as an 
     administrative service organization to any entity.
       ``(5) Dissemination of information.--The HealthMart 
     collects and disseminates (or arranges for the collection and 
     dissemination of) consumer-oriented information on the scope, 
     cost, and enrollee satisfaction of all coverage options 
     offered through the HealthMart to its members and eligible 
     individuals. Such information shall be defined by the 
     HealthMart and shall be in a manner appropriate to the type 
     of coverage offered. To the extent practicable, such 
     information shall include information on provider 
     performance, locations and hours of operation of providers, 
     outcomes, and similar matters. Nothing in this section shall 
     be construed as preventing the dissemination of such 
     information or other information by the HealthMart or by 
     health insurance issuers through electronic or other means.
       ``(6) Filing information.--The Health-
     Mart--
       ``(A) files with the applicable Federal authority 
     information that demonstrates the HealthMart's compliance 
     with the applicable requirements of this title; or
       ``(B) in accordance with rules established under section 
     2803(a), files with a State such information as the State may 
     require to demonstrate such compliance.
       ``(b) Health Benefits Coverage Requirements.--
       ``(1) Compliance with consumer protection requirements.--
     Any health benefits coverage offered through a HealthMart 
     shall--
       ``(A) be underwritten by a health insurance issuer that--
       ``(i) is licensed (or otherwise regulated) under State law 
     (or is a community health organization that is offering 
     health insurance coverage pursuant to section 330B(a));
       ``(ii) meets all applicable State standards relating to 
     consumer protection, subject to section 2802(b); and
       ``(iii) offers the coverage under a contract with the 
     HealthMart;
       ``(B) subject to paragraph (2), be approved or otherwise 
     permitted to be offered under State law; and
       ``(C) provide full portability of creditable coverage for 
     individuals who remain members of the same HealthMart 
     notwithstanding that they change the employer through which 
     they are members in accordance with the provisions of the 
     parts 6 and 7 of subtitle B of title I of the Employee 
     Retirement Income Security Act of 1974 and titles XXII and 
     XXVII of this Act, so long as both employers are purchasers 
     in the HealthMart.
       ``(2) Alternative process for approval of health benefits 
     coverage in case of discrimination or delay.--
       ``(A) In general.--The requirement of paragraph (1)(B) 
     shall not apply to a policy or product of health benefits 
     coverage offered in a State if the health insurance issuer 
     seeking to offer such policy or product files an application 
     to waive such requirement with the applicable Federal 
     authority, and the authority determines, based on the 
     application and other evidence presented to the authority, 
     that--
       ``(i) either (or both) of the grounds described in 
     subparagraph (B) for approval of the application has been 
     met; and
       ``(ii) the coverage meets the applicable State standards 
     (other than those that have been preempted under section 
     2802).
       ``(B) Grounds.--The grounds described in this subparagraph 
     with respect to a policy or product of health benefits 
     coverage are as follows:
       ``(i) Failure to act on policy, product, or rate 
     application on a timely basis.--The State has failed to 
     complete action on the policy or product (or rates for the 
     policy or product) within 90 days of the date of the State's 
     receipt of a substantially complete application. No period 
     before the date of the enactment of this section shall be 
     included in determining such 90-day period.
       ``(ii) Denial of application based on discriminatory 
     treatment.--The State has denied such an application and--

       ``(I) the standards or review process imposed by the State 
     as a condition of approval of the policy or product imposes 
     either any material requirements, procedures, or standards to 
     such policy or product that are not generally applicable to 
     other policies and products offered or any requirements that 
     are preempted under section 2802; or
       ``(II) the State requires the issuer, as a condition of 
     approval of the policy or product, to offer any policy or 
     product other than such policy or product.

       ``(C) Enforcement.--In the case of a waiver granted under 
     subparagraph (A) to an issuer with respect to a State, the 
     Secretary may enter into an agreement with the State under 
     which the State agrees to provide for monitoring and 
     enforcement activities with respect to compliance of such an 
     issuer and

[[Page H9444]]

     its health insurance coverage with the applicable State 
     standards described in subparagraph (A)(ii). Such monitoring 
     and enforcement shall be conducted by the State in the same 
     manner as the State enforces such standards with respect to 
     other health insurance issuers and plans, without 
     discrimination based on the type of issuer to which the 
     standards apply. Such an agreement shall specify or establish 
     mechanisms by which compliance activities are undertaken, 
     while not lengthening the time required to review and process 
     applications for waivers under subparagraph (A).
       ``(3) Examples of types of coverage.--The health benefits 
     coverage made available through a HealthMart may include, but 
     is not limited to, any of the following if it meets the other 
     applicable requirements of this title:
       ``(A) Coverage through a health maintenance organization.
       ``(B) Coverage in connection with a preferred provider 
     organization.
       ``(C) Coverage in connection with a licensed provider-
     sponsored organization.
       ``(D) Indemnity coverage through an insurance company.
       ``(E) Coverage offered in connection with a contribution 
     into a medical savings account or flexible spending account.
       ``(F) Coverage that includes a point-of-service option.
       ``(G) Coverage offered by a community health organization 
     (as defined in section 330B(e)).
       ``(H) Any combination of such types of coverage.
       ``(4) Wellness bonuses for health promotion.--Nothing in 
     this title shall be construed as precluding a health 
     insurance issuer offering health benefits coverage through a 
     HealthMart from establishing premium discounts or rebates for 
     members or from modifying otherwise applicable copayments or 
     deductibles in return for adherence to programs of health 
     promotion and disease prevention so long as such programs are 
     agreed to in advance by the HealthMart and comply with all 
     other provisions of this title and do not discriminate among 
     similarly situated members.
       ``(c) Purchasers; Members; Health Insurance Issuers.--
       ``(1) Purchasers.--
       ``(A) In general.--Subject to the provisions of this title, 
     a HealthMart shall permit any small employer to contract with 
     the HealthMart for the purchase of health benefits coverage 
     for its employees and dependents of those employees and may 
     not vary conditions of eligibility (including premium rates 
     and membership fees) of a small employer to be a purchaser.
       ``(B) Role of associations, brokers, and licensed health 
     insurance agents.--Nothing in this section shall be construed 
     as preventing an association, broker, licensed health 
     insurance agent, or other entity from assisting or 
     representing a HealthMart or small employers from entering 
     into appropriate arrangements to carry out this title.
       ``(C) Period of contract.--The HealthMart may not require a 
     contract under subparagraph (A) between a HealthMart and a 
     purchaser to be effective for a period of longer than 12 
     months. The previous sentence shall not be construed as 
     preventing such a contract from being extended for additional 
     12-month periods or preventing the purchaser from voluntarily 
     electing a contract period of longer than 12 months.
       ``(D) Exclusive nature of contract.--Such a contract shall 
     provide that the purchaser agrees not to obtain or sponsor 
     health benefits coverage, on behalf of any eligible employees 
     (and their dependents), other than through the HealthMart. 
     The previous sentence shall not apply to an eligible 
     individual who resides in an area for which no coverage is 
     offered by any health insurance issuer through the 
     HealthMart.
       ``(2) Members.--
       ``(A) In general.--Under rules established to carry out 
     this title, with respect to a small employer that has a 
     purchaser contract with a HealthMart, individuals who are 
     employees of the employer may enroll for health benefits 
     coverage (including coverage for dependents of such enrolling 
     employees) offered by a health insurance issuer through the 
     HealthMart.
       ``(B) Nondiscrimination in enrollment.--A HealthMart may 
     not deny enrollment as a member to an individual who is an 
     employee (or dependent of such an employee) eligible to be so 
     enrolled based on health status-related factors, except as 
     may be permitted consistent with section 2742(b).
       ``(C) Annual open enrollment period.--In the case of 
     members enrolled in health benefits coverage offered by a 
     health insurance issuer through a HealthMart, subject to 
     subparagraph (D), the HealthMart shall provide for an annual 
     open enrollment period of 30 days during which such members 
     may change the coverage option in which the members are 
     enrolled.
       ``(D) Rules of eligibility.--Nothing in this paragraph 
     shall preclude a HealthMart from establishing rules of 
     employee eligibility for enrollment and reenrollment of 
     members during the annual open enrollment period under 
     subparagraph (C). Such rules shall be applied consistently to 
     all purchasers and members within the HealthMart and shall 
     not be based in any manner on health status-related factors 
     and may not conflict with sections 2701 and 2702 of this Act.
       ``(3) Health insurance issuers.--
       ``(A) Premium collection.--The contract between a 
     HealthMart and a health insurance issuer shall provide, with 
     respect to a member enrolled with health benefits coverage 
     offered by the issuer through the HealthMart, for the payment 
     of the premiums collected by the HealthMart (or the issuer) 
     for such coverage (less a pre-determined administrative 
     charge negotiated by the HealthMart and the issuer) to the 
     issuer.
       ``(B) Scope of service area.--Nothing in this title shall 
     be construed as requiring the service area of a health 
     insurance issuer with respect to health insurance coverage to 
     cover the entire geographic area served by a HealthMart.
       ``(C) Availability of coverage options.--A HealthMart shall 
     enter into contracts with one or more health insurance 
     issuers in a manner that assures that at least 2 health 
     insurance coverage options are made available in the 
     geographic area specified under subsection (a)(3)(A).
       ``(d) Prevention of Conflicts of Interest.--
       ``(1) For boards of directors.--A member of a board of 
     directors of a HealthMart may not serve as an employee or 
     paid consultant to the HealthMart, but may receive reasonable 
     reimbursement for travel expenses for purposes of attending 
     meetings of the board or committees thereof.
       ``(2) For boards of directors or employees.--An individual 
     is not eligible to serve in a paid or unpaid capacity on the 
     board of directors of a HealthMart or as an employee of the 
     HealthMart, if the individual is employed by, represents in 
     any capacity, owns, or controls any ownership interest in a 
     organization from whom the HealthMart receives contributions, 
     grants, or other funds not connected with a contract for 
     coverage through the HealthMart.
       ``(3) Employment and employee representatives.--
       ``(A) In general.--An individual who is serving on a board 
     of directors of a HealthMart as a representative described in 
     subparagraph (A) or (B) of section 2801(a)(1) shall not be 
     employed by or affiliated with a health insurance issuer or 
     be licensed as or employed by or affiliated with a health 
     care provider.
       ``(B) Construction.--For purposes of subparagraph (A), the 
     term ``affiliated'' does not include membership in a health 
     benefits plan or the obtaining of health benefits coverage 
     offered by a health insurance issuer.
       ``(e) Construction.--
       ``(1) Network of affiliated healthmarts.--Nothing in this 
     section shall be construed as preventing one or more 
     HealthMarts serving different areas (whether or not 
     contiguous) from providing for some or all of the following 
     (through a single administrative organization or otherwise):
       ``(A) Coordinating the offering of the same or similar 
     health benefits coverage in different areas served by the 
     different HealthMarts.
       ``(B) Providing for crediting of deductibles and other 
     cost-sharing for individuals who are provided health benefits 
     coverage through the HealthMarts (or affiliated HealthMarts) 
     after--
       ``(i) a change of employers through which the coverage is 
     provided; or
       ``(ii) a change in place of employment to an area not 
     served by the previous HealthMart.
       ``(2) Permitting healthmarts to adjust distributions among 
     issuers to reflect relative risk of enrollees.--Nothing in 
     this section shall be construed as precluding a HealthMart 
     from providing for adjustments in amounts distributed among 
     the health insurance issuers offering health benefits 
     coverage through the HealthMart based on factors such as the 
     relative health care risk of members enrolled under the 
     coverage offered by the different issuers.
       ``(3) Application of uniform minimum participation and 
     contribution rules.--Nothing in this section shall be 
     construed as precluding a HealthMart from establishing 
     minimum participation and contribution rules (described in 
     section 2711(e)(1)) for small employers that apply to become 
     purchasers in the HealthMart, so long as such rules are 
     applied uniformly for all health insurance issuers.

     ``SEC. 2802. APPLICATION OF CERTAIN LAWS AND REQUIREMENTS.

       ``(a) Authority of States.--Nothing in this section shall 
     be construed as preempting State laws relating to the 
     following:
       ``(1) The regulation of underwriters of health coverage, 
     including licensure and solvency requirements.
       ``(2) The application of premium taxes and required 
     payments for guaranty funds or for contributions to high-risk 
     pools.
       ``(3) The application of fair marketing requirements and 
     other consumer protections (other than those specifically 
     relating to an item described in subsection (b)).
       ``(4) The application of requirements relating to the 
     adjustment of rates for health insurance coverage.
       ``(b) Treatment of Benefit and Grouping Requirements.--
     State laws insofar as they relate to any of the following are 
     superseded and shall not apply to health benefits coverage 
     made available through a HealthMart:
       ``(1) Benefit requirements for health benefits coverage 
     offered through a HealthMart, including (but not limited to) 
     requirements relating to coverage of specific providers, 
     specific services or conditions, or the amount, duration, or 
     scope of benefits, but

[[Page H9445]]

     not including requirements to the extent required to 
     implement title XXVII or other Federal law and to the extent 
     the requirement prohibits an exclusion of a specific disease 
     from such coverage.
       ``(2) Requirements (commonly referred to as fictitious 
     group laws) relating to grouping and similar requirements for 
     such coverage to the extent such requirements impede the 
     establishment and operation of HealthMarts pursuant to this 
     title.
       ``(3) Any other requirements (including limitations on 
     compensation arrangements) that, directly or indirectly, 
     preclude (or have the effect of precluding) the offering of 
     such coverage through a HealthMart, if the HealthMart meets 
     the requirements of this title.

     Any State law or regulation relating to the composition or 
     organization of a HealthMart is preempted to the extent the 
     law or regulation is inconsistent with the provisions of this 
     title.
       ``(c) Application of ERISA Fiduciary and Disclosure 
     Requirements.--The board of directors of a HealthMart is 
     deemed to be a plan administrator of an employee welfare 
     benefit plan which is a group health plan for purposes of 
     applying parts 1 and 4 of subtitle B of title I of the 
     Employee Retirement Income Security Act of 1974 and those 
     provisions of part 5 of such subtitle which are applicable to 
     enforcement of such parts 1 and 4, and the HealthMart shall 
     be treated as such a plan and the enrollees shall be treated 
     as participants and beneficiaries for purposes of applying 
     such provisions pursuant to this subsection.
       ``(d) Application of ERISA Renewability Protection.--A 
     HealthMart is deemed to be a group health plan that is a 
     multiple employer welfare arrangement for purposes of 
     applying section 703 of the Employee Retirement Income 
     Security Act of 1974.
       ``(e) Application of Rules for Network Plans and Financial 
     Capacity.--The provisions of subsections (c) and (d) of 
     section 2711 apply to health benefits coverage offered by a 
     health insurance issuer through a HealthMart.
       ``(f) Construction Relating to Offering Requirement.--
     Nothing in section 2711(a) of this Act or 703 of the Employee 
     Retirement Income Security Act of 1974 shall be construed as 
     permitting the offering outside the HealthMart of health 
     benefits coverage that is only made available through a 
     HealthMart under this section because of the application of 
     subsection (b).
       ``(g) Application to Guaranteed Renewability Requirements 
     in Case of Discontinuation of an Issuer.--For purposes of 
     applying section 2712 in the case of health insurance 
     coverage offered by a health insurance issuer through a 
     HealthMart, if the contract between the HealthMart and the 
     issuer is terminated and the HealthMart continues to 
     make available any health insurance coverage after the 
     date of such termination, the following rules apply:
       ``(1) Renewability.--The HealthMart shall fulfill the 
     obligation under such section of the issuer renewing and 
     continuing in force coverage by offering purchasers (and 
     members and their dependents) all available health benefits 
     coverage that would otherwise be available to similarly-
     situated purchasers and members from the remaining 
     participating health insurance issuers in the same manner as 
     would be required of issuers under section 2712(c).
       ``(2) Application of association rules.--The HealthMart 
     shall be considered an association for purposes of applying 
     section 2712(e).
       ``(h) Construction in Relation to Certain Other Laws.--
     Nothing in this title shall be construed as modifying or 
     affecting the applicability to HealthMarts or health benefits 
     coverage offered by a health insurance issuer through a 
     HealthMart of parts 6 and 7 of subtitle B of title I of the 
     Employee Retirement Income Security Act of 1974 or titles 
     XXII and XXVII of this Act.

     ``SEC. 2803. ADMINISTRATION.

       ``(a) In General.--The applicable Federal authority shall 
     administer this title through the division established under 
     subsection (b) and is authorized to issue such regulations as 
     may be required to carry out this title. Such regulations 
     shall be subject to Congressional review under the provisions 
     of chapter 8 of title 5, United States Code. The applicable 
     Federal authority shall incorporate the process of `deemed 
     file and use' with respect to the information filed under 
     section 2801(a)(6)(A) and shall determine whether information 
     filed by a HealthMart demonstrates compliance with the 
     applicable requirements of this title. Such authority shall 
     exercise its authority under this title in a manner that 
     fosters and promotes the development of HealthMarts in order 
     to improve access to health care coverage and services.
       ``(b) Administration Through Health Care Marketplace 
     Division.--
       ``(1) In general.--The applicable Federal authority shall 
     carry out its duties under this title through a separate 
     Health Care Marketplace Division, the sole duty of which 
     (including the staff of which) shall be to administer this 
     title.
       ``(2) Additional duties.--In addition to other 
     responsibilities provided under this title, such Division is 
     responsible for--
       ``(A) oversight of the operations of HealthMarts under this 
     title; and
       ``(B) the periodic submittal to Congress of reports on the 
     performance of HealthMarts under this title under subsection 
     (c).
       ``(c) Periodic Reports.--The applicable Federal authority 
     shall submit to Congress a report every 30 months, during the 
     10-year period beginning on the effective date of the rules 
     promulgated by the applicable Federal authority to carry out 
     this title, on the effectiveness of this title in promoting 
     coverage of uninsured individuals. Such authority may provide 
     for the production of such reports through one or more 
     contracts with appropriate private entities.

     ``SEC. 2804. DEFINITIONS.

       ``For purposes of this title:
       ``(1) Applicable Federal authority.--The term `applicable 
     Federal authority' means the Secretary of Health and Human 
     Services.
       ``(2) Eligible employee or individual.--The term `eligible' 
     means, with respect to an employee or other individual and a 
     HealthMart, an employee or individual who is eligible under 
     section 2801(c)(2) to enroll or be enrolled in health 
     benefits coverage offered through the HealthMart.
       ``(3) Employer; employee; dependent.--Except as the 
     applicable Federal authority may otherwise provide, the terms 
     `employer', `employee', and `dependent', as applied to health 
     insurance coverage offered by a health insurance issuer 
     licensed (or otherwise regulated) in a State, shall have the 
     meanings applied to such terms with respect to such coverage 
     under the laws of the State relating to such coverage and 
     such an issuer.
       ``(4) Health benefits coverage.--The term `health benefits 
     coverage' has the meaning given the term group health 
     insurance coverage in section 2791(b)(4).
       ``(5) Health insurance issuer.--The term `health insurance 
     issuer' has the meaning given such term in section 2791(b)(2) 
     and includes a community health organization that is offering 
     coverage pursuant to section 330B(a).
       ``(6) Health status-related factor.--The term `health 
     status-related factor' has the meaning given such term in 
     section 2791(d)(9).
       ``(7) HealthMart.--The term `HealthMart' is defined in 
     section 2801(a).
       ``(8) Member.--The term `member' means, with respect to a 
     HealthMart, an individual enrolled for health benefits 
     coverage through the HealthMart under section 2801(c)(2).
       ``(9) Purchaser.--The term `purchaser' means, with respect 
     to a HealthMart, a small employer that has contracted under 
     section 2801(c)(1)(A) with the HealthMart for the purchase of 
     health benefits coverage.
       ``(10) Small employer.--The term `small employer' has the 
     meaning given such term for purposes of title XXVII.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall take effect on January 1, 2000. The Secretary of Health 
     and Human Services shall first issue all regulations 
     necessary to carry out such amendment before such date.

                TITLE IV--COMMUNITY HEALTH ORGANIZATIONS

     SEC. 401. PROMOTION OF PROVISION OF INSURANCE BY COMMUNITY 
                   HEALTH ORGANIZATIONS.

       (a) Waiver of State Licensure Requirement for Community 
     Health Organizations in Certain Cases.--Subpart I of part D 
     of title III of the Public Health Service Act is amended by 
     adding at the end the following new section:


     ``waiver of state licensure requirement for community health 
                     organizations in certain cases

       ``Sec. 330D. (a) Waiver Authorized.--
       ``(1) In general.--A community health organization may 
     offer health insurance coverage in a State notwithstanding 
     that it is not licensed in such a State to offer such 
     coverage if--
       ``(A) the organization files an application for waiver of 
     the licensure requirement with the Secretary of Health and 
     Human Services (in this section referred to as the 
     `Secretary') by not later than November 1, 2005; and
       ``(B) the Secretary determines, based on the application 
     and other evidence presented to the Secretary, that any of 
     the grounds for approval of the application described in 
     subparagraph (A), (B), or (C) of paragraph (2) has been met.
       ``(2) Grounds for approval of waiver.--
       ``(A) Failure to act on licensure application on a timely 
     basis.--The ground for approval of such a waiver application 
     described in this subparagraph is that the State has failed 
     to complete action on a licensing application of the 
     organization within 90 days of the date of the State's 
     receipt of a substantially complete application. No period 
     before the date of the enactment of this section shall be 
     included in determining such 90-day period.
       ``(B) Denial of application based on discriminatory 
     treatment.--The ground for approval of such a waiver 
     application described in this subparagraph is that the State 
     has denied such a licensing application and the standards or 
     review process imposed by the State as a condition of 
     approval of the license or as the basis for such denial by 
     the State imposes any material requirements, procedures, or 
     standards (other than solvency requirements) to such 
     organizations that are not generally applicable to other 
     entities engaged in a substantially similar business.
       ``(C) Denial of application based on application of 
     solvency requirements.--With respect to waiver applications 
     filed on or after the date of publication of solvency 
     standards established by the Secretary under

[[Page H9446]]

     subsection (d), the ground for approval of such a waiver 
     application described in this subparagraph is that the State 
     has denied such a licensing application based (in whole or in 
     part) on the organization's failure to meet applicable State 
     solvency requirements and such requirements are not the same 
     as the solvency standards established by the Secretary. For 
     purposes of this subparagraph, the term solvency requirements 
     means requirements relating to solvency and other matters 
     covered under the standards established by the Secretary 
     under subsection (d).
       ``(3) Treatment of waiver.--In the case of a waiver granted 
     under this subsection for a community health organization 
     with respect to a State--
       ``(A) Limitation to state.--The waiver shall be effective 
     only with respect to that State and does not apply to any 
     other State.
       ``(B) Limitation to 36-month period.--The waiver shall be 
     effective only for a 36-month period but may be renewed for 
     up to 36 additional months if the Secretary determines that 
     such an extension is appropriate.
       ``(C) Conditioned on compliance with consumer protection 
     and quality standards.--The continuation of the waiver is 
     conditioned upon the organization's compliance with the 
     requirements described in paragraph (5).
       ``(D) Preemption of state law.--Any provisions of law of 
     that State which relate to the licensing of the organization 
     and which prohibit the organization from providing health 
     insurance coverage shall be superseded.
       ``(4) Prompt action on application.--The Secretary shall 
     grant or deny such a waiver application within 60 days after 
     the date the Secretary determines that a substantially 
     complete waiver application has been filed. Nothing in this 
     section shall be construed as preventing an organization 
     which has had such a waiver application denied from 
     submitting a subsequent waiver application.
       ``(5) Application and enforcement of state consumer 
     protection and quality standards.--A waiver granted under 
     this subsection to an organization with respect to licensing 
     under State law is conditioned upon the organization's 
     compliance with all consumer protection and quality standards 
     insofar as such standards--
       ``(A) would apply in the State to the community health 
     organization if it were licensed as an entity offering health 
     insurance coverage under State law; and
       ``(B) are generally applicable to other risk-bearing 
     managed care organizations and plans in the State.
       ``(6) Report.--By not later than December 31, 2004, the 
     Secretary shall submit to the Committee on Commerce of the 
     House of Representatives and the Committee on Labor and Human 
     Resources of the Senate a report regarding whether the waiver 
     process under this subsection should be continued after 
     December 31, 2005.
       ``(b) Assumption of Full Financial Risk.--To qualify for a 
     waiver under subsection (a), the community health 
     organization shall assume full financial risk on a 
     prospective basis for the provision of covered health care 
     services, except that the organization--
       ``(1) may obtain insurance or make other arrangements for 
     the cost of providing to any enrolled member such services 
     the aggregate value of which exceeds such aggregate level as 
     the Secretary specifies from time to time;
       ``(2) may obtain insurance or make other arrangements for 
     the cost of such services provided to its enrolled members 
     other than through the organization because medical 
     necessity required their provision before they could be 
     secured through the organization;
       ``(3) may obtain insurance or make other arrangements for 
     not more than 90 percent of the amount by which its costs for 
     any of its fiscal years exceed 105 percent of its income for 
     such fiscal year; and
       ``(4) may make arrangements with physicians or other health 
     care professionals, health care institutions, or any 
     combination of such individuals or institutions to assume all 
     or part of the financial risk on a prospective basis for the 
     provision of health services by the physicians or other 
     health professionals or through the institutions.
       ``(c) Certification of Provision Against Risk of Insolvency 
     for Unlicensed CHOs.--
       ``(1) In general.--Each community health organization that 
     is not licensed by a State and for which a waiver application 
     has been approved under subsection (a)(1), shall meet 
     standards established by the Secretary under subsection (d) 
     relating to the financial solvency and capital adequacy of 
     the organization.
       ``(2) Certification process for solvency standards for 
     chos.--The Secretary shall establish a process for the 
     receipt and approval of applications of a community health 
     organization described in paragraph (1) for certification 
     (and periodic recertification) of the organization as meeting 
     such solvency standards. Under such process, the Secretary 
     shall act upon such a certification application not later 
     than 60 days after the date the application has been 
     received.
       ``(d) Establishment of Solvency Standards for Community 
     Health Organizations.--
       ``(1) In general.--The Secretary shall establish, on an 
     expedited basis and by rule pursuant to section 553 of title 
     5, United States Code and through the Health Resources and 
     Services Administration, standards described in subsection 
     (c)(1) (relating to financial solvency and capital adequacy) 
     that entities must meet to obtain a waiver under subsection 
     (a)(2)(C). In establishing such standards, the Secretary 
     shall consult with interested organizations, including the 
     National Association of Insurance Commissioners, the Academy 
     of Actuaries, and organizations representing Federally 
     qualified health centers.
       ``(2) Factors to consider for solvency standards.--In 
     establishing solvency standards for community health 
     organizations under paragraph (1), the Secretary shall take 
     into account--
       ``(A) the delivery system assets of such an organization 
     and ability of such an organization to provide services to 
     enrollees;
       ``(B) alternative means of protecting against insolvency, 
     including reinsurance, unrestricted surplus, letters of 
     credit, guarantees, organizational insurance coverage, 
     partnerships with other licensed entities, and valuation 
     attributable to the ability of such an organization to meet 
     its service obligations through direct delivery of care; and
       ``(C) any standards developed by the National Association 
     of Insurance Commissioners specifically for risk-based health 
     care delivery organizations.
       ``(3) Enrollee protection against insolvency.--Such 
     standards shall include provisions to prevent enrollees from 
     being held liable to any person or entity for the 
     organization's debts in the event of the organization's 
     insolvency.
       ``(4) Deadline.--Such standards shall be promulgated in a 
     manner so they are first effective by not later than April 1, 
     2000.
       ``(e) Definitions.--In this section:
       ``(1) Community health organization.--The term `community 
     health organization' means an organization that is a 
     Federally-qualified health center or is controlled by one or 
     more Federally-qualified health centers.
       ``(2) Federally-qualified health center.--The term 
     `Federally-qualified health center' has the meaning given 
     such term in section 1905(l)(2)(B) of the Social Security 
     Act.
       ``(3) Health insurance coverage.--The term `health 
     insurance coverage' has the meaning given such term in 
     section 2791(b)(1).
       ``(4) Control.--The term `control' means the possession, 
     whether direct or indirect, of the power to direct or cause 
     the direction of the management and policies of the 
     organization through membership, board representation, or an 
     ownership interest equal to or greater than 50.1 percent.''.

  The SPEAKER pro tempore (Mr. Hastings of Washington). Pursuant to 
House Resolution 323, the gentleman from Virginia (Mr. Bliley), the 
gentleman from Michigan (Mr. Dingell), the gentleman from Pennsylvania 
(Mr. Goodling), the gentleman from Missouri (Mr. Clay), the gentleman 
from Texas (Mr. Archer), and the gentleman from New York (Mr. Rangel) 
each will control 20 minutes.
  The Chair recognizes the gentleman from Virginia (Mr. Bliley).


                             General Leave

  Mr. BLILEY. Mr. Speaker, I ask unanimous consent that all Members may 
have 5 legislative days within which to revise and extend their remarks 
and include extraneous material on this bill and all bills considered 
pursuant to this resolution.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from Virginia?
  There was no objection.
  Mr. BLILEY. Mr. Speaker, I yield myself 5 minutes.
  Mr. Speaker, I rise today to support H.R. 2990, the Quality Care for 
the Uninsured Act. I appreciate the hard work of my colleagues, the 
gentleman from Missouri (Mr. Talent) and the gentleman from Arizona 
(Mr. Shadegg) on this bill. I urge all of my colleagues to support this 
important measure.
  This bill will have a greater impact on Americans struggling to 
access basic health coverage than anything else we do here this week. 
That is because this bill is designed to address the real crisis in 
health care in this country, the crisis of the rising numbers of 
uninsured.
  The problem is bad and it is getting worse. The headline in the 
Washington Post this past Monday highlighted the true health care 
crisis in America today, ``one million more in the U.S. lacked health 
care coverage in study of 1998.'' This is at a time when we are 
virtually at full employment.
  The Census Bureau tells us the number of uninsured increased to over 
44 million in 1998, as this chart here demonstrates. Over the last 
decade, we have had a long period of economic growth. Household incomes 
are up and everyone is trading stocks, but as this chart shows the 
number of uninsured grow every year.
  Who are the uninsured? The majority of the 44 million uninsured come 
from

[[Page H9447]]

hard-working families. My committee held a hearing back in June to look 
at the problems with access to health coverage. We heard compelling 
testimony from Mary Horsley, a wife and mother from Cape Charles, 
Virginia. The Horsley family is uninsured. Mrs. Horsley told the 
committee about her family's struggles with illness. They cannot afford 
health insurance because they make too much money to qualify for 
Medicaid but not enough to buy insurance that will cover her husband's 
preexisting medical condition.
  Like millions of other Americans, the Horsleys are in what I like to 
call the coverage gap. This chart shows us that low income workers tend 
to fall in this coverage gap.
  Now, there are two ways this gap can be filled. One can try and fill 
it by expanding public programs like medicaid. Historically, this is 
how we have tried to address the problems of the lower-income 
uninsured. Using this approach, however, places millions of people in a 
one-size-fits-all, big government program.
  There is a better way, however. We can begin to address this problem 
by making sure low-income workers, who do not want to go on Medicaid, 
have access to private health coverage like a majority of Americans 
have today.
  This is what H.R. 2990 will do. It will expand access to private 
health insurance by providing tax incentives and regulatory relief.
  A key feature of this bill, which I am proud to have offered, is the 
proposal to create HealthMarts. HealthMarts are private, voluntary 
health care supermarkets; employers who elect to join a HealthMart. But 
just like in our own health plan, the Federal Employee Health Benefit 
Plan, FEHBP, individual employees would make the choice of coverage 
from the options available in the HealthMart, not the employer.
  These charts show us how HealthMarts would provide employees with new 
coverage options.
  How can HealthMarts help the uninsured? First it would help with 
costs. The General Accounting Office tells us that in my home State 
alone, Virginia, mandated benefit laws account for 12 percent of 
premium costs. HealthMarts would be free to offer plans that did not 
include these costly mandates. Further, cost savings would be achieved 
by competition in the HealthMart, because the consumer can choose the 
plan he wants or she wants and is able to switch plans on an annual 
basis.
  Insurers would compete for this business. This competition is surely 
lacking in health coverage today. There is one system where this type 
of choice in competition is alive and well, and it is our plan, the 
Federal Employee Health Benefit Plan. My colleagues and I enjoy a great 
treasure in our Federal health program. We have multiple plans to 
choose from. We are all pooled together to spread the cost of caring 
for the sick with the healthy and, most important, once a year we all 
get the chance to fire our health plan if we do not like it and hire a 
new one.
  This choice drives quality in the health care system. This choice 
drives affordability in the health care system. This is a choice all 
Americans should have. Giving consumers the freedom to make the choice 
is why we are here today. We will never get to the root of the problems 
faced by the uninsured or the dissatisfaction some have with their 
current coverage until we create a true marketplace for health care.
  Today, patients lack real control. They are riding shotgun in a 
system driven by employers and insurance companies. H.R. 2990 seeks to 
change this by putting patients in the driver's seat where they belong. 
The answers to the problems we are trying to address today do not lie 
in more costly mandates on health insurers.
  Mr. DINGELL. Mr. Speaker, I yield myself 5 minutes.
  (Mr. DINGELL asked and was given permission to revise and extend his 
remarks.)
  Mr. DINGELL. Mr. Speaker, let us put this in the simplest terms. 
Health care is paid for with insurance premiums and deductibles. The 
payments buy a promise that health care is there when it is needed.
  Is that true? Probably not. When one has a problem, one visits their 
doctor. Someone might have a numb feeling in their leg or a lesion or 
migraine headaches. The doctor examines them and decides they need a 
procedure or medication or a diagnostic test.
  So what happens? The doctor talks to the administrative office in the 
HMO. They check with the insurance company. The insurance bureaucrat at 
the other end of the 800 telephone number says, no, we cannot pay for 
that procedure or treatment or medication. So the doctor gets on the 
phone, argues with the bureaucrat. The HMO still says no.
  What does one do then? That is when Norwood-Dingell comes in. We give 
a person the right to see a qualified specialist. We give a person the 
ability to get into a clinical trial. We say women and children can see 
obstetricians and pediatricians or cancer specialists are available to 
cancer patients. We say a person can go to the nearest emergency room 
without prior approval or extra charges, and we give a person a fair 
chance to appeal an unfair or biased decision to get the treatment that 
is needed.

                              {time}  1415

  In short, Norwood-Dingell makes the health insurance work.
  We are going to hear a lot about lawyers and employers, but let us 
keep a few things in mind.
  If a doctor makes a wrong medical decision, that doctor can be and is 
held accountable. In a word, he can be sued. But if an insurance 
company makes a medical decision by denying someone treatment, that 
denial causes injury or death, the insurance company gets off scot 
free. Only the insurance companies and foreign diplomats escape 
liability. They are the only ones who get a complete shelter against 
wrongdoing.
  A lot of people want us to believe that this debate is all about 
lawsuits, but that fails the simple test of common sense. When someone 
is sick, do they want to go to court? Do they want to see a lawyer? Do 
they want to have litigation? Of course not. What they want to do is to 
see a doctor, not a judge; and they want to get their pain and their 
suffering alleviated.
  We are going to hear a lot of talk about helping the uninsured today. 
My good friend and colleague, the gentleman from Virginia (Mr. Bliley) 
who I dearly love, spent a lot of time on it; but we could have written 
bipartisan legislation to help the uninsured. No effort in that 
direction was made, and that is not the bill on which we will vote 
today. This bill and the question before this body is about giving 
people health insurance. The bill that we have before us at this moment 
is simply about giving Members of Congress political insurance against 
those who know they are not being properly treated by HMOs.
  Let us look at the facts. Who are the 46 million Americans without 
health insurance? Well, here they are. Half of them work in low-wage 
jobs. Many of them are people moving from welfare to work who are no 
longer covered by Medicaid. One-quarter of the uninsured are children. 
According to the General Accounting Office one-third of the uninsured 
pay no income taxes whatsoever. Many others pay far less than will do 
them any good on a tax credit. What we have to talk about here is 
getting the money to the people who have the need. What is needed here 
is a tax credit which is refundable in character. That is not before 
this body at this time, and the practical result of that is then that 
the uninsured are not going to be benefited.
  The bill that we have before us is a bill which helps the wealthy and 
which helps the healthy.
  Now let us talk about the people who are uninsured. The health 
insurance industry pointed out three factors that are pricing employers 
out of the market: modern medical technologies, rising cost of 
prescription medication, and longer lives for old people who need more 
care. This bill does nothing, nothing about any of those questions.
  If this is to be a serious exercise in helping the uninsured, and I 
have many friends on the other side of the aisle who are sincere in 
that, we could have found a common ground. We have legislation around 
here which will really cover every American, and I think that is the 
way in which we should proceed. This bill does nothing except help the 
insurance companies and to help the well to do and to help the healthy. 
It creates a long downward spiral of adverse selection which is going 
to reduce

[[Page H9448]]

the number of people who are really eligible to get insurance coverage 
and which is going to raise the costs by leaving those people who have 
the least ability to pay dependent upon those services.
  It is interesting to note that only one of the bills we are going to 
consider in this cycle of legislation was written before yesterday. 
Only one has been examined in broad daylight. Only one is bipartisan 
and has a chance of being signed into law. Only one has been endorsed 
by more than 300 organizations representing doctors, teachers, 
consumers, union members, specialists, women, doctors, and others. Only 
one has a chance of making life easier for the people who desperately 
have need.
  That is Norwood-Dingell, and I would commend my colleagues to the 
fact that if they really want to do something about people, do not mess 
around with this nonsensical piece of legislation. Vote for Norwood-
Dingell to get what we want.
  What is this debate about today?
  Let me put it in the simplest terms.
  You pay for your health care with insurance premiums and deductibles. 
Those payments buy a promise that you can get health care when you need 
it.
  When you think you have a problem, you visit your doctor.
  You might have a numb feeling in your arm or leg, or a lesion, or 
migraine headaches. Your doctor examines you, and decides you need a 
procedure, or medication, or a diagnostic test.
  So your doctor talks to the administrative staff in the office, and 
they check with your insurance company. The insurance bureaucrat at the 
other end of the 800 telephone number says, no, we won't pay for that 
procedure or treatment or medication. So the doctor gets on the phone 
and argues with the bureaucrat, and still they say no.
  So what do you do then? That's what the Norwood-Dingell bill is 
about. We give you the right to see a qualified specialist. We give you 
the ability to get into a clinical trial. We say women and children can 
see obstetricians and pediatricians, or cancer patients oncologists. We 
say you can go to the nearest emergency room without prior approval or 
extra charges. And we give you a fair chance to appeal the decision and 
get the treatment you need.
  In short, we make your insurance work.
  We're going to hear a lot of talk about lawyers and employers in the 
next two days. But keep a few things in mind.
  If a doctor makes the wrong medical decision, a doctor can be--and 
is--held accountable, the doctor can be sued--
  But if an insurance company makes a medical decision by denying you 
treatment, and that denial causes injury or death, the insurance 
company gets off free. Only insurance companies and HMO's get this 
protection against accountability for their wrong doing.
  A lot of people want you to believe this debate is all about 
lawsuits. But that claim fails the simple test of common sense. If 
you're sick, do you want to go to court--or do you want to get better? 
When you need treatment for an illness, do you want to see a doctor or 
a judge?
  We're also going to hear a lot of talk about helping the uninsured 
today.
  We could have written bipartisan legislation to help the uninsured. 
But that's not the bill we'll consider and vote on today. That bill 
isn't about giving people health insurance. That bill is designed to 
give Members of Congress political insurance.
  Let's look at the facts. Who are the 46 million Americans without 
health insurance?
  Half of them work in low wage jobs. Many of them are people moving 
from welfare to work who are no longer covered by Medicaid.
  One quarter of the uninsured are children. According to the General 
Accounting Office, one third of the uninsured pay no income taxes. Are 
people who neither pay nor file taxes really going to be helped by tax 
deductions?
  Why are these people uninsured? A spokesman for the health insurance 
industry pointed to three factors that are pricing employers out of the 
market: new medical technologies, the rising cost of prescription 
medication, and longer lives for older people who need more care.
  The access bill H.R. 2990 does nothing to address any of those 
issues.
  If this were a serious exercise in helping the uninsured--and I have 
many friends on the other side of the aisle who are sincere in that 
desire--we could have found common ground. We could have put together a 
package to help children, small businesses, and the self-employed. We 
could have targeted those at lower income levels, instead of showering 
tax deductions on the wealthy.
  We could have, but we didn't. Instead we have before us a bill that 
helps the healthy and wealthy. It actually reduces existing consumer 
protections for those who today have insurance. And it dynamites an 
almost $50 billion hole in the deficit.
  Only one of the bills we'll consider in the next two days was written 
before yesterday. Only one has been examined in broad daylight. Only 
one is bipartisan and has a chance of being signed into law. Only one 
has been endorsed by more than 300 organizations representing doctors, 
teachers, consumers, union members, specialists, women, and others. 
Only one has a chance of making life a little easier for the people who 
buy health insurance in the hope that it will pay for care when it's 
needed.
  That bill is the one offered by my friends Mr. Norwood, Mr. Ganske, 
Mr. Berry, and myself. Support that bill, and reject all other bills 
and substitutes.
  Mr. BILIRAKIS. Mr. Speaker, I ask unanimous consent to control the 
remainder of the time in place of the gentleman from Virginia (Mr. 
Bliley).
  The SPEAKER pro tempore (Mr. Hastings of Washington). Is there 
objection to the request of the gentleman from Florida?
  There was no objection.
  Mr. BILIRAKIS. Mr. Speaker, I yield myself such time as I may 
consume.
  Mr. Speaker, I rise in support of the Quality Care for the Uninsured 
Act. This bill is designed to increase access to care for millions of 
Americans who currently lack health coverage. It includes a proposal 
that I crafted to expand the ability of community health centers to 
provide quality care to individuals in need. Community health centers 
are not-for-profit health care providers. By law they are established 
in America's medically underserved areas and must make their sources 
accessible to everyone regardless of individuals' ability to pay.
  H.R. 2990 would expand the ability of community health centers to 
private affordable health care services to individuals who lack health 
coverage. It would authorize community health organizations to form 
networks of providers, to increase access to care and medically 
underserved areas. These networks will expand health options in 
communities that currently lack the necessary infrastructure to fully 
support the comprehensive delivery of health care services.
  Specifically, Mr. Speaker, the bill will authorize a waiver of State 
financial requirements that may prevent managed care organizations 
controlled by community health centers from fully participating in the 
private health care market. By allowing the establishment of 
alternative Federal solvency standards for community health 
organizations, this proposal recognizes the unique circumstances facing 
community health centers and the communities that they serve. Community 
health organizations will help expand the patient base of health 
centers while providing a cost-effective coverage option for the small 
employers. These networks will be operated by local providers whose 
primary mission is to meet the health care needs of the communities 
they serve. These networks will enhance competition among commercial 
managed care plans because they will deliver care that is responsive to 
local needs. Competition will drive quality up while driving costs 
down.
  Mr. Speaker, I was proud to cosponsor H.R. 2990, and I strongly urge 
Members to support its passage. The Census Bureau has underscored the 
urgent need for this legislation by announcing that the number of 
uninsured Americans rose to over 44 million last year. This legislation 
builds on the efforts of previous Congresses to expand health care to 
the uninsured.
  During the 103rd Congress I joined then Congressman Roy Rowland in 
leading a bipartisan coalition in support of consensus health reforms. 
Our targeted plan included significant measures to expand health care 
access to the uninsured. Among its key provisions, our plan would 
expand the role of community centers in providing access to care in 
medically underserved areas. We also proposed insurance reforms to help 
individuals with preexisting conditions obtain coverage and to help 
workers keep their insurance when they changed jobs. These insurance 
provisions were ultimately, I underline ultimately, enacted into law 
during the 104th Congress, but those individuals had to wait 2 years 
for assistance.
  Mr. Speaker, we should not repeat that mistake today. H.R. 2990 
represents an important opportunity to

[[Page H9449]]

 expand coverage to the uninsured. It is not perfect, it can go 
further, it can consider some of the items that the gentleman from 
Michigan (Mr. Dingell) mentioned; but it would be an important 
opportunity to at least expand coverage, make available coverage to the 
uninsured. We should not make 44 million Americans wait any longer for 
access to the health care they need. I challenge those who support 
patients' rights to put people ahead of politics and join us in 
supporting passage of this critical measure.
  Mr. Speaker, I reserve the balance of my time.
  Mr. DINGELL. Mr. Speaker, I yield 1 minute to the distinguished 
gentleman from California (Mr. Stark).
  Mr. STARK. Mr. Speaker, I thank the ranking member for yielding this 
time to me, and I just want to bring to light some new information. The 
Joint Committee on Taxation has given us some estimates on what this 
wonderful access bill will do.
  It will provide access perhaps to 160,000 families; that is all. At a 
cost of $48 billion, and try this with your shoes and socks on, that is 
$300,000 per family or $30,000 a year to give 160,000 families, 320,000 
people, coverage. That is all it does. The benefits go to those people 
who are currently insured, which means the Republicans are squandering 
$300,000 per family for 160,000 families who are uninsured, and my 
colleagues want to talk about wasting money? Trust the Republicans to 
do it.
  Mr. Speaker, the Joint Tax Committee has estimated how many people 
the Access bill would help.
  The answer: almost no one.
  The tax deduction for individuals paying for more than 50% of the 
cost of their health insurance will cost $31.2 billion over 10 years 
and result in 200,000 uninsured people getting insurance.
  That's $156,000 per new insured person--$15,600 per year!
  The acceleration of the 100% tax deduction for the self-employed will 
help 120,000 previously uninsured and cost about $3 billion over 4 
years.
  That's $6,250 per person per year--a cadillac cost for sure!
  Just for comparison, an individual policy in the Federal Employee 
Health Benefit Plan costs about $2,500 to $2,800.
  The Republican plan is a massive waste of money.
  The Joint Tax's letter follows:

                                  Joint Committee on Taxation,

                                  Washington, DC, October 6, 1999.
     Hon. Edward M. Kennedy,
     U.S. Senate, Washington, DC.
       Dear Senator Kennedy: This is in response to your letter of 
     October 4, 1999, requesting revenue estimates and other 
     information concerning several of the health care tax 
     provisions in the conference agreement on H.R. 2488 and two 
     of the health care tax provisions in S. 1344.
       The conference agreement on H.R. 2488 contains an above-
     the-line deduction for health insurance expenses and long-
     term care insurance expenses for which the taxpayer pays at 
     least 50 percent of the premium. The deduction would be 
     phased in at 25 percent for taxable years beginning in 2002 
     through 2004, 35 percent for taxable years beginning in 2005, 
     65 percent for taxable years beginning in 2006, and 100 
     percent for taxable years beginning in 2007 and thereafter. 
     Taxpayers enrolled in Medicare, Medicaid, Champus, VA, the 
     Indian Health Service, the Children's Health Insurance 
     Program, and the Federal Employees Health Benefits Program 
     would be ineligible for the deduction for health insurance 
     expenses.
       The conference agreement on H.R. 2488 also contains a 
     provision that would allow long-term care insurance to be 
     offered as part of cafeteria plans, effective for taxable 
     years beginning after December 31, 2001.
       For the purpose of preparing revenue estimates for these 
     provisions in H.R. 2488, we have assumed that the provisions 
     will be enacted during calendar year 1999. Estimates of 
     changes in Federal fiscal year budget receipts are shown in 
     the enclosed table.
       We estimate that in calendar year 2002 about 9.1 million 
     taxpayers would claim the 25-percent deduction for health 
     insurance expenses. About 100,000 of these 9 million 
     taxpayers would be new purchasers of health insurance. 
     Assuming an average of two persons covered by each policy, 
     about 200,000 persons would be newly insured as a result of 
     the 25-percent deduction for health insurance expenses.
       We estimate that in calendar year 2002 about 4.7 million 
     taxpayers would claim the 25-percent deduction for long-term 
     care insurance expenses, and an additional 300,000 taxpayers 
     would use cafeteria plans to pay their share of premiums for 
     employer-sponsored long-term care insurance. About 80,000 of 
     these 5 million taxpayers would be new purchasers of long-
     term care insurance.
       S. 1344 contains a provision that would increase the 
     deduction for health insurance expenses of self-employed 
     individuals. Under present law, when certain requirements are 
     satisfied, self-employed individuals are permitted to deduct 
     60 percent of their expenditures on health insurance and 
     long-term care insurance. The deduction is scheduled to 
     increase to 70 percent of such expenses for taxable years 
     beginning in 2002 and 100 percent in all taxable years 
     beginning thereafter. S. 1344 would increase the rate of 
     deduction to 100 percent of health insurance and long-term 
     care insurance expenses for taxable years beginning after 
     December 31, 1999.
       S. 1344 also contains provisions that would eliminate 
     certain restrictions on the availability of medical savings 
     accounts, remove the limitation on the number of taxpayers 
     that are permitted to have medical savings accounts, reduce 
     the minimum annual deductibles for high-deductible health 
     plans to $1,000 for plans providing single coverage and 
     $2,000 for plans providing family coverage, increase the 
     medical savings account contribution limit to 100 percent of 
     the annual deductible for the associated high-deductible 
     health plan, limit the additional tax on distributions not 
     used for qualified medical expenses, and allow network-based 
     manage care plans to be high-deductible plans. These 
     provisions would be effective for taxable years beginning 
     after December 31, 1999.
       For the purpose of preparing revenue estimates for these 
     provisions in S. 1344, we have assumed that the provisions 
     will be enacted during calendar year 1999. Estimates of 
     changes in Federal fiscal year budget receipts are shown in 
     the enclosed table.
       We estimate that in calendar year 2000, about 3.3 million 
     taxpayers would claim the 100-percent deduction for health 
     insurance expenses of self-employed individuals. About 60,000 
     of these taxpayers would be new purchasers of health 
     insurance. Assuming an average of two persons covered by each 
     policy, about 120,000 persons would be newly insured as a 
     result of the 100-percent deduction for health insurance 
     expenses.
       We do not have an estimate of the numbers of individuals 
     who would be newly insured as a result of the medical savings 
     account provisions of S. 1344.
       I hope this information is helpful to you. If we can be of 
     further assistance, please let me know.
           Sincerely,
                                                   Lindy L. Paull.
       Enclosure: Table #99-3 206

                                                             ESTIMATED REVENUE EFFECTS OF VARIOUS PROVISIONS RELATING TO HEALTH CARE
                                                                            [By fiscal years, in millions of dollars]
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
              Provision                          Effective              2000      2001      2002      2003      2004      2005      2006      2007       2008       2009     2000-04    2000-08
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Health care provisions in the
 conference agreement for H.R. 2488:
    1. Provide an above-the-line       tyba 12/31/01................        --        --      -444    -1,379    -1,477    -1,803    -3,137    -5,878     -8,299     -8,848     -3,300    -31,264
     deduction for health insurance
     expenses--25% in 2002 through
     2004, 95% in 2005, 65% in 2006,
     and 100% thereafter.
    2. Provide an above-the-line       tyba 12/31/01................        --        --       -48      -328      -964      -417      -677    -1,315     -2,027     -2,146       -741     -7,324
     deduction for long-term care
     insurance expenses--25% in 2002
     through 2004, 35% in 2006, 65%
     in 2006, and 100% thereafter.
    3. Allow long-term care insurance  tyba 12/31/01................        --        --      -104      -151      -171      -190      -202      -204       -215       -247       -426     -1,484
     to be offered as part of
     cafeteria plans; limited to
     amount of deductible premiums
     [1].
                                                                     ---------------------------------------------------------------------------------------------------------------------------
      Total of health care provisions  .............................        --        --      -596    -1,858    -2,012    -2,410    -4,016    -7,397    -10,541    -11,241     -4,467    -60,074
       in the conference agreement
       for H.R. 2488.
                                                                     ===========================================================================================================================
Health care provisions in S. 1344, as
 passed by the Senate:
    1. Immediate 100% deductibility    tyba 12/31/99................      -245    -1,007    -1,040      -657  ........  ........  ........  ........  .........  .........     -2,949     -2,844
     of health insurance and long
     term care insurance premiums of
     the self-employed.
    2. Liberalization of conditions    tyba 12/31/99................       -93      -281      -326      -370      -414      -458      -502      -546       -590       -634     -1,483     -4,214
     for enrolling in MSAs.
                                                                     ---------------------------------------------------------------------------------------------------------------------------
      Total of health care provisions  .............................      -338    -1,268    -1,866    -1,027      -414      -458      -502      -546       -590       -634     -4,432    -7,164
       in S. 1344, as passed by the
       Senate.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Note.--Details may not add to totals due to rounding.
Legend for ``Effective'' column: tyba=taxable years beginning after [1] Estimate assumes concurrent enactment of the above-the-line deducation for long-term care Insurance (item 2.)
  Source: Joint Committee on Taxation.


[[Page H9450]]

  Mr. BILIRAKIS. Mr. Speaker, I yield 3 minutes to the gentleman from 
Tennessee (Mr. Bryant).
  Mr. BRYANT. Mr. Speaker, I thank the gentleman from Florida for 
yielding me time. I do rise in strong support of this bill this day. So 
as there will not be any confusion, I want to remind all my colleagues 
here that later on today and tomorrow we will be debating the bill that 
provides protection to those people in this country who have insurance; 
but, Mr. Speaker, today and right now we are talking about those 45 
million men, women, and children in this country who do not have any 
insurance; and, therefore, patient protections that we will be talking 
about later mean nothing, zero, to those people without health 
insurance. For those 44 million people, which by the way translates 
into 1 out of 6 Americans, getting access to quality, affordable health 
care is the most important and most basic patient protection.
  No other bill before this body this week addresses this crisis of the 
uninsured in this country. This legislation does address the problem, 
and it does it the right way, by providing access to affordable quality 
private-sector health care coverage through tax incentives and free 
market reforms. The Quality Care For the Uninsured Act achieves these 
in several ways.
  First, it would expand access to the medical savings accounts. This 
legislation would also create two new innovative ways for people to 
pool together, to come together in groups to obtain more affordable 
health insurance. The association health plans allow small businesses 
and people who are self-employed to have that freedom to join together 
and design more affordable health plans; and the HealthMarts, which is 
the second one, are private organizations similar in concept to a 
supermarket where employers, employees, and other individuals can come 
to purchase health insurance.
  The bill would also provide or allow local community providers to 
form health care networks to meet the special needs of employers and 
employees in medically underserved areas. These community health center 
networks would particularly be helpful in rural areas, certainly in 
areas that I represent and others in this Congress represent.
  Last, but not least, this bill provides for 100 percent tax 
deductible premiums for the self-employed and the uninsured for health 
care insurance premiums and long-term health care premiums. This will 
be of tremendous help to the farmers that I represent.
  Mr. Speaker, none of these proposals alone will completely solve this 
problem of underinsured and uninsured, but together they have the 
potential to expand access to care, opportunity to see a doctor or go 
to a hospital, this opportunity to a significant number of Americans 
without busting the budget, without creating new entitlement programs, 
and without expanding existing government programs.
  Mr. Speaker, this legislation is a responsible approach to providing 
access to care for these 44 million American men, women, and children. 
I urge all of my colleagues to support it and help these people who 
have fallen through the cracks and who do not have that opportunity to 
get affordable good quality health care.
  Mr. DINGELL. Mr. Speaker, I yield 3 minutes to the distinguished 
gentleman from Georgia (Mr. Norwood), my good friend and a man of 
remarkable courage and integrity.
  Mr. NORWOOD. Mr. Speaker, I thank the gentleman for yielding this 
time to me.
  Mr. Speaker, I thought, if I could, I would take a few minutes and 
try to put this debate in perspective. There really are a couple of 
serious, serious problems in health care in America today; and since 
that involves each of us, each of our families, it involves each of us, 
each of our families, and it involves every constituent we have whether 
one is a Republican or Democrat. It is a very important debate, and I 
am so pleased that we are going to have this opportunity to stand up 
and discuss it, but let us try to put this in the box.
  We are going to talk about two things. One of those things that must 
be discussed and will be discussed over the next 2 days is that we have 
a serious problem with so many Americans without any coverage.

                              {time}  1430

  Both sides, Democrats and Republicans, recognize this is a problem. 
Both sides say they want to correct it, and I believe that to be the 
case. I have often said if we thought that was a top priority in the 
Congress of the United States, you need to stand up and say that is a 
top priority in the Congress of the United States. We are going to 
correct that, and we are going to fund that. We are going to take the 
dollars it takes to make sure that we do not have 43 million uninsured 
Americans.
  The other part of the debate though is equally important. It is about 
people who actually do have insurance. I had a colleague say to me that 
health care reform does not do a bit of good if you do not have health 
care insurance. That is most assuredly true. But health care insurance 
does not do you a bit of good either if the benefits that the plan has 
offered you are being denied on a regular basis.
  What we have done in this country over the last 30 years is we have 
turned over the health care industry of this country to the insurance 
industries, and they are in total charge. We preempted state laws, we 
are very silent at the Federal level, there is no public policy at all. 
The insurance industry is very much in charge.
  The access bill that is before us is about the 21st century. It is 
about health care in the future and how we will try to help people have 
access to the health care. I will be perfectly honest with you, I am on 
my fourth or fifth bill, I forget. In the 101st Congress we had a bill, 
H.R. 2400. In the 105th Congress I had a bill named Parker, H.R. 1415. 
It had 234 cosponsors on it. This year I dropped another health care 
bill, H.R. 216. And all of this was about your benefits within your 
plan and who is in charge of health care.
  But realizing early on this year that this business of access is 
equally important, I dropped an access bill in February very clearly 
stating we need to deal with the problem of 43 million Americans that 
are uninsured. What I was saying back in February are these are two 
separate subjects, though they are health care. You must keep these 
separate, because each solution has a different constituency. Perhaps 
you can pass both things, but if you blend them together very much, you 
can kill both things.
  Mr. Speaker, let me just wrap this up and simply say we have two 
subjects. One is access, that is, looking into the future of health 
care, how we can solve some problems, and it should be debated. We are. 
It should be voted on, and it will be. It should be paid for though. I 
think if we ever get there, we will do that too.
  But the other part of this is about Bob Schumacher from Macon, 
Georgia, whose wife is dying, and she has been denied a benefit that is 
in her plan. If we do not deal with this problem right now, we are 
going to find that further Americans are complaining about their health 
care, further Americans are going to be harmed, further Americans are 
going to be killed.
  All I ask you to do is let us have both debates, let us have separate 
votes on this, and let us try to come to an American vote; not a 
Republican vote and not a Democratic vote. Let us vote as patients on 
this. What would you have done if it was your family?
  I look forward to the debate, Mr. Speaker, over the next two days, 
and I am sure that if we are careful about it, the American people will 
enjoy it.
  Mr. BILIRAKIS. Mr. Speaker, I yield 2 minutes to the gentlewoman from 
Texas (Ms. Granger).
  Ms. GRANGER. Mr. Speaker, today I am pleased to stand up and to speak 
out on behalf of the Quality Care for the Uninsured Act. I believe this 
is a commonsense solution to an all too common problem of access to 
health insurance.
  As a mother and a small businesswoman, I understand how important 
health care is to each American and to every employer. The issue of 
health care is not just about dollars and cents or rules and 
regulations, or even liability. First and foremost, the issue of health 
care is about people and their

[[Page H9451]]

access to doctors. It is about knowing there is someone to call when 
your 3 year old wakes up with a fever. It is about knowing there is a 
doctor who understands the reoccurring ear infection.
  Access has to be the number one goal in this entire health care 
issue. Today there are 44 million Americans without any health care 
coverage. These people are not concerned about whether they can sue 
their HMO, they are concerned about whether they can see a doctor. I am 
proud to say today may be the day we finally listen to the voices of 
the uninsured. The Quality Care for the Uninsured Act addresses access 
with HealthMarts and Association Health Plans, and also full 100 
percent deductibility of health insurance.
  These proposals hold the promise of health insurance for millions of 
Americans. By increasing the choices and options, we can decrease the 
number of uninsured Americans, and is that not really the most 
important issue? I think it is. After all, when it comes to health 
care, access to a doctor is far more important than access to a lawyer.
  If we are really serious about expanding access to health care, we 
will vote for this very important proposal. I urge my colleagues to put 
the patients' interests ahead of special interests. Too many people are 
still uninsured. Today we have the chance to change that. In short, 
this bill will mean more access for more Americans. I encourage us all 
to lower our voices, to raise our sights, and to reach out for the 
uninsured by passing the Quality Care for the Uninsured Act.
  Mr. DINGELL. Mr. Speaker, I yield 2 minutes to the distinguished 
gentleman from Texas (Mr. Green).
  Mr. GREEN of Texas. Mr. Speaker, I would like to thank my good friend 
and ranking member of the Committee on Commerce for yielding me time.
  Mr. Speaker, I rise in reluctant opposition to H.R. 2990. Clearly, 
access to health care is not a Democrat or Republican issue. In fact, I 
have introduced legislation in the last two Congresses that would do 
some of the things that this bill would do. In fact, we have not even 
had a hearing on my bill the last two Congresses, so it is good to be 
able to talk about it on the floor today.
  My bill would allow everyone to deduct from their taxes what their 
health and long term care costs would be. Unfortunately, the bill we 
are considering today is poorly timed and irresponsibly drafted.
  The Republican leadership has gone out of their way to say they will 
not spend a dime of the Social Security funds until the program is 
fixed. Yet that seems to have lasted about a week.
  Earlier this week we found out that they were dipping into Social 
Security for about $16 billion, and today we are proposing an 
agriculture bill that would dip into the Social Security trust fund to 
the tune of about $48 billion with H.R. 2990. So this is how it works. 
They also started running TV ads saying that they were going to devote 
100 percent of the Social Security surplus. Hopefully when this 
Congress is through, we will be able to do that.
  This bill promises a lot, but gives little results because it is not 
funded. Some of the specific things I think that is wrong with it, it 
expands the MSAs, a demonstration project that has failed, and we have 
seen that happen. Throwing more tax benefits at the MSAs will not make 
it become a reality and it will increase health costs for those who 
remain in traditional health care or insurance or managed care plans.
  It misdirects Federal dollars through the tax deduction, 
disproportionately helps the wealthy by not expanding it to all 
employees and just doing self-employed predominantly. You are taking 
the highest income brackets, and the deductions will not help those 32 
million people in the 0 to 15 percent tax bracket who will not be able 
to benefit from this bill.
  The last concern I have is that because in Texas we have passed 
managed care reform and over the years had a very aggressive insurance 
commissioner or State Department of Insurance, this would bypass state 
regulation on benefits in Texas in favor of new Federal regulations, 
and it would disrupt state insurance markets. That is just not true in 
Texas, but that is in all our states. One size does not fit all.
  Mr. BILIRAKIS. Mr. Speaker, I am pleased to yield 1 minute to the 
gentlewoman from Illinois (Mrs. Biggert).
  (Mrs. BIGGERT asked and was given permission to revise and extend her 
remarks.)
  Mrs. BIGGERT. Mr. Speaker, I rise in strong support of H.R. 2990, the 
Quality Care for the Uninsured Act. Reducing the number of uninsured 
Americans is one of the biggest challenges facing this Congress. My 
predecessor, Harris Fawell, worked tirelessly toward expanding access 
to care for those who are currently uninsured. Congressman Fawell's 
good work continues with this bill, H.R. 2990.
  By combining free market reforms with health care tax provisions, 
this bill expands access to affordable insurance for individuals and 
small businesses across the country. We in Congress have a 
responsibility to make it easier, not more difficult, for small 
businesses to offer health insurance. H.R. 2990 will go a long way 
towards reaching this goal.
  Mr. Speaker, we should not let this opportunity pass us by. I ask all 
of my colleagues to support this legislation.
  Mr. DINGELL. Mr. Speaker, I yield 2 minutes to the distinguished 
gentleman from Arkansas (Mr. Berry).
  Mr. BERRY. Mr. Speaker, I rise to urge a vote against this fiscally 
irresponsible legislation. It does not make sense to enact legislation 
that would cost more than $48 billion without paying for it. The 
authors of this bill claim that it is paid for out of the non-Social 
Security surplus. They have been spending this surplus once a week for 
the last month and a half. We started out, as this chart shows, the 
first of July with $14 billion in surplus, and now we are down to 
something less than $25 billion that we have overspent.
  Here we go again. Although we are projected to begin running 
substantial on-budget surpluses in 2001, these are just projections. 
This is not real money. Enacting policies now that will result in a 
permanent revenue loss based on projected surpluses that may not 
materialize is irresponsible. Adding to the debt our children have to 
pay off is reckless and foolhardy.
  Why would we want to rob the Social Security trust fund again? This 
is a tax bill that is not paid for. Let us not do this to our precious 
children and to their future. Let us save the Social Security trust 
fund.
  Mr. DINGELL. Mr. Speaker, I yield 2 minutes to the distinguished 
gentlewoman from Connecticut (Ms. DeLauro).
  Ms. DeLAURO. Mr. Speaker, I rise in strong opposition to this bill. 
The fact is that this bill is not paid for. It is a $48 billion raid on 
Social Security. That is one reason to vote against it.
  The so-called access bill fails to provide any access for the people 
who truly need it most. It includes discredited medical savings 
accounts that only help the wealthy and the healthy. In fact, nearly 
one-third of all uninsured Americans would receive no help under this 
bill. As has been pointed out, only 160,000 people would be the 
beneficiaries of this bill. A second good reason to vote against it.
  The third reason to vote against the bill is that it represents a 
last-ditch effort to kill the Patients' Bill of Rights. The Republican 
leadership has announced that they will attach this sham bill to the 
bipartisan Patients' Bill of Rights. A strong bipartisan majority in 
this body supports the Dingell-Norwood bill, but we have been fighting 
against a small minority in the Republican leadership every step of the 
way.
  Why do they oppose HMO reform? Because they are in league with the 
insurance lobby, a major campaign contributor to the Republican Party. 
In fact, just yesterday, on the eve of this important health care 
debate, the Republican leadership held a breakfast with the insurance 
industry, a sad testament.
  We should not be surprised that the Republican leadership is 
thwarting the will of this House. There is nothing new here. It is what 
we saw earlier this year on gun safety legislation, it is what we saw 
on campaign finance reform, an unwillingness to allow an honest debate 
and the use of clever procedural tricks to defeat reform.
  People in this country are dying because our health care system is 
broken,

[[Page H9452]]

and the Republican leaders' response? Meet with the insurance lobby and 
devise a clever way to try to kill HMO reform.
  Vote against this legislation. Let us have a fair and an open debate 
on Patients' Bill of Rights, a bill that would put medical decision 
making back into the hands of doctors and patients and make HMOs 
accountable.

                              {time}  1445

  Mr. DINGELL. Mr. Speaker, I yield 2 minutes to the distinguished 
gentleman from North Dakota (Mr. Pomeroy).
  Mr. POMEROY. Mr. Speaker, can we imagine the fireworks that would 
erupt on this floor if the Democrats brought forward a bill that was 
$45 billion in a hit to the Treasury, without a nickel in how it is 
paid for? That is precisely the proposal offered by the majority with 
this access bill, a $45 billion hit over 10 years to the Treasury, and 
not one nickel in terms of how those monies would be paid for.
  I am for full deductibility of health insurance premiums paid by 
individuals, but let us show how we are going to pay for it, so we are 
not spending the social security trust fund to do it.
  I rise for another very important reason on this bill. I am the only 
former insurance commissioner in Congress. I know the consumer 
protection role played by State insurance departments. Every day State 
insurance department officials are helping people get claims paid, 
helping them deal with insurance complaints.
  This bill in a major way would preempt all of that. Association 
health plans, community health center networks, HealthMarts, all of 
these features of this access bill would take it from State insurance 
departments and place it into a never-never-land of a soon-to-be-
created Federal bureaucracy for regulation.
  This whole Patients' Bill of Rights is about getting patients 
protections, because they right now do not have sufficient protections 
with their HMOs. How ironic that the majority would come up with a 
proposal that literally would take those who are now protected and push 
them also into the unprotected categories.
  Consumers should not have to turn to some Federal bureaucracy to get 
a claim paid. Consumers should not have to call someone in the Federal 
bureaucracy to get approval to get the medical procedures that they 
need. They should go to their State insurance department, fifty State 
insurance departments, all with toll-free lines located right in the 
State capitols.
  This bill, through the association health plans, the community health 
center networks, and the HealthMarts, would take it all away. Keep 
consumer protection. Defeat the access bill.
  Mr. DINGELL. Mr. Speaker, I yield such time as he may consume to the 
gentleman from Illinois (Mr. Davis).
  (Mr. DAVIS of Illinois asked and was given permission to revise and 
extend his remarks.)
  Mr. DAVIS of Illinois. Mr. Speaker, I rise in opposition to this 
bill.
  Mr. Speaker, I rise today to oppose this legislation that purports to 
provide access to health care for those who need it most--the 
uninsured. I know this is the month that we celebrate Halloween, but it 
is way too early for these gimmicks and tricks. The American people 
expect treats not tricks and this bill represents a trick for two 
reasons.
  First, at a time when we are experiencing unprecedented economic 
growth the number of uninsured individuals has risen more than one 
million over the past year to 44 million Americans. This legislation 
that purports to help the needy does more by way of giving tax breaks 
to help the wealthy--that the needy would hardly benefit from this 
bill. According to the General Accounting Office nearly one-third of 
all uninsured Americans do not pay income taxes. These families would 
not benefit under this bill. Instead the greatest benefits under this 
bill would go to the 600,000 families that make almost $100,000 per 
year.
  Secondly, this bill expands medical savings accounts--a special tax 
break for the healthy and wealthy that threatens to increase health 
insurance premiums for everyone else. This provision was added to an 
important health portability bill in 1996--and this provision drew a 
veto from President Clinton--ultimately killing the bill. Here we are 
again, a chance to do something meaningful to improve the quality of 
life and health care for those who do not have access, but yet we would 
attach provisions that effectively make the bill DOA (dead on arrival). 
The effect of merging this bill with the Norwood-Dingell bill is to 
kill meaningful managed care legislation.
  I support improving access to health care, in my congressional 
district 175,000 people live at or below the poverty level. It is a 
district that has pockets of poverty and great need. Unfortunately, 
this bill does not help to alleviate the hurt and pain of the uninsured 
in my district. If we are serious about providing access then we need 
to pass a universal health care bill. A bill that allows individuals to 
go to the doctor when they need to go, a bill that allows them to see a 
specialist, a bill that allows them prescription drug coverage. That is 
what access is all about. This bill is a trick, a sham, and not a treat 
for the vast majority of Americans who need health coverage. I urge my 
colleagues to vote ``no'' on this gimmick laden legislation.
  Mr. DINGELL. Mr. Speaker, I yield myself the balance of my time.
  Mr. Speaker, we have heard it already. This access package is going 
to cost $156,000 for a well-to-do patient. It is not going to give 
anything to the poor. The reason for that is that this is a tax 
deduction. The poor do not pay taxes.
  So who is going to get, then, the money that is going to come under 
this proposal? Only the well-to-do. What will be the practical effect 
on the insurance pool? To suck out the well-to-do out of the 
conventional insurance pool and to set up a very special, privileged 
insurance pool for the well-to-do. That is what this legislation does.
  In addition to that, the legislation expands SMAs. This is another 
proposal which benefits the well-to-do, because they do not care 
whether they have to buy the insurance or not, what they want to do is 
to get the tax deduction and tax break which benefits only those of 
substantial means.
  The other thing that it does, it misdirects Federal tax dollars to 
tax deductions that help the wealthy. This is hardly a defensible 
expansion. Remember, we are paying $156,000 per new insurance 
beneficiary. The whole of this program is going to cost $31.2 billion. 
Guess from what part of the government accounting structure it is 
coming. It is coming from the social security deficit, which is now a 
reality at this particular time.
  I think it is time we recognize that what we are here for is to craft 
good legislation. This is not. If Members want to craft good 
legislation in the field of covering new people, then the minority 
stands ready to help our Republican colleagues towards that end. This 
bill does not do that.
  We came here to talk about the Patients' Bill of Rights, about 
protecting the rights of patients, not in obfuscating the issue by 
bringing forward a lot of phony tax breaks and a lot of help to fatten 
the rich at the expense of the poor. What we need here is attention to 
the real problem. Then if they want to go on in a carefully packaged 
and carefully programmed set of rules, regulations, and laws which will 
address the problems of people in terms of providing uniform coverage 
for all Americans, I stand ready to do it.
  I remind my Republican colleagues that it was they who killed, 
together with the assistance of their same good friends in the 
insurance lobby, the President's last proposal to expand health care to 
all Americans. It looks like they are up to the same game today.
  Mr. BILIRAKIS. Mr. Speaker, I yield the balance of my time to the 
gentleman from Arizona (Mr. Shadegg).
  The SPEAKER pro tempore (Mr. Hastings of Washington). The gentleman 
from Arizona (Mr. Shadegg) is recognized for 5 minutes.
  (Mr. SHADEGG asked and was given permission to revise and extend his 
remarks.)
  Mr. SHADEGG. Mr. Speaker, let me begin by thanking the chairmen of 
the Committee on Commerce and the Subcommittee on Health, the gentleman 
from Virginia (Mr. Bliley) and the gentleman from Florida (Mr. 
Bilirakis), for making this debate possible, and for their hard work.
  Secondly, let me set the record straight. On two different occasions, 
the gentleman from Virginia (Mr. Bliley) and the gentleman from Florida 
(Mr. Bilirakis) offered to work with the gentleman from Michigan (Mr. 
Dingell) on access legislation, and their staffs made an offer to work. 
That offer was not taken up, so the notion that we have not attempted 
to work with the minority on access legislation is simply wrong.
  Let me address a second argument made here, which is that these two

[[Page H9453]]

issues do not belong together. If Members do not believe these two 
issues belong together, they are not looking at what is happening in 
health care in America today.
  If they can say, well, we should not deal with quality of care at the 
same time we deal with access to care, at a point in American history 
when we have 44 million people who are uninsured, they do not get what 
is going on here. If they think we should not deal with affordability 
at the same time we deal with quality, they do not understand that this 
is all about health care. If they do not think we should give people 
choice at the same time that we improve quality, they do not understand 
markets or how this system works.
  We have to deal with access, affordability, and choice in order to 
get quality. So let me set the record straight on that point, as well.
  The next issue I want to deal with is the question of pay-for. The 
other side says these tax relief measures, attempting to give Americans 
who do not have health insurance now a chance to get health insurance, 
are not paid for, that we cannot afford this bill. Let me tell the 
Members, we cannot afford not to pass this bill.
  Thankfully, these people are getting care, but they are getting care 
in the most expensive form of all. They are getting it in emergency 
rooms. This bill lets every single American have a better chance to 
access affordable care. The statement that it does not help an entire 
group of Americans is flat false. It is wrong. Let me explain why.
  This bill allows small businesses to pool together through 
HealthMarts and association health plans and to offer coverage. That 
includes small businesses who today cannot provide their employees any 
insurance, forget the tax bracket they are in. To talk about an 
employee the other side has talked about who does not pay a dime in 
income tax, but works for an employer that cannot give that employee 
any health care, this bill makes it possible for that employer to give 
that employee health care because they can pool together and offer them 
more affordable coverage. So, so much for the claim that it does not 
help anybody at all.
  Then let us talk about access for the insured. This is a USA Today 
editorial. It appeared earlier this year. It points out that more and 
more Americans are losing choice. They are offered one plan and one 
plan only.
  The minority may think that is great, a single system, take it or 
leave it; too bad, no choice. If it does not fit you and your family, 
you are stuck. Too bad. Indeed, they must think it is okay because they 
have offered nothing to counter that.
  We have offered something. We have said, we ought to give all 
Americans, including those lucky enough to have coverage, more choices. 
Let us talk about how many people do not have choices. Seventy-nine 
percent of all employers in firms with less than 200 employees offer 
their employees one choice, only one choice. Almost 80 percent say, you 
get one choice. That is small business America. You are stuck with the 
plan you are offered.
  Our bill would let those employers offer those employees not one but 
five or six or eight choices. Maybe Members are against choice. I did 
not think so. But this legislation would help those employees just like 
it would help the uninsured, regardless of their tax break. By the way, 
it helps everybody that does pay income taxes.
  Let us talk about big employers. Even in firms with more than 200 
employees, only 46 percent offer their employees two plans to choose 
from. That is, most, barely over or almost half, say you get one 
choice, even when you work in a fairly large company, a company with 
over 200 employees.
  This bill is about access for the uninsured. It is about 
affordability for the uninsured, and it is about choice for every 
single American. The other side says, no, we do not want access. We do 
not want choice. We are not worried about affordability. It is a poison 
pill to simply discuss this the same day we talk about quality.
  It is not a poison pill. The marriage of these two bills does not 
occur until after they leave the floor. That is the point in time when 
we ought to be dealing with a comprehensive fix for health care in 
America.
  I urge my colleagues to vote for this bill. It is good legislation. 
Regardless of the obstructionist tactics of the minority, 
affordability, access, and choice will help health care in America. I 
urge my colleagues to vote for H.R. 2990, a bill which I cosponsored 
with the gentleman from Missouri (Mr. Talent) and which I am proud of.
  Mr. TALENT. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, we said a little while ago that this bill is obfuscating 
the real issue. This bill is about the uninsured. Let us look at the 44 
million people who some believe are obfuscating the real issue.
  Three-quarters of those people work for small businesses. One out of 
every six Americans is uninsured. Eleven million kids in the United 
States are uninsured. As I said, three-quarters of these people either 
own small businesses or work in small businesses or are dependents of 
people who own or work in small businesses.
  What does it mean to be uninsured in America today? It means you face 
the risk of illness without the shield of health insurance. You gamble 
that you are not going to get sick. We have 44 million people running 
that gamble every day, and a lot of them lose.
  Linda Welch-Green has lost. Her story was reported in the Baltimore 
Sun today. Three of her teeth have fallen out because she cannot afford 
to go to the dentist anymore. She has Bell's palsy that has paralyzed 
part of her face. She cannot get it treated. The reason is she works, 
she works full-time, and her employer offers health insurance, but it 
is so expensive for small employers that she cannot afford the buy-in, 
so she uses her money to pay for her mortgage instead of for health 
care for herself.
  We can do something about that, Mr. Speaker, if we pass this bill. 
This is the only bill we are going to have a chance to consider that 
does anything for the uninsured, and it does a lot, the part of it that 
we passed out of the Committee on Education on association health 
plans. It is a simple thing. It allows small businesses to pool 
together in their trade or professional associations or farm 
associations, would allow farmers to do this, and when they pool 
together, they can buy health insurance with the same kinds of 
economies and efficiencies that big businesses already have.
  So if you work for a restaurant, instead of being part of a six-
person pool or an eight-person pool, you can be part of a pool of 
20,000 or 30,000 people, because you can be part of a pool of 
restaurants all around the country.
  We have had hearings on this bill year after year after year. Our 
estimate is that, at a minimum, and this is a conservative estimate, it 
will reduce the cost of health insurance to small businesses by 10 
percent to 20 percent. That means 4 to 8 million of these people are 
going to be able to get insurance who do not have it.
  Yes, by the way, as the gentleman from Arizona (Mr. Shadegg) said so 
eloquently, maybe others who now have access to one bare-boned HMO are 
going to have access to a whole lot more choices.
  It is about these people who are running this gamble every day. Many 
of them are losing. We can help them today. Let us help them. Let us 
not let politics get in the way of this. Let us vote for this bill 
today. We take up the second half of this health care reform later 
today or tomorrow. We can do this.
  Mr. Speaker, I reserve the balance of my time.
  Mr. CLAY. Mr. Speaker, I yield myself 2 minutes.
  Mr. Speaker, I support access and choice for the uninsured health 
care consumer. However, I rise in opposition to the proposal before us 
today because it will not deliver on either. It fails because it 
promotes such flawed ideas as association health plans.
  Many experts have criticized association health plans, yet 
Republicans continue to trumpet them. They do so at the behest of their 
special interest friends, and not because of any real demand from 
health care consumers. The dangers inherent in association health plans 
became apparent to me when legislation to establish them was first 
considered by the Committee on Education and the Workforce back in 
1997.

                              {time}  1500

  The experts told us then that they had major concerns about the 
effect on

[[Page H9454]]

the insurance marketplace. The National Governors Association, the 
National Conference of State Legislatures, and the National Association 
of Insurance Commissioners advise that Association Health Plans would 
undermine positive State reforms already in place to help consumers and 
would contribute to the collapse of small group health insurance.
  According to CBO, Association Health Plans would increase the risk of 
health plan failures and allow groups of healthier people to receive 
favorable premium rates while leaving groups with sick and elderly 
enrollees to pay higher ones.
  The American Academy of Actuaries advise that Association Health 
Plans could increase solvency risks and create regulatory confusion. 
The Urban Institutes Research determined that Association Health Plans 
would not reduce the number of the uninsured because nonparticipating 
firms are likely to drop their health insurance coverage rather than 
pay the higher rates that would result from a deteriorating risk pool.
  I urge my colleagues to reject these dangerous remedies and vote no 
on H.R. 2990.
  Mr. Speaker, I reserve the balance of my time.
  Mr. TALENT. Mr. Speaker, I yield myself 30 seconds to address two 
points.
  We have very strong reserve requirements in this bill. There is no 
solvency problem, no reason why these associations cannot sponsor plans 
the same way that big companies do.
  The second thing is that the bill requires that employers must offer, 
must carry, they must offer this coverage to every employee they have 
on the payroll, even if they have a history of illness. This will 
result in sick people going into Association Health Plans because they 
are going to get better coverage there.
  Mr. Speaker, I am pleased to yield 2 minutes to the gentleman from 
Ohio (Mr. Boehner).
  Mr. BOEHNER. Mr. Speaker, when we look at today's health care system, 
there are two problems that most all of us can agree on, that we need 
more accountable in managed care, which virtually every Member of this 
Chamber is supportive of, and we that have 44 million people who have 
no insurance whatsoever.
  So as we proceed in this debate, it is clear to me that we have three 
principles that we have to follow. How do we make sure that we get more 
accountability in managed care.
  Secondly, how do we make sure that health care insurance is 
affordable for all Americans to ensure that all Americans have greater 
access. Accountability, affordability, accessibility.
  In my view, we cannot deal with one of these issues without dealing 
with all of them. We cannot deal with one principle and ignore one. 
That is why this rule today and this debate that we are having is about 
accessibility today, and we will deal with accountability tomorrow.
  When we look at the uninsured, as the gentleman from St. Louis, 
Missouri (Mr. Talent) pointed out, they work for small businesses. They 
want to buy insurance, but they cannot afford to do it.
  When one looks at what we are going to do tomorrow, we are going to 
raise the cost of insurance. As we add more accountability for 
insurers, employers, and others, we are going to raise the cost of 
insurance. That is what the debate earlier was about. We wanted to 
offset the cost of it.
  As we raise it, we are going to push more people into the ranks of 
the uninsured. That is because there is a clear link between the cost 
of health care and people's access to it.
  So we have got to move this bill, this access bill today, because 
whether one has insurance or not, one wants to be protected. We ought 
to help all patients in America today whether one has insurance or not.
  I think that the bill that we have today guaranteeing greater access 
to health care for the uninsured is the first major step that we take. 
Then tomorrow we will deal with more accountability.
  Mr. CLAY. Mr. Speaker, I yield 1 minute to the gentlewoman from Ohio 
(Mrs. Jones).
  (Mrs. JONES of Ohio asked and was given permission to revise and 
extend her remarks.)
  Mrs. JONES of Ohio. Mr. Speaker, we all know that Halloween is fast 
approaching. The question is trick or treat. H.R. 2990 is, in effect, a 
trick or treat measure.
  We offer a treat with Norwood-Dingell, the Patients' Bill of Rights. 
However, Americans are being tricked by H.R. 2990.
  The trick: getting health care in America. The treat: goes only to 
the wealthy. The trick: pooling and separating of persons with greater 
health risks from those with less, leaving many people uninsured. The 
trick: MSAs, Medical Savings Accounts, they are MIA, missing in action. 
No insurance company has yet to offer this coverage to senior citizens. 
The treat: health care access for small business. I sit on the 
Committee on Small Business. I know what they need.
  The trick is that these Association Health Plans would not be subject 
to State regulation and cannot be sued in court just like the HMOs. 
Just like Halloween, H.R. 2990 is a hollow effort. Let us deflate this 
pumpkin now.
  Mr. CLAY. Mr. Speaker, I yield 2 minutes to the gentleman from Iowa 
(Mr. Ganske).
  Mr. GANSKE. Mr. Speaker, I have spoken on the floor of the House many 
times on the issue of access. I have grave concerns about one of the 
provisions in this bill as it relates to Association Health Plans. The 
times that I have spoken before on the House floor, I have entered into 
the Congressional Record these letters which I am going to cite. The 
National Governors Association, National Conference of State 
Legislatures, and National Association of Insurance Commissioners have 
expressed reservations about Association Health Plans.
  Here is a memo from the HIAA. It strikes my colleagues as a little 
ironic that I am citing this. I happen to think they are right on this, 
because insurers like Blue Cross Blue Shield and others are the 
insurers of last resort. They know about the risk pool in the United 
States.
  They say, ``We have grave concerns about the calls for Association 
Health Plans and HealthMarts, because they would hurt many small 
employers who provide coverage to their employees; and that could in 
turn cause many of those employers to drop their coverage because it 
would be too costly.'' That would be exactly the opposite purpose of 
what we want to achieve in this bill.
  Here we have a memo from Blue Cross Blue Shield. ``Association Health 
Plans, the unraveling of State insurance reforms.'' Same source, 
``Association Health Plan, national survey finds that small businesses 
reject Association Health Plan legislation.'' Blue Cross Blue Shield, 
``Association Health Plan legislation would increase administrative 
costs for small businesses.''
  Association Health Plan study shows that a claim that coverage would 
increase is fundamentally flawed.
  Here is a Blue Cross Blue Shield study, ``Association Health Plan 
legislation would reduce insurance coverage.'' Another Blue Cross Blue 
Shield study, ``Association Health Plan legislation would require 
billions in Federal regulatory spending.''
  Then I have a letter that is from a number of organizations that say, 
key concerns about Association Health Plans are that it would increase 
the cost of insurance rather than decrease it, that it would leave a 
sicker pool for those States and thereby actually result in the exact 
opposite of our access legislation.
  Mr. Speaker, this is a poor provision, and we should oppose it.
  Mr. Speaker, I include for the Record the letter I referred to as 
follows:
                                                    June 24, 1999.
       Dear Representative: As representatives of consumers, 
     seniors, labor, the religious community, and people with 
     disabilities and chronic illnesses, we are writing to urge 
     you to oppose H.R. 2047, the ``Small Business Access and 
     Choice for Entrepreneurs Act of 1999.'' This bill would move 
     our health care system in the wrong direction. As long as 
     Congress continues on the path of incremental health reform, 
     we believe that such reforms must meet this litmus test: does 
     the bill make health care more affordable for American 
     families, without creating harmful side effects that offset 
     its benefits? We believe that Association Health Plans 
     (AHP's), as defined in this bill, will do more harm than good 
     to our health care system.
       Our key concerns about the bill are:
       ``Affordable'' health coverage through skimpy benefits. The 
     bill allows AHP's to design their benefit options, exempting 
     AHP's

[[Page H9455]]

     from state benefit mandates that apply to other insurance 
     plans (except laws that prohibit an exclusion of a specific 
     disease). This means that AHP's will be free to create 
     barebones policies with skimpy benefits. The premium may well 
     be low and ``affordable'' but when policyholders get 
     seriously sick, or when they seek cancer screening or 
     preventive care that would have been covered, they are likely 
     to find their out-of-pocket costs to be very high.
       Fragmentation of health risk pool. AHP's have the potential 
     to further fragment the risk pool. Because AHP's would be 
     exempt from state benefit standards, they would attract 
     healthier, low-cost members. There is a grave danger that 
     associations will form in part to offer low cost coverage to 
     people with low health risks or avoid high cost areas. The 
     net effect is to undermine state regulatory efforts to spread 
     risks broadly.
       Existing AHP's exempt from state premium taxes. The bill 
     allows states to collect a ``contribution tax'' only on plans 
     started after enactment of the Act. This creates an unfair 
     loophole for existing associations; unlike other health plans 
     they will be exempt from premium taxes that are used to cover 
     health care costs for the uninsured and certain high-cost 
     individuals.
       Exemption from state consumer protection regulation. In 
     addition to being exempt from state benefit mandates, AHP's 
     could be exempt from state consumer protection regulation, 
     like other self-insured health plans. Creating a new loophole 
     from regulation is a step in the wrong direction for our 
     health care system.
       We agree that small businesses--as well as large 
     businesses, individuals, and families--should all have access 
     to affordable health care coverage. But we believe that to 
     achieve this goal, we need to set rules so that marketplace 
     competition benefits consumers, not health plans (or 
     associations) that cherry pick the healthy. We need standard, 
     comprehensive benefits. We need market reforms that spread 
     the cost between the healthy and the sick. We need sizable 
     subsidies to bring premiums in reach of moderate-income 
     families. Association Health Plans do not move the health 
     care system in the right direction.
           Sincerely,
       American Counseling Association, American Federation of 
     State, County, and Municipal Employees, Bazelon Center for 
     Mental Health Law, Brain Injury Association, Center on 
     Disability and Health, Committee on Children, Communication 
     Workers of America, Consumer Coalition for Quality Health 
     Care, Consumers Union, Eldercare America, Inc.
       Families USA, Friends Committee on National Legislation, 
     General Board of Church and Society of The United Methodist 
     Church, National Association of Developmental Disabilities 
     Councils, National Association of People with AIDS, National 
     Association of School Psychologists, National Association of 
     Social Workers, National Council of Senior Citizens, National 
     Health Law Program, National Mental Health Association, 
     National Osteoporosis Foundation.
       National Partnership for Women & Families, National Patient 
     Advocate Foundation, National Senior Citizens Law Center, 
     National Women's Health Network, Neighbor to Neighbor, 
     Network: A National Catholic Social Justice Lobby, Public 
     Citizen, Service Employees International Union, The Arc of 
     the United States, UNITE, Union of Needletrades, Industrial & 
     Textile Employees, United Church of Christ, Office of Church 
     & Society, United Food and Commercial Workers International 
     Union, Universal Health Care Action Network (UHCAN).

  Mr. TALENT. Mr. Speaker, I yield myself 1 minute to respond.
  The gentleman is quite correct, the insurance companies do not like 
this legislation and neither do the insurance regulators, because it 
will result in small businesses being able to participate in 
associations which will have at least some self-funded plans.
  The insurance companies do not like that because they lose business. 
The insurance regulators do not like that because they lose business. 
They do not get to regulate the self-funded plans.
  As for this costing small businesses more money, tell that to the 
small funeral home in North Carolina with less than 10 employees that 
was hit with a 73 percent increase this year by Blue Cross Blue Shield 
because it is on the small group market.
  Tell that to the members of the Western Retail Implement and Hardware 
Association which was hit with a 65 percent increase this year because 
it is on the small group market. Tell that to the small businesses 
around this country that are experiencing on average a 20 percent 
increase in health costs.
  No, the reason all the small business groups support this, Mr. 
Speaker, is because it is going to reduce their costs and decrease the 
number of uninsured.
  Mr. Speaker, I am very happy to yield 3 minutes to the gentleman from 
California (Mr. Dooley), my friend and cosponsor of the Association 
Health Plan bill.
  Mr. DOOLEY of California. Mr. Speaker, I rise in support to draw the 
attention of my colleagues to a provision in this bill that would 
dramatically expand access to affordable health care for small 
businesses and working families. The bill allows small businesses and 
self-employed individuals to purchase health insurance for themselves 
and the workers through Associated Health Plans.
  We all saw on the news last week the ranks of those without insurance 
grew by 1 million last year, up to 44.3 million. It also was not lost 
on us that, of that number, 60 percent of those individuals are working 
for a small business.
  I support this legislation because it would expand access to health 
insurance to the working poor of our country. My district in the 
Central Valley of California has one of the lowest private insurance 
coverage rates in the State, and the problem is getting worse. It is 
also one of the lowest income districts in the country. These low-
income families have few options for gaining health insurance.
  But an excellent solution to this problem has already emerged in the 
form of an Associated Health Plan that is already providing coverage to 
thousands of farmers, farm workers, and their families.
  In my district, where agriculture represents the heart of our 
economy, Association Health Plans have made a significant impact and 
can make an even stronger impact by providing health insurance to more 
seasonal and migrant farm workers.
  I would like to share with my colleagues just one story. The Lopez 
family from Visalia, California, in my district, has firsthand 
knowledge on how Association Health Plans can provide top quality care. 
Amalia Lopez works at a citrus packing house in Visalia and receives 
her health insurance through an Association Health Plan through Western 
Growers Association. Her daughter Lizette was diagnosed at age 10 with 
a heart ailment; and it became apparent, unless she had a heart 
transplant, she would die.
  In June of last year, Lizette was informed that a donor had been 
found in Western Growers insurance plan, helicoptered to the UCLA 
Medical Center for an operation. The operation was a success, and, 
today, Lizette is back in school and living the life of a normal 
teenager.
  The hospital bill for Lizette's operation was $270,000. But the 
Association Health Plan covered the vast majority of the cost and 
Lizette's family only had to pay $5,000.
  Lizette's story demonstrates that Association Health Plans work in 
delivering affordable health care to working families. They provide a 
compelling and cost effective means of providing affordable quality 
health insurance to a greater number of people.
  The issue for the Lopez family and thousands of other low-income 
families is not a choice between different insurance plans, it really 
is a choice oftentimes whether they will have health insurance through 
an Association Health Plan or no health insurance at all.
  Let us not deny low-income families an opportunity to have quality 
health insurance that can be provided through an Association Health 
Plan.
  Mr. CLAY. Mr. Speaker, I yield myself 10 seconds.
  Mr. Speaker, it is noteworthy that the gentleman from Missouri (Mr. 
Talent) cited that insurance commissioners and insurance companies 
oppose the Associated Health Plans. Also noteworthy, he did not cite 
the 31 Republican governors that also oppose it.
  Mr. Speaker, I yield 2 minutes to the gentlewoman from the Virgin 
Islands (Mrs. Christensen).
  Mrs. CHRISTENSEN. Mr. Speaker, I thank the gentleman from Missouri 
for yielding me this time.
  Mr. Speaker, the Republican leadership has a knack for putting an 
attractive name on terrible bills. They are doing this today with H.R. 
2990, what is called the Quality Care For The Uninsured Act.
  H.R. 2990 provides no increased access to health care for the 
uninsured; and, yet, it would take up to $43 billion away from 
important programs that do help the American people.
  This bill is a sham. We do not need it to make health insurance tax 
deductibility for the self-employed. That will happen even without this 
bill.
  Among other deceptive things that H.R. 2990 would provide are Medical 
Savings Accounts. We told our colleagues this was a bad idea when it 
was

[[Page H9456]]

forced down our throat 2 years ago. Even the insurance industry has not 
used them. MSAs are a proven failure, and we do not need to be voting 
for them today.
  This bill would also provide tax deductions for long-term care. Who 
will that help? Only those who pay taxes, those who, after living 
expenses, have money left over to pay for it, the usual people the 
Republican leadership looks out for, the rich.
  Mr. Speaker, we should care about the 44 million uninsured in this 
country. They are mostly women, people of color, and the poor. I am 
committed to working with my colleagues on both sides of the aisle and 
groups around this country to make sure that we do achieve universal 
access and universal coverage.
  But this bill, H.R. 2990, does nothing, absolutely nothing to provide 
any help to these people who are largely poor to purchase any coverage.

                              {time}  1515

  The only bill that will give back access to health care for those 
from whom managed care has taken it is H.R. 2723, Norwood-Dingell bill. 
Let us pass that bill to provide real access to quality care for the 
insured. That is the first step. Then let us work together to give real 
access to health care for the 44 million who currently have none. Vote 
``no'' on H.R. 2990.
  Mr. CLAY. Mr. Speaker, I yield 2 minutes to the gentleman from New 
Jersey (Mr. Andrews).
  Mr. ANDREWS. Mr. Speaker, I thank the gentleman for yielding me this 
time, and I rise in opposition to this bill.
  Mr. Speaker, this bill provides taxpayer subsidized access to people 
who largely do not need it, who already have it, and does virtually 
nothing for those who have nothing.
  We heard some talk on the floor earlier about the typical uninsured 
person, and that is the person I want to focus on for a few minutes 
this afternoon. She is usually a working person. She makes $20,000 or 
$21,000 a year. She has children, and she is working 40 hours a week.
  I want us to examine how little this bill does for that person. The 
first thing she is supposed to do under this bill is, if she is self-
employed, is to have a sped-up deduction from her income tax return, 
which is worth the princely sum of $300 a year, when fully phased in, 
toward her $6,000 that she would have to pay in premiums or more. That 
is nothing more than superficial help for someone.
  The next thing she is supposed to hope for is that her employer, if 
she is employed by someone else, will join an association health plan. 
The most optimistic projections I have ever heard about these things 
say they might lower the cost to small business by 15 or 20 percent. 
Now, that is nothing to sneer at. That is nothing to sneer at, but she 
has to keep her fingers crossed that maybe her employer will do such a 
thing and she will get lucky.
  Of course, once she gets into such a plan, all the protections of 
State law, the mandatory stay if she has a C-section, the mandatory 
coverage for breast or cervical cancer, the mandatory coverage for 
immunization for her kids are not subject to these plans. So she can 
wind up with a health insurance plan that is not worth the paper it is 
written on.
  Finally, this bill gives her the tremendous opportunity to contribute 
to her medical savings account. After she has paid her rent and her 
utility bills and her groceries and her auto insurance and her car 
payment and her child care and all the other things she has to do, this 
enormous amount of money that she has left over she can now put into an 
MSA.
  This is a cruel hoax. It should be defeated because it does not 
provide access.
  Mr. TALENT. Mr. Speaker, I yield 2 minutes to the gentlewoman from 
New York (Mrs. Kelly).
  Mrs. KELLY. Mr. Speaker, as we begin the floor debate today on 
patient protections, it is important that we do not forget those 44 
million uninsured Americans who have no protections at all. More than 
60 percent of the uninsured have one thing in common; they are either 
self-employed or their family is employed by a small business that 
cannot afford to provide health benefits.
  As a former small business owner, I understand firsthand that small 
businesses have difficulties in providing health care to their 
employees. Conventional health insurance and administrative costs are 
just too expensive for small businesses. In 1997, a typical small 
business owner paid $4,342 per employee for a family plan, yet a 
Fortune 500 company paid an average of $3,521.
  Association health plans would empower small business owners with the 
purchasing power of a large business. In fact, AHPs would reduce health 
care costs for small businesses by 10 percent.
  Providing health care for small business employers ought not to be a 
choice between feeding their own families and taking care of their 
employees. The small business owners of this Nation want and need to do 
both. AHPs will help 8 million small business employees obtain 
coverage. Small businesses need equal fitting in the health insurance 
market. That is protection we cannot afford to pass up.
  Let us open up health care for all working people. I strongly support 
this bill, and I urge my colleagues to vote in support of it.
  Mr. CLAY. Mr. Speaker, I yield 2 minutes to the gentlewoman from 
Michigan (Ms. Kilpatrick).
  (Ms. KILPATRICK asked and was given permission to revise and extend 
her remarks.)
  Ms. KILPATRICK. Mr. Speaker, I thank the gentleman from Missouri (Mr. 
Clay) for his fine leadership.
  One of the most important issues we will face in this 106th Congress 
is health care. Will Americans in the richest country in the world have 
available to them the health care they need for themselves and their 
families?
  Access. Will they have the access to get the health care that they 
need? I am afraid, my colleagues, the bill before us today does not 
address that issue. Our own Government Accounting Office has said to us 
that the poorest of the poor who are uninsured today, with this access 
bill before us, still will not have access.
  Is it the right thing to do? I think not. First of all, the bill is 
for the wealthiest and the healthiest. Yes, we want everyone to have 
insurance. Yes, we want those small business owners to be able to have 
insurance for themselves and their employees. But we also want the 
others who are uninsured to have insurance, too.
  All week long we have been hearing that over 40 million Americans do 
not have health insurance, that one out of six do not have health 
insurance, that 11 million children or more do not have health 
insurance. Will this bill address those people? In large part, it will 
not.
  It is unfortunate as we debate this subject today, with this most 
important issue that our country faces, that this bill continues to 
leave too many people out. The bill is not offset.
  We, in our other proposal, which is a bipartisan proposal I might 
add, and would cost $7 billion over the next 5 years, wanted to have 
offsets for it. Our leadership, the Republican leadership, said no. 
This bill will cost $40-plus billion. It is not paid for. It is not 
offset. And we think that is unfair and unconscionable.
  It does not improve the affordability of health care if an individual 
does not have the up-front money. Many families and many children who 
live in those families do not have that. It does not help the poorest 
of the poor in America. When will they have access?
  It digs into our Social Security Trust Fund in that it will take out 
from the Treasury before we put into it. It is not fair.
  Mr. Speaker, I urge my colleagues, let us not adopt this. Let us get 
back to work on a real bipartisan solution that actually accesses those 
things that people need to carry on their daily lives. It is a bad 
idea; it is a bad bill; and I urge my colleagues to vote ``no.''
  Mr. TALENT. Mr. Speaker, I yield 3 minutes to the gentleman from 
Kentucky (Mr. Fletcher).
  Mr. FLETCHER. Mr. Speaker, I certainly appreciate the gentleman from 
Missouri (Mr. Talent) and the gentleman from Arizona (Mr. Shadegg) for 
the work they have done on this bill to make sure that we make health 
care more affordable and more accessible.
  Let me first start in saying, what does it mean to be uninsured in 
this country? I will share with my colleagues, and especially those on 
this side of the aisle that oppose this, what it really means.

[[Page H9457]]

  A patient named Mary came to me a few years ago. She had no 
insurance. She was not the poorest of poor, because the poorest of poor 
have Medicaid. She was working, but she did not have insurance. She 
came to me and, upon exam, it was very obvious that she had a very 
large tumor. Cancer, metastatic cancer, that probably could have been 
prevented had she had health care and had the kind of preventive care 
that patients that will benefit from this legislation will have.
  Now, many will say this is not a perfect solution. I agree with that. 
But what it means to not have health care means an individual does not 
have access to getting the kind of preventive care that will prevent 
the kind of diseases that will take an individual's life too soon.
  In Kentucky, what is happening? We have had health care reform. Now, 
if an individual is on the individual market, they only have two 
choices of insurance. And small businesses only have a few. This plan 
with associated health plans and health marts gives the opportunity for 
individuals to have health care, as small businesses can help reduce 
their costs from 10 to 15 percent and be able to offer a spectrum of 
choice that will enable them to get the kind of health care and the 
preventive care that they need.
  Some folks say, well, we should not link these two. I am kind of 
disappointed they were not linked to begin with because they are 
inseparable. The whole debate about patient protection is about how the 
money, cost of reimbursal, affects access. Because if an insurance 
company says they are not going to pay for something, they do not 
prevent an individual from having treatment; but they limit the access 
because the patient cannot afford it.
  Right now we have limited access because folks cannot afford health 
insurance, because small businesses cannot offer it, because we do not 
have legislation that encourages small businesses to offer it. This 
will allow the tax deductions for individuals to allow small companies 
to come together.
  And now insurance companies do not like it. Why? Because they will 
have to contract and negotiate with a group of individuals much larger 
than just a small company. I have been a small business owner. I know 
what it is like to buy insurance. I have seen the costs escalate every 
year, and I think this will help small businesses.
  I ask those folks on the left that oppose this to look at themselves 
in the mirror and look at patients like Mary, who I am talking about, 
and ask themselves whether this will help her get insurance. I hope my 
colleagues can look at themselves in the mirror and say, this is not 
perfect, but at least it is a step in the right direction. My intent in 
coming to Congress was to make sure that we eventually get every 
American covered with health insurance. This is a step.
  Some would like a government-run, single-payer system; others like a 
market-based system. I think a market-based system with choice is the 
way to go. This does that. I encourage my colleagues to vote for this 
measure.
  Mr. CLAY. Mr. Speaker, I yield 2 minutes to the gentlewoman from 
North Carolina (Mrs. Clayton).
  Mrs. CLAYTON. Mr. Speaker, I thank the gentleman from Missouri for 
yielding me this time.
  Mr. Speaker, some will say this is about access for the more than 44 
million Americans that are now known to be without health care. In 
fact, we now know, since 1998, that more than 1.3 million new persons 
that are uninsured.
  But let us examine if this is really about access for all of those 
people or for the majority of those people. Certainly coming from rural 
North Carolina, I can tell my colleagues that rural North Carolina does 
not have as many insured people with HMOs as they would have in urban 
areas. So access is important. Uninsured people are very important.
  But when we consider that this tax break is designed for those who 
have been substantially paying into the revenue, we know that that 
eliminates immediately a majority of the children who are uninsured who 
may have working parents who are not on Medicaid. They make too much 
for Medicaid but are not insured. We have to understand that these 
individuals would have to pay a substantial amount to make any sense. 
If indeed they had the $4,500 or the $5,000 to pay for the premium, 
perhaps they would get $700 as a break.
  Help me understand how those 33 million people can call this access. 
Indeed, this is insufficient and should not be labeled as access. The 
Norwood-Dingell bill is about access. It is about access for those who 
have insurance to have better access, to ensure that their care is 
based on medical necessity, that they will not be denied based on an 
insurance promise that we will not allow you to be covered.
  Indeed, this is a fraud. This is inadequate. We should be ashamed of 
ourselves thinking we are addressing the needs of the American people 
by calling this access. Defeat this bill and, indeed, support the 
Norwood-Dingell bill.
  Mr. CLAY. Mr. Speaker, I yield 2 minutes to the gentlewoman from 
Florida (Mrs. Thurman).
  Mrs. THURMAN. Mr. Speaker, I thank the gentleman for yielding me this 
time.
  One year ago, I actually introduced a piece of legislation because of 
an article that was in the St. Pete Times about a group of employees 
whose company actually was on the verge of bankruptcy. They allegedly 
pocketed their employees' health care premiums. The health insurer, 
hoping that the employer would catch up on overdue premiums, agreed to 
work with the employer to resolve the unpaid debt.
  Meanwhile, the unsuspecting employees continued to receive authorized 
health care coverage. When the company ultimately filed for bankruptcy, 
the health insurer retroactively terminated the employees' health plan. 
One woman in this article ended up having to be stuck with $20,000 
worth of medical bills.
  As a result, the cost of any health visit or procedure conducted the 
preceding 3 months became the sole responsibility of each employee. In 
addition, because they did not meet the 63-day standard under HIPAA, 
because it went 70, they could not even get any kind of insurance.

                              {time}  1530

  I think it is unconscionable. As we introduced this legislation, we 
found out that there were several other areas around this country that 
these same things happen. So on Monday I went to the Committee on Rules 
because I, too, am concerned about access and I am really concerned 
about access for people who had it and lost it because they do not have 
the opportunity to contract with this company but the employee does. 
The insurance commissioner in Florida said, in fact, they were in their 
rights because the contract was with the employer.
  So we went in and we said, okay, look. They ought to prohibit 
retroactive termination of health insurance by requiring that the 
insurance company provide 30 days' notice of pending termination of 
coverage.
  In addition, we required that such employees be extended HIPAA 
protections for obtaining alternative coverage. I do not want to hear 
about access. This was not included and this was one that cost nothing.
  Mr. TALENT. Mr. Speaker, I yield 1 minute to the gentleman from Ohio 
(Mr. Chabot).
  Mr. CHABOT. Mr. Speaker, as we consider health care legislation in 
Congress today, it is essential that we find ways to make health care 
more affordable for American families.
  There are 44 million uninsured people in this country; and this 
number, unfortunately, is growing steadily. Comprehensive health 
insurance is rapidly becoming too expensive for the average working 
family, and many small businesses are unable to provide costly group 
plans. We need to help the millions of Americans that do not have 
health insurance, as well as those who are struggling to afford quality 
care.
  The Quality Care for the Uninsured Act will do just that by allowing 
taxpayers to deduct their health insurance premiums and giving small 
businesses and associations the freedom to provide their employees more 
comprehensive and flexible health care. Mr. Speaker, this proposal is a 
positive step forward.
  Earlier this year I introduced similar legislation that received 
bipartisan support. I would ask both sides of the aisle to support 
this.
  Mr. CLAY. Mr. Speaker, I yield 2 minutes to the gentleman from 
Illinois (Mr. Davis).

[[Page H9458]]

  Mr. DAVIS of Illinois. Mr. Speaker, I agree that small businesses 
need help for their employees. As a matter of fact, all consumers of 
health care need help. The 44 million uninsured in this country need 
help. Patients need access to primary care and to physicians.
  What this country needs is a national health insurance, a national 
health policy that takes care of the needs of all the people. But what 
we need right now is to reform managed care. And the only bill that 
provides any real help for managed care reform, for real access for 
physician-patient communication, the only bill that moves us seriously 
in the direction of taking care of the immediate needs of millions of 
people in this country is the bipartisan Dingell-Norwood bill.
  I would urge that all other items before us, while they may contain 
meaningful elements, really do not do the job. The only way to do the 
real job is to vote for the Dingell-Norwood bipartisan bill.
  Mr. CLAY. Mr. Speaker, I yield 1\1/2\ minutes to the gentlewoman from 
Texas (Ms. Jackson-Lee).
  (Ms. JACKSON-LEE of Texas asked and was given permission to revise 
and extend her remarks.)
  Ms. JACKSON-LEE of Texas. Mr. Speaker, I know that the intentions of 
the gentleman were good with respect to the staggering numbers of 
uninsured Americans.
  Forty-four million Americans lack access to basic health care, and 44 
million Americans live in fear of getting sick. But what we must 
realize is that we must not give them a bucket of water with a leak in 
it. And right now that is what this legislation does. That is why we 
should stick to passing the Dingell-Norwood health care reform, a 
straight-up vote on giving the American people what they want.
  I have a letter here, Mr. Speaker, that I would like to submit into 
the Record from a nurse and three doctors who said, ``We are mad as 
hell, and we are not going to take it anymore,'' Dr. Self, Dr. 
Zaremski, and Nurse Self. And the reason is because they were trying to 
express their beliefs on behalf of the patients and they lost their 
positions in the medical profession.

                          (September 29, 1999)

An ``Open Letter'' To The Honorable Members of the United States House 
         of Representatives Regarding Managed Care Legislation

    (By Thomas W. Self, MD, FAAP, Linda P. Self, RN, BSN, Miles J. 
                          Zaremski, JD, FCLM)

                                               September 29, 1999.
       Dear Honorable Members of the House of Representatives: We 
     hope that our remarks that follow will be able to be part of 
     the floor debate that will occur on managed care legislation, 
     scheduled for early next month. While we have endeavored to 
     communicate with several of you, either by letter, phone or 
     by in-person conferences with you or your staffs, we feel our 
     individual, yet collective, wisdom on the underpinnings of 
     this legislation before you is critical and important. Two of 
     us have a unique experience not shared by other health care 
     providers in our country. The other has considerable 
     expertise based on experience and writings on managed care 
     liability, what our courts have done with ERISA preemption, 
     and what is likely to be done in the future by our judicial 
     system. Two final introductory remarks. First, there is so 
     much that needs to be said that brevity in our remarks could 
     not be achieved. Second, while this letter comes from the 
     three of us, we refer to each of us in the third person.
                                         Thomas W. Self, MD, FAAP.
                                           Linda P. Self, RN, BSN.
                                      Miles J. Zaremski, JD, FCLM.
       Our plea comes not as Democrats, Republicans or members of 
     other political parties. Our plea comes to you as a 
     physician, nurse and lawyer, representatives of those at the 
     crossroads of medicine, health care and law. Our plea comes 
     to you also as people who are deeply and passionately 
     concerned about the quality and delivery of health care for 
     America's patients, all patients, and the legal and 
     legislative efforts to do the right thing--insure fairness 
     and accountability for parties and by those delivering health 
     care.
       To quote a famous line from a motion picture of some years 
     back, the battle cry of patients is, ``We are mad as hell and 
     we are not going to take it anymore!'' Patients and providers 
     alike should not be subject to the grave inequities foisted 
     upon them by what managed care has done to the delivery of 
     health care. Linda and Tom Self are fitting and, perhaps, 
     unfortunately, unique examples of what has to occur before 
     managed care moguls will listen.
       As a San Diego doctor trained at Yale and UCLA, who ran 
     afoul of managed care and who was actually fired for spending 
     ``too much time'' with his patients, Dr. Self is unique among 
     health care providers in that he fought back against the 
     medical group that fired him and won a three year ``battle'' 
     that culminated in a three month jury trial. His victory is 
     the first of its kind in the nation, and was profiled by 
     ABC's ``20/20'', on August 6, 1999.
       His experience, where managed care profit motives 
     infiltrated and contaminated the professional ethics of his 
     medical group, shows clearly the murky and often brutal 
     influences wielded by HMOs which have only profit, not 
     quality of care, as their goal. In this scenario, patients 
     become ``cost units'' and doctor is pitted against doctor, 
     undermining the very foundation of medicine and throwing to 
     the winds the Hippocratic axiom, ``first of all do no harm.''
       With the art and science of medicine controlled by managed 
     care forces, it is not surprising that the number of patient 
     casualties continue to soar. The ability of a clerk with no 
     medical training, in the employ of a payor thousands of miles 
     away, to overrule medical decisions of a trained physician is 
     allowed in no other profession, but is the standard of 
     practice under managed care! Furthermore, this type of 
     employee and also the managed care entity which acts as the 
     puppeteer behind the clerk are completely immune from any 
     legal accountability when their faulty medical decisions 
     cause patient harm. That this situation is allowed to 
     continue is also peculiar only to the medical profession. 
     This is unfair and inequitable!
       As an experienced diagnostician with the reputation of 
     being thorough and careful, Dr. Self was criticized under 
     managed care dictates as a physician who ordered too many 
     costly tests and as a ``provider'' who ``still doesn't 
     understand how managed care works.'' Sadly, this situation 
     continues nationwide, as more and more experienced doctors 
     are unjustly censored, dropped from managed care plans or 
     terminated from medical groups anxious to conform to managed 
     care policies, leaving their needy patients feeling confused, 
     frightened and abandoned.
       This pillage and waste of medical resources (under the yoke 
     of managed care which destroys the very quality and 
     continuity so necessary for a positive outcome from medical 
     treatment) is running rampant in America. Dr. Self and his 
     wife have put their lives and their careers on the line to 
     combat the wrongs caused by the health care delivery 
     system called managed care. Now, representing, in 
     microcosm, all health care providers, they turn to you as 
     lawmakers, representing all past, present and future 
     patients, to stop the horror and carnage by health plans 
     by voting for the Norwood-Dingell bill, H.R. 2723, and 
     restoring quality, decency and humanity to health care for 
     the American people.
       Linda Self, a registered nurse, is, like her husband, a 
     healer. Always active in charitable activities, she returned 
     to nursing full time four years ago to work with her husband 
     when he lost his job. After being away from nursing for many 
     years, she realized that her compassion and love for the art 
     of healing was now even stronger, especially after raising 
     two children, one of whom had a serious illness. Devoted to 
     caring for children with chronic diseases and giving support 
     to their families, she was shocked and unprepared for the 
     massive de-emphasis on patient care that had been fostered by 
     health plans. Linda realized that her commitment to people 
     had not changed nor had the needs of such children--what had 
     changed, and changed for the worse, was the indifference to 
     patient suffering held by the managed care system. She 
     realized that in order to care for sick patients and their 
     families in the 90's, there is, and was going to be, a 
     constant controversy with the managed care bureaucracy 
     involving patient referrals, treatment authorizations and, 
     above all, the daily need to appeal treatment decisions lost, 
     delayed or denied by their patients' health plans.
       As if also in microcosm to what other private medical 
     practitioners face, this office ``busy work,'' in addition to 
     the requirements of providing necessary medical support to 
     sick patients, has created enormous frustrations among health 
     care providers as well as increasing the costs of running a 
     practice. Conversely, reimbursements from health plans have 
     steadily diminished, regardless of the severity of the 
     patient's illness or the increased amount of physician and 
     nursing time expended.
       Additionally, in her dual role as nurse and office 
     administrator, Linda works daily to insure that patients 
     receive the appropriate medical care they need and deserve 
     without suffering the indignity and humiliation of having 
     their health plans ignore, delay, or deny health care that is 
     not only medically necessary, but for which the patient has 
     already paid insurance premiums. This endless paper shuffle 
     mandated by managed care without its cost cutting mentality 
     further decreases the amount of time that a nurse can devote 
     to patient care. This dilemma has driven competent and caring 
     paraprofessionals from the medical field in droves, thereby 
     further weakening the overall quality of medical care needed 
     by patients nationwide. The resulting upswing in poorly 
     trained, undedicated office personnel hired to replace the 
     nursing flight has created a hemorrhage in medical care 
     delivery which, if not stopped, will hasten the demise of 
     American medicine as far as any vestige of quality of care 
     which still remains.
       Patients must not be considered commodities to be bartered 
     by health plans. Payors must be held fully and judicially 
     accountable wherever their pressures on physicians to curtail 
     tests, delay or deny treatment plans,

[[Page H9459]]

     or by clogging the wheels of medicine with mountains of 
     paperwork cause patient harm. Therefore, Linda Self, speaking 
     as a mother, a patient, and a nurse brings her experiences to 
     the House floor and adds her plea to those of Dr. Self and 
     Mr. Zaremski to bring dignity and salvation to the practice 
     of medicine.
       Those in the House, listen, as we have done for years, to 
     the voices of the grass roots populace when they cry out for 
     help and relief from a medical system that harms, not heals. 
     Read, if you will, the numerous e-mails and other written 
     communications from viewers of the ABC ``20/20'' program on 
     Dr. Self and other well wishes after he and his wife's 
     historic jury verdict, which we have included as a attachment 
     to this letter. A sampling of quotations from these 
     communications (emphasis added) follows:

       ``As an R.N. I have had similar experiences as Dr. Self 
     concerning HMO's. He is the type of doctor HMO's do not want, 
     since he actually takes enough time for each patient, and 
     does the right thing. A warning to all patients: do not 
     choose an HMO if you have a chronic or rare illness! They 
     will hasten your demise; they are Goliath and you are David. 
     . . . Until patients become better-informed and less passive 
     about their health care, and until doctors start standing up, 
     like Dr. Self, HMO's will continue to run over the patients 
     they are supposed to serve.''--Sheryl W. McIntosh.
       ``Your August 6 piece on Dr. Self who was fired for 
     ignoring his group's bottom line and putting his patient's 
     needs first was excellent. This is happening more frequently 
     than people realize. Only when people have access to 
     information like you provided--or when they get sick and 
     learn firsthand--do they realize how corporate managed care 
     has affected American lives. I hope you will talk to other 
     medical caregivers and deal with other facets of this 
     complicated problem.''--Francis Conn.
       ``This might be just the tip of the iceberg. Our health 
     care should not be treated as a commodity, i.e., something to 
     make money on at your or my expense. Neither should it be a 
     political football where the vote goes to the place with the 
     most political donations . . .''--James A. Eha, M.D.
       ``. . . At first HMOs were VERY good but every single year 
     that passes it get volumes worse. Now, it is so hard to get a 
     referral, a prescription, a test or an office visit. . . . My 
     husband has to take off work because you have to take the 
     appointment they give you. . . . They make it nearly 
     impossible to get care. They have those drug lists that they 
     are always changing so the doctors are changing your meds all 
     the time making you very sick. They do not allow doctors to 
     do their jobs . . .''--Diann Wolf.
       ``An identical story happened . . . with my brother who is 
     a family practitioner. . . . He dealt mostly with AIDS 
     patients and the HMO found that to be too costly. He and his 
     fellow practitioners in his office decided to leave the 
     medical practice and regroup mentally to figure what to do. 
     They had spent many months without pay at all due to the 
     methods of saving costs by the HMO. . . . and just so the 
     HMO's could make some money, good doctors are leaving the 
     profession.''--Michele Drumond.
       ``. . . For the past 11 years I have cared for people in 
     long term care. . . . just imagine the lack of incentive 
     there is for good care of the elderly or disabled. Many newer 
     meds are not covered as they are not cost effective . . . 
     patient loads rise but staffing does not, rules and 
     regulations of documentation rise, staff does not nor does 
     equitable pay. The diagnosis to dollar mentality is ripping 
     the caring soul and commitment out of medicine. Everyday I 
     ask God to give me both compassion and wisdom in my job, but 
     my soul feels that the battle of excellence in care and cost 
     will always be won by cost. I feel called to this job, and 
     just have to do what I do the best that I can, but NEVER 
     would I want any of my four children involved in direct 
     patient care. the physical, emotional and psychological load 
     is becoming  too  great!!  I  strongly  believe  we  will see 
     life expectance decline . . .''--Barbara Harland, RN.
       ``. . . I work for a doctor's office . . . I do all 
     referrals, authorizations and surgery precerts for our 
     patients. It has become a nightmare to approve any surgeries 
     without going thru the third degree for patients. They can't 
     begin to realize what we in the ``field'' go thru to get 
     these things approved . . .''--Susie Wallace.
       `` `There are men too gentle to live among wolves' to a 
     gentle and courageous man & woman [Tom and Linda Self].''--
     Brian Monahan.
       ``. . . It is a great irony that, after a generation of 
     tremendous growth of our knowledge and our ability to care 
     for patients and diseases in a manner far better than we ever 
     could before, greedy companies are seeking to limit our doing 
     so. . . .''--Herbert J. Kauffman, M.D.
       ``. . . I deeply respect what you've accomplished and 
     appreciate the way in which your victory benefits patients 
     and those of us who choose to treat patients according to 
     sound clinical decision-making versus adherence to the 
     masters and dictates of those more concerned with profit than 
     quality patient care . . .''--Robert Alexander Simon, Ph.D.
       ``. . . Seven years ago I was hired as a homecare Social 
     Worker. . . . Then, managed care entered the scene--
     frequently denying approval for a social-worker's services. 
     Since urgent social worker intervention was often necessary 
     with our patients, there were many times that I was 
     dispatched to the patient's home to provide emergency 
     services . . . only to later receive a ``denial of payment'' 
     from the managed care company . . . [Hospital] required me to 
     find any excuse possible to visit those patients whose 
     insurance would pay, and would cram as many patients as 
     possible every day into my schedule. It was all so very, very 
     wrong. For months this unethical practice tore me apart--and 
     eventually made me very ill. I quit my job. . . . I had been 
     forced to compromise my ethics in order for [Hospital] to 
     maximize their profits. I applaud your courage, and I just 
     wanted you to know that I am proud to be the parent of one of 
     your patients.''--Ruth Bronske.
       ``You stood tall for yourself and set a perfect example for 
     the rest of us. I am so pleased.''--George Jackson, M.D.
       ``. . . Congratulations on winning your lawsuit! Truth 
     always comes out triumphant. Hopefully the HMOs . . . of the 
     world will put the patients' interest first and the bottom 
     line at the bottom as it should be from now on. . . .''--
     Faith H. Kung, M.D.
       ``. . . Dr. Self stuck his neck out and he lost his job, 
     but he stood up for what he believed in and hopefully other 
     doctors will do the same. He should be commended for what he 
     did. I hope . . . that if something really bad ever happens 
     to me and I need tests run or extensive surgery done, the 
     doctor better not look at what kind of insurance I have 
     rather than giving me the best medical attention I need that 
     could save my life . . .''--Kim Lewis.
       ``. . . I have quit the medical field in the past month 
     because medicine is no longer about patient care and needs. 
     It is only about how much money can be made off of them. 
     Thank you for letting me see it is not just the employee that 
     is affected!''--Linda Copp.

       As a legislator, you can therefore appreciate first hand, 
     the anger, frustration, and hopelessness expressed by your 
     constituents such as what we have quoted above. Then, recall 
     the quote by Margaret Mead, ``Never doubt that a small group 
     of dedicated people can change the world. Indeed, it is the 
     only thing that ever has.'' The ``rank and file'', the grass 
     roots populace is, we think, what Ms. Mead had in mind when 
     it comes to health care in our country.
       The third major thrust of our letter pertains to the three 
     of us having seen and heard the disingenuous expressions of 
     opponents of what patients really need and which is embodied 
     in the Norwood-Dingell bill. First, we have heard that 
     lifting the ERISA preemption will cause employers to 
     terminate health plans for their employees, that lifting this 
     so-called shield will cause premiums to increase and that 
     trial lawyers will gain an avenue to sue. To all of this, and 
     with all the passion we can muster, we say, ``absolutely 
     not!''
       First, ERISA, enacted in 1974, had nothing to do with 
     shielding managed care plans from accountability for their 
     medical decision-making process. There has never been 
     anything in the legislative history on ERISA having to do 
     with this subject. The American Bar Association, not known at 
     all for representing trial attorneys, voted last February 
     302-36 to lift the ERISA shield.
       Next, allowing for accountability by health plans to 
     patients, as contained in H.R. 2723, provides for real equity 
     in distributing responsibility to all those persons and 
     entities involved in the medical decision-making process. 
     This does not mean increased or additional litigation! The 
     liability exposure to managed care entities that would exist 
     with removal of the ERISA preemption shield will force these 
     entities to insure improvement in patient care, by, for 
     example, not allowing clerks to override physician treatment 
     decisions, providing a review process to all treatment denial 
     determinations, etc. As a result, the number of bad-outcomes 
     leading to litigation will likely decrease, leading to less 
     litigation. And where bad-outcomes do occur, allowing direct 
     suits against health plans will not create more lawsuits, but 
     will rather lead to roughly the same number of lawsuits--with 
     one additional defendant. This one additional defendant will 
     better allow a trier of fact to equitably distribute 
     liability to the persons and entities responsible for the 
     harm. In the end, there are fewer bad-outcomes, less 
     litigation and better equity in the distribution of fault.
       Alsi, realize that H.R. 2723 provides for accountability 
     and responsibility of health plans according to state laws. 
     State courts are where this area of responsibility and 
     accountability for health plans should reside. For example, 
     if your state has ``caps'' on the amount of money that an 
     injured person could receive, such as in California, then 
     those caps would equally apply to exposures faced by health 
     plans.
       And if the Texas state statute on holding HMOs responsible 
     is any example, fears of increased litigation are totally 
     without any basis in fact. In the three years since that 
     state's law was enacted, there have been less than a handful 
     of cases filed against health plans in that state. Also, in 
     joining with Georgia legislators, the California \1\ state 
     assembly of 80 members (overwhelmingly) passed legislation 
     recently providing that HMOs can be held accountable for 
     their medical decision-making. On September 27, 1999, 
     Governor Grey Davis signed into law this legislation, and, in 
     so doing, stated, ``It's

[[Page H9460]]

     time to make the health of the patient the bottom line in 
     California HMOs.''
---------------------------------------------------------------------------
     \1\ California is said to be the ``birthplace'' of managed 
     care.
---------------------------------------------------------------------------
       In conclusion, we implore each and every one of you to do 
     the right thing. Vote your conscience by voting for the 
     rights of each and every American who has been, or will be, a 
     patient in our health care delivery system. Remember that a 
     person's health is unlike anything that can be bought, 
     traded, negotiated or sold. Don't hold hostage human sickness 
     and injury to a ``bottom line'' mentality. Keep in mind the 
     words of a colleague in medicine who wrote Dr. Self after his 
     jury verdict, ``The rewards of being a doctor are largely 
     measured in identifying what is best for the patient and then 
     having to do what one believes is correct and best for the 
     patient.'' Again, we reiterate the quotation by Mead: ``Never 
     doubt that a small group of dedicated people can change the 
     world. Indeed, it is the only thing that ever has.'' In 
     passing H.R. 2723, each one of you will heed her message, 
     and, accordingly, insure that the tendrils of greed and 
     disregard for legal accountability in managed care will no 
     longer be able to find fertile soil in which to take root and 
     grow.
       Thank you.
           Sincerely,
                                         Thomas W. Self, MD, FAAP.
                                           Linda P. Self, RN, BSN.
                                      Miles J. Zaremski, JD, FCLM.

  This particular legislation gives tax benefits to the uninsured, but 
nearly two-thirds of the uninsured population are in the 15 percent tax 
bracket, which means they only receive a 15 percent relief. We are 
talking about poor people, working people, Mr. Speaker, who cannot 
afford any sort of excess funds to buy the insurance and then others 
are already on Medicaid. This is an important issue to ensure that 
those who are uninsured get health coverage.
  But, Mr. Speaker, we need deliberation. We need hearings. We need the 
opportunity to do the right thing. Let us just vote for the Norwood-
Dingell reform bill.
  Self-employed taxpayers may deduct payments for health insurance. The 
deduction cannot exceed the net profit and any other earned income from 
the business under which the plan is established. It is not available 
for any month in which the taxpayer or the taxpayer's spouse is 
eligible to participate in a subsidized employment-based health plan.
  These restrictions prevent taxpayers with little net income from 
their business, which is not uncommon in a new business, or in a part-
time business that grows out of a hobby, from deducting much if any of 
their insurance payments.
  What about the 12.5 million people who do not pay income taxes? What 
about the 12.5 million who work on low wage jobs, those who do not make 
enough for health coverage?
  In 1996, close to 33 percent of the U.S. residents were living in 
poverty or near poverty. Twenty percent of all households had incomes 
below $14,768 per year. Among the near poor, those who work on low wage 
jobs, 35 percent of all men and 29 percent of all women are uninsured. 
Whites account for close to 27 percent, African Americans account for 
55 percent, Hispanics account for 60 percent and Asian Americans 
account for 31 percent of the uninsured.
  What about the woman who called my office last week who had cancer 
and congestive heart failure? She was dropped from her insurance when 
she became a widow. She was worried about the high cost of her 
prescriptions that she is unable to afford. She was worried because she 
receives samples from her doctor and she wonders how long his good will 
can last.
  What about the Hispanic family with several children? Although both 
parents work, they do not make enough to afford health coverage. One of 
the children has developed a serious illness and needs to be 
hospitalized. The child cannot survive without the operation and the 
parents cannot afford to pay for it.
  What about the woman who just discovered a lump in her breast. She is 
nervous because of the lump, but she is more nervous because she has no 
health insurance. She cannot go to a doctor for screening and she 
cannot afford a mammogram.
  What about the man who went to the emergency room because he became 
ill and discovered that he had diabetes? In addition to the bills he 
accumulated because of his hospital stay, he also has to pay for 
insulin and other supplies to manage his condition.
  These are the people that need our help. These stories only represent 
a few of the people that need access to health insurance.
  Like many of my colleagues, I received many letters from businesses 
in support of this bill. I am sensitive to the needs and concerns of 
small businesses. I understand the various costs associated with 
running a small business and I respect the entrepreneurs that want to 
provide health insurance to their employees.
  Many of these employers want to do the right thing. However, this 
bill does not benefit the small business owner, nor does it benefit the 
employees. This bill will only benefit the insurance companies and 
wealthier Americans.
  I urge my colleagues to vote against this bill. We need to go back to 
the drafting table to come up with a better plan for these 44 million 
Americans. Let's offer some real reform for those working families and 
their children.
  Mr. CLAY. Mr. Speaker, I yield the balance of my time to the 
gentleman from Tennessee (Mr. Ford).
  The SPEAKER pro tempore (Mr. Hastings of Washington). The gentleman 
from Tennessee (Mr. Ford) is recognized for 1 minute and 20 seconds.
  Mr. FORD. Mr. Speaker, although I applaud the Republican realization 
that improving access to health care is vital to all Americans, I must 
oppose the bill.
  The Census Bureau, as we all know, has reported that more than one 
million people last year, and now the number is up to 44 million 
people, are without health insurance. In my State of Tennessee, close 
to three-quarters of a million people are without health insurance. 
That amounts to about 15 percent of the State's population.
  As a healthy 29-year-old male with a comfortable income, I would be 
eager to set up a medical savings account, which is one of the features 
of this proposal put on the floor today. However, this would help far 
too few of my constituents. It would hurt the poorest working people 
who have plans with the smallest deductibles. Eleven million children 
nationwide are without the basic care afforded to prison inmates in 
America. The most disproportionate groups of Americans uninsured were 
women and the working poor.
  The Republican access bill does nothing to alleviate the problems of 
the working poor and children have in gaining health insurance. The 
main provision of the access bill is an expansion of medical savings 
accounts. This assumes that those without health care have enough money 
to save or are healthy enough to wait for interest to accrue.
  The access bill also contains two other troubling provisions, the 
Associated Health Plans and HealthMarts. Each would allow insurance 
companies to bypass State laws and regulations, allowing plans to 
select the young and the healthy from the State-regulated markets. This 
would drive up the premiums for the sick and the old.
  This $48 billion, which my dear friend says this will cost, again 
represents another raid on the Social Security Trust Fund. The $792 
billion tax scheme they are attempting to pass cannot be paid for 
without dipping into the trust fund, and neither can this.
  Mr. TALENT. Mr. Speaker, I yield myself the balance of my time.
  Mr. Speaker, this is about people who do not have health insurance. 
Let us remember who they are. Three-quarters of them work for small 
businesses or they are dependents of people who work for small 
businesses or they own small businesses. They are our friends. They are 
our neighbors. They are people who have been down-sized by big 
companies and who have had to go to work as consultants. They are 
people who have retired from companies who are not old enough yet for 
Medicare. They are people who have histories of illnesses, and they 
cannot get insurance on the individual market unless they want to pay 
$1,000 or $1,200 a month.
  I bet everyone in this room is somebody like that or knows somebody 
like that. We know who the uninsured are. And we can help them. We can 
help all those people who are working for small businesses that cannot 
afford to provide them with health insurance or cannot afford to 
provide it at a cost that they can afford, and we can do it with 
Association Health Plans that allow small businesses to pool together 
just the way big businesses do and buy health insurance for groups of 
thousands and thousands of people across this country, with all 
the efficiencies that that means, without the insurance companies' 
marketing costs and the profit margin and with the efficiencies of a 
big pool.

  We have studied this bill a number of years. We passed it in the 
House last year. We can make a difference for people who desperately 
need to have us make a difference for them.
  What are the reasons given for not doing this? It costs too much. 
Well, the Associated Health Plans do not cost the Government anything. 
The rest of

[[Page H9461]]

the bill costs $8 billion over the future 5 years. We paid $20 billion 
in agricultural relief over the last 2 years. I supported that. I 
thought that was important.
  Everybody in this House, the White House, and most of the people here 
want to pass a tax cut of at least a couple hundred billion dollars. So 
we cannot spend $8 billion helping the uninsured? We cannot afford not 
to help these people who are sick.
  The Association Health Plans are not safe. The reserves are not high 
enough. We met every objection of the American Academy of Actuaries. 
These are going to be fully regulated by the Department of Labor or by 
the States if they want to. The insurance companies do not like it. No, 
the insurance companies do not like Association Health Plans. We will 
have to live with that. It increases costs to small businesses and 
farmers.
  Tell that to the coalition of 90 small business people and farmers 
who support this bill because they know it will reduce their costs and 
enable them to make health insurance available.
  It is only for the healthy. Mr. Speaker, it is precisely the ill 
people who want to get in big groups. That is why they like to work for 
big businesses. They are the ones who will be benefited by Association 
Health Plans.
  And then the one I cannot understand more than any of the others: it 
is only for the rich. Only the rich people are going to benefit from 
this.
  Well, tell that to Lasette Lopez, who my friend from California 
talked about. Her mom is a migrant worker. She got a heart transplant 
and she is alive because of a State Association Health Plan. I do not 
think she is rich. Tell that to Linda Welch-Green, a report in the 
Baltimore Sun today, who works as a cashier at a garage. She would be 
able to get her health insurance under this and get her Bell's Palsy 
taken care of. She is not rich.
  Let us forget about those tired old arguments, the old class envy 
thing that gets brought out every time we try to do something good for 
America. Let us help these people. This is the only opportunity we are 
going to have to do that. It is a real opportunity. We have studied it 
long enough. We passed it last year. Let us pass it now and send it 
over to the Senate and insist that they do something for our friends 
and our neighbors who do not have health insurance and face the risk of 
illness every day without it.
  Mr. STARK. Mr. Speaker, I yield myself 3 minutes.
  (Mr. STARK asked and was given permission to revise and extend his 
remarks.)
  Mr. STARK. Mr. Speaker, I do want to remind my colleagues that this 
bill is the penultimate waste of taxpayers' money.
  The Joint Committee on Internal Revenue Taxes, a committee run by the 
Republican majority on the Committee on Ways and Means to estimate the 
cost and benefits of tax bills, has estimated that there will be a 
grand total of 160,000 uninsured individuals who could possibly benefit 
from this bill, 160,000 people, I say to the gentleman from Missouri 
(Mr. Talent), at a cost of $48 billion over 10 years.
  Mr. Speaker, would the gentleman from Missouri (Mr. Talent) like to 
respond to a question?
  Why does he think it is so important to spend $48 billion to help 
160,000 people? Because that is all this bill does.
  Mr. TALENT. Mr. Speaker, will the gentleman yield?
  Mr. STARK. I yield to the gentleman from Missouri.
  Mr. TALENT. Mr. Speaker, there are 44 million people who are 
uninsured.
  Mr. STARK. Mr. Speaker, reclaiming my time, but according to the 
Joint Tax Committee, only 160,000 people who are uninsured will receive 
any benefit.
  Mr. TALENT. Mr. Speaker, if the gentleman will continue to yield, the 
Association Health Plan provision in the bill about which I just spoke 
will, conservatively speaking, provide health insurance to 48 million 
people who currently do not have it.
  I would say to the gentleman, if there is a chance that this bill can 
provide help for these people, it is a chance that we ought to take. I 
would ask the gentleman why is he not willing to do that on behalf of 
these people.
  Mr. STARK. Mr. Speaker, I am not willing to waste $30,000 a year per 
family to pay for it because the insurance is not worth that much. This 
is squandering the taxpayers' money. I will repeat what the Joint 
Committee on Taxes has said.

                              {time}  1545

  That the total people benefiting from this bill, while there will be 
12,400,000, all of them already have insurance. There are only 160,000 
people who are eligible who are uninsured.
  So we are spending, I just want to repeat, we are spending $48 
billion to help 160,000 people. They may each insure two people so to 
give my colleagues credit, I will say it is 320,000 people. That is a 
cost of $15,000 a head, $30,000 a family, for 10 years. My colleagues 
could buy them a hospital and a doctor for that kind of money.
  The Republicans just do not know what they are doing. They are 
squandering the taxpayers' money.
  I just want to remind everybody, $48 billion to help, according to 
the Committee on Ways and Means, Republicans-controlled Joint Committee 
on Taxation, there are only 160,000 people who are uninsured who 
qualify. That is ridiculous.
  Mr. ARCHER. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, as the House prepares now to consider legislation on 
liability and lawsuits, it is important that we consider that there are 
44 million Americans who lack even the basic coverage of today's health 
plans.
  What we do in this health access bill will keep many of them from 
falling into the uninsured. It will, furthermore, qualify more and more 
people who work, who are self-employed to be able to have access to 
plans. It will level the playing field within the Tax Code for 
everyone.
  The gentleman from California has just said we are squandering the 
taxpayers' money. Far more billions of dollars are going out for the 
deductibility of employers who are providing health insurance today. 
They get a tax deduction. Why should only the employer get a tax 
deduction? Why should not the self-employed get an equal tax deduction? 
And why should those who pay their own premiums, without the benefit of 
an employer's program, not also get a deduction?
  This is equity within the system, as well as making insurance more 
affordable for all of those people.
  This bill also is not just about that type of insurance. It is about 
long-term care, which is a medical concern of a different sort for more 
and more millions of Americans, and greater access to long-term care, 
helping those people who are taking care of the elderly in their own 
home by giving them an extra tax exemption.
  Now, the gentleman from California says that is squandering the 
taxpayers' dollars. I dare say to those families who are taking care of 
the elderly in their homes, that to get a little bit of tax relief is 
certainly not squandering the dollars that are coming in to Washington.
  The 44 million people will increase that are uninsured unless we 
address the barriers to access. This bill is a first step to do that. 
It is not the ultimate answer, but these barriers are preventing 
Americans from getting affordable care at a rate of nearly 1 million a 
year; and, frankly, all the lawsuits in the world will not add anything 
to help a worker struggling to buy health insurance for his or her 
family or struggling to maintain their elderly in their own home.
  The best patient protection of all is health insurance, and our plan 
is the only one before the Congress that helps families get the 
coverage and the care that they need.
  Our plan is based on three fundamental principles: Affordability, 
accessibility, and individual choice. A major source of America's 
frustration with HMOs is a lack of control, which both patients and 
doctors feel. Patients want to be able to pick up the phone and get an 
appointment to see their own doctor. Doctors want more time with their 
patients and to treat them as they see fit.
  Answers to these frustrations, however, are found when we empower 
people, not lawyers. Our plan helps make health care available and 
affordable for every generation. Baby-boomers caring for elderly family 
members at home will get help from our tax breaks, as I mentioned. We 
even help them plan for

[[Page H9462]]

their future and the long-term care that they may need through 
deductions for the purchase of long-term care health insurance.
  A new family will also get help with its health insurance costs, 
costs that have outpaced average household income last year by nearly 
two-to-one. And small businesses, which create 95 percent of new jobs, 
will benefit with accelerated deductions for the self-employed, so 
start-up companies can offer competitive benefits to attract and retain 
the best workers.
  Finally, nothing embodies the vision of choice and accessibility more 
than medical savings accounts. Expanding MSAs will give consumers more 
control over their health care dollars, offering them the freedom to 
consult any doctor they choose to lower their deductibles or premiums 
and to save any unused funds for future health care expenses. With 
MSAs' patients and not insurance companies, not a third party payer, 
controls the choices. There are no gatekeepers, and there are no 
middlemen.
  More Americans are using medical savings accounts because they put 
patients back in charge and not insurance companies. In fact, 28 
percent more Americans opened MSAs last year. That means that thousands 
of Americans who previously had no health insurance are now covered 
because of MSAs, and that is our top priority.
  By the way, this is $9 billion of revenues over 5 years, not the $50 
billion that we have heard over and over again from the other side. 
After all, the House budgets only for 5 years, and they have been 
prepaid by the American people in the form of a projected surplus that 
will be close to $300 billion over the next 5 years; $8 billion out of 
$300 billion, and that is all according to the Congressional Budget 
Office.
  Are Democrats now saying that they are not for any tax relief 
whatsoever, even to help low- and middle-income Americans get health 
insurance? Are they opposed to giving some relief for those caring for 
their elderly relatives at home?
  I would remind my colleagues what Senator Bob Kerry, a Democrat, 
said, and I quote, to suggest that we cannot afford to cut taxes when 
we are running a $3 trillion surplus is ludicrous, unquote.
  In closing, let us not lose sight of the real health care problem 
facing Americans and their families today: Lack of the most basic 
patient protection of all through health insurance. And while 
accountability in health care is an important aspect of the managed 
care debate, there are 44 million reasons why Republicans are 
broadening the focus to include affordability, accessibility and 
individual choice. Americans want more ambulances, not more ambulance 
chasers, and they want to spend more time in front of their doctors and 
not in front of a judge.
  This bill is the right kind of health care reform, and I urge a 
``yes'' vote.
  Mr. Speaker, I reserve the balance of my time.
  Mr. STARK. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, I wonder if the gentleman from Texas (Mr. Archer) would 
indulge me and respond to a question. I had stated that over 10 years 
this bill would cost, just for the tax deduction, $31 billion.
  The gentleman is quite correct, for 5 years it would cost less, but 
in the outyears the cost goes up.
  Is it not correct that there would only be 200,000 uninsured people, 
or 100,000 insured individuals, policyholders, who would benefit from 
the tax, according to our own Joint Committee on Taxation?
  Mr. ARCHER. Mr. Speaker, will the gentleman yield?
  Mr. STARK. I yield to the gentleman from Texas.
  Mr. ARCHER. Mr. Speaker, the gentleman appears to be quoting the 
Joint Committee on Taxation for his numbers, and I have requested the 
Joint Committee on Taxation to give me the basis of that, and they say 
they have no knowledge of that. So there is some misunderstanding 
relative to those figures.
  Mr. STARK. I will be glad to share with the gentleman those figures, 
and perhaps we can discuss it later.
  Mr. Speaker, I yield 3 minutes to the gentleman from New York (Mr. 
Rangel), the ranking member of the Committee on Ways and Means.
  Mr. RANGEL. Mr. Speaker, I think the whole country now knows the 
substance of the bipartisan bill, the Norwood-Dingell patients' rights 
bill. I think all over, people are saying that the patients' rights 
should be determined by physicians and when that does not occur and 
when there is liability that they should have the right to sue.
  I think that there are enough people on the other side of the aisle 
that have decided that this was the right, this was the decent, and 
this was the moral thing to do.
  I think that both the majority and minority have come to believe that 
now the majority of the Members of the House were going to vote on the 
Norwood-Dingell Patients' Bill of Rights, and every editorial indicated 
it would pass and the President would sign it into law.
  We wondered what little tricks anyone could come up with; what could 
they possibly do and what could they pull out of this hat of tricks 
that they manage to come up with from time to time? They could spread 
EITC further and not give the poor folks what they are entitled to when 
they work every day. They could look for the thirteenth and the 
fourteenth month. They could start determining that everything that 
came up they could not pay for was an emergency. But we never, never, 
never thought that they would just pull out of the hat a tax bill that 
never came out of the tax-writing committee.
  I say a tax bill that never came out of the tax-writing committee 
because I am led to believe that the provisions that are in this health 
access bill came out of the conference the Joint Committee on Taxation 
had, that is the Republicans had, and that no Democrats were involved 
in it, except to vote against it.
  So why would they take a bipartisan bill that Republicans have worked 
hard on and try to attach this poison pill to it, knowing that it is 
not paid for? It can be said that it is $9 billion, it is $12 billion; 
it can be said that it is not $40 billion or $50 billion, but if the 
President has promised that if it is not paid for he is going to veto 
it, then I guess the only answer to the senseless, committeeless bills 
that have come out to the floor from either the Committee on 
Appropriations or the Committee on Rules is that the majority has 
decided that it really does not intend to legislate at all. What it 
intends to do is to send out political statements so that the President 
of the United States can fulfill his commitment to the American people 
and to veto those bills that are not funded.
  It is not fair. It is not fair to do this for a bill that my 
colleagues know we have the votes to pass in the House of 
Representatives.
  Mr. ARCHER. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from 
Texas (Mr. Sam Johnson).
  Mr. SAM JOHNSON of Texas. Mr. Speaker, again I find myself on the 
floor in another debate about freedom, the basic principle of 
democracy. To debate over freedom means to choose the quality health 
care that one wants.
  This bill permits all individuals access to health care by expanding 
medical savings accounts. Medical savings accounts allow all Americans 
to have the freedom to choose their own doctor and decide, with their 
doctor, what sort of medical care they need.
  My colleagues will notice that medical savings accounts have been 
expanded by more than 28 percent last year. We need to allow them to 
choose. The best way to provide health care to every American is not to 
add government regulations but to lift the regulations that prevent 
people from getting quality care.
  I believe the path to good medicine and health care should pass 
through the doctor's office, not the lawyer's office.
  I think that it is important for us to help people learn new 
innovations, and this bill also contains a medical innovation tax 
credit which helps our teaching hospitals and research facilities 
continue their fight to find cures for deadly diseases such as cancer.
  The American people have said they want control over their own health 
care. The answer to this problem is to give every American the freedom 
and control to choose their own doctor and medical savings accounts, 
and this legislation will do just that.

[[Page H9463]]

                              {time}  1600

  Mr. STARK. Mr. Speaker, I yield 2 minutes to the gentleman from 
Maryland (Mr. Cardin).
  Mr. CARDIN. Mr. Speaker, let me thank my friend from California for 
yielding me this time.
  Mr. Speaker, every Member here is concerned about the rising number 
of uninsured Americans, now more than 43 million; and we recognize that 
steps must be taken to address this problem. But H.R. 2990 is not the 
answer. This bill does very little to reduce the number of uninsured. 
Instead, its sponsors are proposing a new set of tax breaks that would 
help those that are least likely to be currently uninsured, as my 
friend from California pointed out.
  It also contains many provisions that will hurt us in covering people 
with insurance. The Health Association Plans that the sponsors brag 
about, there is a reason why the National Governors' Association and 
the National Conference of State Legislators are opposed to it, for it 
preempts these plans from State reform. Under the guise of helping 
small business be able to find health insurance, instead what we are 
doing is preempting State reform.
  And I could tell my colleagues in my own State of Maryland we have a 
small market reform; it is working. Small employers can find affordable 
health insurance. If we pass this provision, we have destroyed the 
Maryland small market reform, and we are going to have less people 
insured by small employers in our State if that provision becomes law.
  But let me tell my colleagues the real reason, the most important 
reason, why we should oppose this effort. If we want to pass a 
patients' protection bill in this Congress, if we want to provide help 
to our constituents from the practices of HMOs, then we need to defeat 
this bill. The unfair rule that we are operating under marries this 
proposal with the Patients' Bill of Rights, and if this becomes part of 
the Patients' Bill of Rights, it is much less likely that we are going 
to enact a Patients' Bill of Rights in this Congress. That is why this 
rule was passed in the way it was, and that is why this bill is on the 
floor today.
  Mr. Speaker, if we are serious about expanding access, let us work 
together to do it. This bill will not do it. I urge my colleagues to 
reject it.
  Mr. CRANE. Mr. Speaker, I yield 1\1/2\ minutes to our distinguished 
colleague from Arizona (Mr. Hayworth).
  Mr. HAYWORTH. Mr. Speaker, I thank my friend from Illinois for 
yielding the time, and I thank my friends on the left for offering a 
clear choice today, because really this comes down to a simple 
question: Who do you trust in terms of health care?
  One of the reasons I left private life and ran for public office is 
because those on the left favored big government to run health care, 
take power out of the hands of patients, put that power in the hands of 
Washington bureaucrats, and that is being reaffirmed, Mr. Speaker, even 
while those on the left offer their incisive legislative analyses of 
why there is a poison pill attached to this.
  Mr. Speaker, how on earth can putting power in the hands of patients 
to choose the doctors they want through medical savings accounts, how 
on earth can that freedom be regarded as a poison pill?
  I rise in strong support of this legislation, mindful of the fact 
that nearly one-quarter of the population of Arizona is uninsured, and 
I wish my friends in the minority would come with me to Show-Low, 
Arizona, to hear the people of that town say give us medical savings 
accounts, give us the ability to choose health care for ourselves, we 
need that help; and I wish they could hear the pleas in the town hall 
meetings I attend where the self-employed say give us 100 percent 
deductibility on health insurance, the same provisions the big boys 
have.
  That is what this legislation does, and association plans, it is 
interesting to hear my friend from Maryland, they cannot have it both 
ways.
  Mr. Speaker, if my colleagues want to federalize health care in one 
arena and then criticize accessibility to insurance through Association 
Health Plans, there is something there that cannot be reconciled.
  Stand for the people, stand for freedom, stand in favor of this 
legislation.
  Mr. STARK. Mr. Speaker, I yield myself such time as I may consume.
  I suspect, Mr. Speaker, that the gentleman from Arizona, like myself, 
gets his health insurance from the Federal Government, and I do not 
hear him complaining about that.
  Further, Mr. Speaker, I would just like to remind my colleagues that 
at a cost for these 200,000 uninsured people of 15,000 a year, the 
Speaker would have to have a breakfast to raise money from lobbyists 
several times to be able to get enough money to pay for the cost of 
this health plan.
  Mr. Speaker, I yield 2 minutes to the gentleman from Michigan (Mr. 
Levin).
  (Mr. LEVIN asked and was given permission to revise and extend his 
remarks.)
  Mr. LEVIN. Mr. Speaker, this so-called access bill is in truth a 
smokescreen, so flimsy that it is easy to see through. Its main effect 
would be to sink Dingell-Norwood, not help the uninsured. It is about 
access of the majority to special interests and their access to the 
majority far more than it is about access of 45 million uninsured to 
health insurance.
  Mr. Speaker, that is clear because, number one, according to the 
analysis of the joint task committee, and I am sorry the chairman of 
the committee is not on the floor; here is the letter dated October 6 
from the Joint Committee on Taxation that is under the control of the 
majority. It says that this bill would help 160,000 taxpayers, only 1 
percent of the uninsured. Ninety-nine percent of the uninsured would be 
left high and dry while giving a tax benefit to those already insured, 
and the higher one's income, the more would be the tax benefit.
  Number two, it is not paid for, and it is going nowhere.
  Three, the majority have refused to allow the minority to present an 
amendment to pay for the cost of Dingell-Norwood. They say they are 
doing that because the amendment would not be germane. What is not 
germane is the inability and unwillingness, not the inability, but the 
unwillingness, of the majority to make this amendment germane. The 
majority claimed there was no consideration in committee of the 
Democratic paid-for proposal, but all but two parts of it were in the 
Republican tax bill that passed this House, and the other two were in a 
proposal presented in the Committee on Ways and Means by Democrats.
  The best answer is a large vote for Dingell-Norwood and place the 
Republican leadership in a quandary as to what to do next to thwart the 
will of the American people. Let us give a resounding vote to Dingell-
Norwood.
  Mr. CRANE. Mr. Speaker, I yield 1\1/2\ minutes to our distinguished 
colleague from Washington (Ms. Dunn).
  Ms. DUNN. Mr. Speaker, I rise today in support of the Quality Care 
for the Uninsured Act, a bill that will address the most critical issue 
facing our Nation's health care system today, that is, the issue of 
access. The total number of uninsured Americans in the United States 
today is 44 million people, 706,000 people in my home State of 
Washington. As we proceed with this debate, we must remember that 
maintaining the world's finest health care system is a balancing act. 
How do we sustain the quality of health care that most Americans enjoy 
and still extend the benefits of that system to those who lack 
coverage?
  The first principle we must accept is that the marketplace, not the 
Government, must be the focus of our support efforts. Our health care 
system is the envy of the world, and American businesses, hospitals and 
researchers are on the forefront of medical innovations that are 
bringing a better quality of life to the people of the United States.
  In my home State of Washington hundreds of companies are researching 
new ways to combat illnesses through biotechnology, through new medical 
devices, and through automated testing. Many of these treatments will 
be the foundation of a new health care system, one that increasingly 
relies on groundbreaking technology to replace traditional treatment 
methods. We must not overly burden this system with new costs that will 
lead to more uninsured Americans or redirection of precious resources 
away from investing in critical new technologies. Helping people 
purchase private-sector insurance is the most important first step we 
can take to improve our system.
  Mr. Speaker, the American people need access to coverage that keeps

[[Page H9464]]

them healthy more than they need mandates to government. Please support 
this bill.
  Mr. STARK. Mr. Speaker, I yield 2 minutes to the distinguished 
gentleman from Washington (Mr. McDermott).
  Mr. McDERMOTT. Mr. Speaker, on the way in here I met a reporter from 
one of the major newspapers that said what is going on up on the floor? 
Why are they adding that access stuff to the perfectly good bill that 
the gentleman from Georgia (Mr. Norwood) and the gentleman from Iowa 
(Mr. Ganske) put together? I said, well, they are just trying to avoid 
for one more time addressing the issue of the uninsured in this 
country.
  This bill will do absolutely nothing. Less than 1 percent are 
affected at all. If my colleagues were serious about the tax break, 
they would make it a refundable tax break. The gentleman from 
California (Mr. Rogan) and I put in a bill that said give a 30 percent 
refundable tax break, but they did not do that because they did not 
want to help the people on the bottom.
  In the census data they talk about, they talk about people who make 
less than $25,000 in this country. One out of four is uninsured, and 
this bill does nothing for those people. So they simply are not serious 
about access.
  Now I believe that the reason this is out here is because the polling 
must be real bad. They took all that credit for beating the President 
who wanted to give affordable health care that could never be taken 
away. They said we killed it; we are going to let the private sector 
take care of it. Well, Mr. Speaker, the private sector has now put them 
in the position where it is not 35 million who do not have insurance; 
it is 44 million who do not have insurance. That is why we have 
Medicare, my colleagues.
  Forty-nine percent of seniors had health insurance in 1963. Today 99 
percent of the people have it. They got it because we had a government 
program run through the private sector, private doctors, private 
hospitals, and what this bill will do; and I kind of hope it passes 
because I know it will fail because what they are doing is cutting up 
the insurance pool, and it is ultimately going to fail, and we are 
going to have more people uninsured.
  The gentlewoman from Washington (Ms. Dunn) talks about it helping her 
State. There is no individual insurance available in the State of 
Washington. So if someone tries to buy it, they cannot buy it. We can 
have all the tax deductions in the world, and we will not get a single 
dime.
  Vote no on this.
  Mr. CRANE. Mr. Speaker, I yield 1 minute to the gentleman from 
Florida (Mr. Foley).
  Mr. FOLEY. Mr. Speaker, I rise in strong support of this package, and 
I will say some of the conversation from the other side of the aisle is 
suggesting if it is not my idea, it is not a good idea.
  I happen to be a cosponsor of Norwood-Dingell, and I support this 
package. I have worked with the great Governor Lawton Chiles in 
Florida, and we came up with similar proposals when I was in the 
legislature. We talked about expanding access. There is a problem of 
uninsurability, there is a problem with fewer people becoming enrolled, 
and there is a crisis of cost shifting. Hospitals, uninsured, all these 
programs are helping to raise premiums because fewer are insured.
  My colleagues, we can do both today. We can pass good health care 
legislation as prescribed by Norwood-Dingell, but we can also talk 
realistically about some tax cuts to make insurance more affordable.
  Now the President goes out and campaigns on giving tax deductions for 
elder care, and from the other side of the aisle we hear applause. But 
if it is a Republican idea, it is stupid, it is bankrupting the system, 
it is too expensive.
  My colleagues, let us stop the rhetoric. Let us help average 
Americans. Let us get out of this chamber, this echo chamber of 
hostility, and pass some real legislation. We do have a chance to do 
both today. Do not shirk from the responsibility and the opportunity.
  Mr. STARK. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, I am pleased to help 160,000 Americans to the tune of 
$48 billion. That is real help to the average taxpayer.
  Mr. Speaker, I yield 2 minutes to the gentleman from Georgia (Mr. 
Lewis).
  Mr. LEWIS of Georgia. Mr. Speaker, I rise today with great concern. I 
am deeply concerned that millions of Americans are without health care. 
I am concerned that parents cannot afford to take their sick children 
to see a doctor. Too many of us are more worried about insurance 
companies than patients' care. We are more concerned with managing 
liability than caring for those who are sick and weak.
  This is not just, this is not right, this is not fair. Access to 
health care is a right.
  Mr. Speaker, we need to pass a meaningful Patients' Bill of Rights. 
We need a bill that will hold insurance companies responsible. We need 
a bill that will give patients the right to sue in State courts.

                              {time}  1615

  We need to do what is right. Let us not jeopardize this remarkable 
opportunity we have worked so hard and so long to build. My colleagues, 
the people of America are counting on all of us.
  Mr. Speaker, let us work together to pass one of the most important 
health care bills in our lifetime. Now is the time, not next year, not 
next month or next week, but now is the time to pass a Patients' Bill 
of Rights, without poison pills.
  Let us do what is right. Do it for the American people. Do it for the 
40 million without any health insurance, without health care. Pass this 
bill for the people. Pass the Dingell-Norwood bill.
  Mr. CRANE. Mr. Speaker, I yield myself 1 minute.
  Mr. Speaker, my State of Illinois saw its ranks of uninsured increase 
from 12.4 percent in 1997 to 15 percent in 1998. That is disheartening 
and unacceptable, and we want to see what this Congress can do to 
address the problem. We have before us today H.R. 2990, the quality 
care for the uninsured, which is intended to reduce the ranks of the 
uninsured.
  Much to the disappointment of some of our colleagues on the other 
side of the aisle, it is not drafted to create a Federal takeover of 
our health care system. Rather, it is intended to help hard-working 
uninsured Americans afford health insurance for their families and it 
will solve the problem, at least better than it is being addressed 
today.
  Will it do all? Probably not. But let us give it a chance. This bill 
contains provisions that our small business community tells us will go 
a long way in bringing more Americans under the protection of health 
insurance so they do not have to fear financial ruin as a result of a 
medical crisis.
  I urge my colleagues to support H.R. 2990 and help the 44 million 
Americans who have been ignored for too long.
  Mr. Speaker, I yield 1\1/2\ minutes to the distinguished gentleman 
from Ohio (Mr. Portman).
  Mr. PORTMAN. Mr. Speaker, I thank the gentleman for yielding me time.
  Mr. Speaker, I rise in strong support of the health access bill 
before us today. It is interesting, the Norwood-Dingell bill is not 
before us. We are talking about another piece of legislation that is 
directly focused on trying to cover more of the uninsured.
  Just two days ago the Census Bureau told us that 44.3 million 
Americans now do not have health insurance in the years 1998 and 1999. 
That means there are about 1 million more uninsured since 1997.
  That is disheartening, that in this time of relative prosperity we do 
have about 16 percent of our population without insured access to 
health care. That is what this bill is all about.
  About 161 million Americans get their health care coverage through 
their employers, and, of course, many of those are small employers. We 
all know small business, self-employed people, typically operate on 
very tight margins, making health insurance very difficult for them to 
afford. And as we debate the managed care issues before us today, we 
have to be sure we are not increasing the ranks of the uninsured, by 
increasing the potential for liability, by increasing the Federal 
mandates, by increasing the costs and burdens of health care.
  The essential provisions of this health care access bill will go a 
long way towards seeing that not fewer, but more Americans receive 
insured access

[[Page H9465]]

to health care. That is why this is so important.
  It has a lot of good provisions on the tax side. Taxpayers who pay 
more than 50 percent of the costs of their premiums that the employers 
are not picking up will now be able to deduct 100 percent of that 
premium cost they incur that is.
  This is a good idea. Over 7 million people now need long term care 
insurance. We now think that by 2050 that number is going to be about 
20 million Americans. This bill addresses this problem by providing 
individuals who purchase long-term insurance with 100 percent 
deduction.
  Mr. Speaker, there are so many other good things in here that will 
focus on the issue of trying to get more access, including medical 
savings accounts, new drugs to find cures for diseases. This is the 
right prescription to making our health system work better.
  Mr. STARK. Mr. Speaker, I am pleased to yield 1\1/2\ minutes to the 
gentleman from California (Mr. Becerra).
  (Mr. BECERRA asked and was given permission to revise and extend his 
remarks.)
  Mr. BECERRA. Mr. Speaker, I thank the gentleman for yielding me time.
  Mr. Speaker, over 44 million Americans do not have health insurance, 
yet this bill that we have before us by the majority wants to spend $48 
billion to cover 160,000 of those 44 million Americans who do not have 
health insurance. It is also a bill that leaves the uninsured out in 
the cold, not just because it does not cover enough of them, it is 
because most of these tax breaks go for those who pay income taxes in 
large portions. So who is left out? Most of those 44 million Americans 
who are working poor, and, therefore, do not pay the substantial number 
of income taxes to get all of those tax breaks.
  Who will benefit? The 160,000 people who benefit are those who are 
higher income individuals who can shop around and buy insurance 
already. It is an abusive way to try to spend money. It is an abusive 
way to try to give coverage. There are better ways to do it.
  Perhaps the worst thing about this bill is it is fiscally 
irresponsible. $48 billion, not paid for, and, worse than that, somehow 
the math does not add up. The majority here is talking about doing an 
$800 billion tax cut. It is already overspending its appropriations 
bills for next year's budget by about $30 billion, and now we are going 
to pile on top of that $48 billion.
  Explain to the American people where you get the money. You can only 
spend a dollar one time. You are trying to tell the American people you 
have a shell game going on and you can spend it lots of times.
  Let us not pass this bill. Let us get real reform, and tomorrow let 
us get to the real work at hand, and that is to provide the American 
people with the rights that they demand. When they go to a hospital, 
they want to know that they have the best information, the best 
doctors, to get the best care, and if they do not get it, they deserve 
to go after whoever was responsible for not giving it to them.
  Let us do the right thing. Let us get beyond this, defeat this, and 
get to getting to the Patients' Bill of Rights.
  Mr. CRANE. Mr. Speaker, I yield 2 minutes to the distinguished 
gentlewoman from Connecticut (Mrs. Johnson).
  Mrs. JOHNSON of Connecticut. Mr. Speaker, I rise in strong support of 
this legislation to provide access to health insurance by the 
uninsured. The number of uninsured people has risen dramatically, a 
very troubling fact, given the economy, the low unemployment and 
poverty rates. Health insurance is a critical component of personal 
financial fitness and we should be doing all we can to help people 
afford health insurance. You can be for patients rights and for 
coverage of uninsured Americans.
  This legislation provides tax deductions for people who pay 50 
percent of the cost of health insurance and long-term care insurance. 
The GAO has said this will expand coverage to 40 million Americans, 25 
million of whom are uninsured. Does it matter whether you help 25 
million of the 43 million uninsured? You bet it does. And by making 
insurance more affordable, you can help them get into the health care 
system we all value and depend on.
  We spend $100 billion in tax breaks for people who have employer-
provided insurance, regardless of their income, so why should we not 
treat those who pay their own premiums exactly the same way? It is a 
matter of fairness, it is a matter of access to critical benefits, 
health insurance.
  In addition, this bill expands availability to MSAs. I have visited a 
company in my district, a manufacturing company. These are working 
people, and they have chosen MSAs. They have a choice and they choose 
MSAs. Why? Because they can spend MSA dollars on dental benefits, 
vision benefits, home health care benefits, drug benefits, a far 
broader range of benefits than most employer plans provide, because 
they can spend those MSA dollars on anything eligible in the Tax Code.
  Why would we not want to offer them that choice? Do we not trust 
them? I think it is terrific to have sure coverage. And the sicker you 
are, the better off you would be in an MSA, because once you meet that 
deductible and you can spend it on everything, then you get 
catastrophic coverage, and that is the best deal for a really sick 
person.
  In addition, the bill provides new and more affordable choices for 
small businesses so they can offer coverage to their employees.
  In short, let me say that this is a great bill, we should support it, 
and if we do not open up access, we need our heads examined, because 
that is the real problem out there. We can do Patients' Bill of Rights 
and access this week in this House.
  Mr. Chairman, I am pleased to rise in strong support of this 
legislation that will help people afford health insurance. The number 
of uninsured people has risen dramatically over the past year--a 
troubling fact, given the growth in our economy and low unemployment 
and poverty rates. Health insurance is a critical component of personal 
financial fitness. We should be doing all we can to help people afford 
health insurance.
  This legislation will expand access to health insurance. First, it 
will offer tax deductions for people who pay at least 50% of the cost 
of their health and long-term care insurance. At my request, the GAO 
has examined the impact of a health deduction and concluded that 40 
million people would have been eligible in 1997 for a tax deduction for 
health insurance. Of these 40 million, 25 million were uninsured. We 
are currently providing over $100 billion in tax breaks to people who 
have employer-provided insurance regardless of their income. We should 
do no less for people who have to pay their own premiums. It's a matter 
of fairness. It's a matter of access to health insurance.
  In addition to helping the uninsured through premium deductibility, 
this bill expands the availability of medical savings accounts (MSAs). 
MSAs are a preferred way for some people to cover their health 
insurance costs. I have visited a small company in my district that 
offers MSAs to their employees. I heard directly from the workers that 
they prefer MSAs because their health care dollars cover a far broader 
range of health benefits, better benefits than almost all employers 
provided plans--dental, vision home care drugs! And gain access to a 
broad range of doctors, instead of a narrow group covered through an 
HMO.
  In addition, this bill provides new and more affordable choices for 
small businesses to offer coverage to their employees. Only 28% of 
employers with less than 25 workers offer health insurance. The main 
reason for small employers not offering health insurance is the higher 
costs they face. Their small size means they cannot spread the risk 
associated with a few unhealthy employees. They also face higher 
administrative costs.
  If we are going to address the problem of uninsured Americans, we 
must help small businesses, which are one of the fastest growing 
employment sectors, afford to offer health insurance coverage. People 
working for small businesses account for 16% of the under-65 
population, but 28% of the uninsured. This legislation will help small 
employers pool together to afford the cost of insuring their workers. 
It will also create access to health insurance and health care services 
for people in urban and rural areas by allowing community health 
centers to serve as insurance networks.
  It is critical that we address the problem of the uninsured. CBO 
estimates that for every 1% increase in health insurance costs, 400,000 
people lose their health insurance. If we consider managed care reform 
legislation without taking steps to increase access to health 
insurance, we are turning a blind eye to the 44 million Americans who 
have no health insurance option plus those who will lose their 
litigation runs premiums up. Our efforts to improve health insurance 
quality must include equal commitment to increasing the number of 
insured Americans. H.R. 2990 takes these steps. I urge its adoption.

[[Page H9466]]

  Mr. STARK. Mr. Speaker, in the interest of explaining how we spend 
$48 billion to give 160,000 people access, I yield 1\1/2\ minutes to 
the gentleman from Texas (Mr. Stenholm),
  (Mr. STENHOLM asked and was given permission to revise and extend his 
remarks.)
  Mr. STENHOLM. Mr. Speaker, I rise in strong opposition to this 
legislation. I do not do so because I do not agree with the goal of 
increasing access to health insurance. In fact, I support many of the 
individual provisions in this legislation.
  I oppose this legislation because it is fiscally irresponsible to 
enact legislation that would cost nearly $50 billion, without paying 
for it and with no clear end game for health care in sight.
  Congress should not consider any tax or spending legislation without 
knowing how it would fit within the context of a comprehensive game 
plan which balances all of the various health needs of all Americans at 
an affordable cost. Any decision to fund tax cuts or new spending out 
of the projected surplus should be made only after we have sat down in 
a regular committee process in a bipartisan way to make sure there will 
be sufficient resources for competing needs.
  As important as the issue before us today is, we also have a 
responsibility to deal with the problems of Medicare that threaten 
rural hospitals, set more realistic discretionary spending levels, deal 
with the long-term problems facing Medicare and Social Security, and 
leave room for tax cuts for purposes in addition to health care.
  This legislation takes the approach of spend first, figure out if we 
can afford it, given all the other demands on the surplus later. Some 
of my friends on the other side of the aisle argue they could not allow 
the gentleman from Georgia (Mr. Norwood) and the gentleman from 
Michigan (Mr. Dingell) to add an amendment paying for the cost of their 
bill that we will be considering tomorrow because it was not germane 
and did not go through the Committee on Ways and Means. I find it very 
curious we are now bringing up a $50 billion tax bill that did not go 
through the Committee on Ways and Means and which violates the budget 
rules. I do not understand that double standard that makes it easy to 
spend money we do not have and impossible to be fiscally irresponsible.
  Mr. CRANE. Mr. Speaker, I yield 1 minute to the distinguished 
gentleman from Pennsylvania (Mr. English).
  (Mr. ENGLISH asked and was given permission to revise and extend his 
remarks.)
  Mr. ENGLISH. Mr. Speaker, in Pennsylvania in 1998, roughly 10 percent 
of the population did not have health insurance of any sort, and these 
were not just the indigent, they were small business people, they were 
self-employed, people who simply could not afford the premiums.
  This legislation contains an element fundamental to any balanced 
debate on health care policy. It would make health care coverage more 
accessible, not for 160,000, for millions, and, in doing so, blunt the 
impact of any cost increases that might result from the imposition of 
health care quality standards.
  American families are concerned about their health care. We in 
Congress must recognize that their concern relates to both the quality 
of health care and its cost. We cannot and we should not address one 
without the other.
  Mr. Speaker, this legislation is not a poison pill for health care 
reform, but an essential ingredient to any balanced approach to health 
care policy. For those of us who support a market oriented incremental 
approach to improving our health care system, this represents an 
important step toward the goal of universal access to affordable care.
  Mr. STARK. Mr. Speaker, I yield such time as he may consume to the 
gentleman from Maine (Mr. Baldacci).
  (Mr. BALDACCI asked and was given permission to revise and extend his 
remarks.)
  Mr. BALDACCI. Mr. Speaker, I appreciate the gentleman yielding me 
time.
  Mr. Speaker, I rise in opposition to this legislation and in favor of 
the Norwood-Dingell bill, and at the same time to express the worry of 
Maine's citizens about the out-of-state health insurance companies 
taking away local control. I am looking forward to working with the 
gentleman from Georgia (Mr. Norwood) and others.
  Mr. Speaker, I am very pleased to rise today in support of this 
bipartisan effort to guarantee minimum standards for access to care for 
all Americans. This legislation provides crucial protections and 
preserves the doctor-patient relationship.
  Most importantly, this bipartisan bill will hold health plans 
accountable for their medical decisions. Let's be clear. When an 
insurance company overrides the decision of a medical professional, 
that plan is clearly making a decision affecting the health of the 
patient. This bill recognizes that simple fact.
  This bipartisan bill empowers our citizens and assures them that at 
the very minimum, their relationship with their doctors--relationships 
built on trust--will not be infringed upon, no matter who owns the plan 
to which they belong. This bill is necessary in a climate where local 
control over health insurance is dwindling.
  I am deeply concerned about this diminishment of local control which 
is evident in the current trend of consolidation of health insurers. I 
am particularly concerned about what this trend means for access to and 
quality of care for Americans in rura areas.
  In my state of Maine, for example, regulators are currently reviewing 
a proposed merger that will dramatically change the health insurance 
landscape. If approved, Blue Cross and Blue Shield of Maine will be 
taken over by an ever-growing regional health insurer. People in my 
state, one-third of whom are covered under Blue Cross, are experiencing 
great anxiety about the coverage they will have under an out-of-state 
insurer with interests spread across the country. The citizens of Maine 
worry about whether large out-of-state health insurers will take away 
local control of their plan, reduce benefits while raising premiums, or 
cut back on quality care.
  As the trend of insurance mergers and acquisitions continues, we in 
Congress ought to continue to review the effects this has on health 
care delivery and quality of care, especially in rural areas. Although 
this is not within the scope of this legislation, I would hope that we 
can soon look further into this trend and ensure that health care 
consumers' interests are being adequately represented. I hope that Mr. 
Norwood agrees that this is something we should revisit in the future.
  I would like to thank Mr. Norwood and Mr. Dingell for their tireless 
efforts to bring managed care reform and patient protection to the 
House floor. The American people are demanding change and 
accountability in this industry. This bill provides real protections 
for citizens and has the teeth needed to make these protections 
meaningful. I am pleased to be an original cosponsor of this important 
legislation, and urge my colleagues to support this bill and to oppose 
amendments that would weaken it.
  Mr. STARK. Mr. Speaker, I yield the balance of my time to the 
gentleman from Georgia (Mr. Norwood).
  The SPEAKER pro tempore (Mr. Hastings of Washington). The gentleman 
from Georgia is recognized for 1\1/2\ minutes.
  Mr. NORWOOD. Mr. Speaker, I thank the gentleman for yielding me time.
  Mr. Speaker, I have listened to this debate through all three 
committees, and I am looking for a place to hang my hat. I am very much 
for the access provisions. I am for medical savings accounts. I am for 
deductible of long-term care, of insurance. I am for HealthMarts. I 
even can live with Associated Health Plans if we will put just a little 
bit of patient protections under ERISA.
  But I am not going to vote for this, even though I have a bill that I 
dropped in the spring that is just like this, because I have concluded, 
after listening to this debate, that this effort is not to have a law. 
This bill was not ever intended to be a law. This bill simply is 
intended to go to conference with patient protections to act as a 
poison pill, to make sure that we cannot pass those protections that we 
want.
  I know my Republican friends. They would never put up a bill, whether 
it costs $50 billion, as some say, $43 billion, as others say, $8 
billion, as others say, it does not matter, I know we would never put 
up a bill we intended to be law without trying to figure out how we are 
going to pay for it.

                              {time}  1630

  We are not going to raise taxes to pay for it. We are not going to 
dip into social security to pay for it. There is no excess in the 
Treasury, there is only excess of our FICA money. Maybe there will be 
next year, but this bill does not give us any assurances at all as to 
how it would be paid for.
  This is a bill that can be passed out of the House of 
Representatives, but it

[[Page H9467]]

is not intended to be the law of the land, at least not this go-round. 
Maybe at another time, another date, we can get that job done.
  So I have to oppose the bill simply on the basis that it is a poison 
pill.
  Mr. CRANE. Mr. Speaker, I yield the balance of my time to the 
gentleman from California (Mr. Thomas), the distinguished chairman of 
the Committee on Ways and Means.
  The SPEAKER pro tempore (Mr. Hastings of Washington). The gentleman 
from California (Mr. Thomas) is recognized for 2 minutes.
  (Mr. THOMAS asked and was given permission to revise and extend his 
remarks.)
  Mr. THOMAS. So, Mr. Speaker, it has come to this. If Members had a 
chance to actually look at the legislation and they had a chance to 
vote, let me ask the Members if they would be in favor of this: 
``Provide an above-the-line deduction for health insurance expenses if 
your employer does not pay for it.''
  That was in the tax bill that was sent to the President. The 
President vetoed it. We think it is important enough to bring it back. 
They said it had not been voted on. It has been voted on.
  ``Provide an above-the-line deduction for long-term care insurance.'' 
Would Members like to have that deduction? We want people to have it. 
We sent it to the President. He vetoed it.
  Accelerate, for those who are self-employed, the ability to write 
off, like corporations, their health insurance, so people who are self-
employed could have 100 percent coverage as well. It was in the tax 
bill that was sent to the President. The President vetoed it. We want 
people to have it. It is in this measure.
  ``Extend the availability of medical savings accounts.'' Young people 
who are not going to get sick maybe want to invest in their health, and 
if they do not spend the money at the end of the year, they can roll it 
over, but let them choose. That was in the bill that was sent to the 
President that he vetoed. We still think it is a good idea.
  How about if we want our long-term care insurance to be part of a 
cafeteria plan, if one has insurance? It was in the bill vetoed by the 
President. We think we should have it.
  How about if someone is taking care of someone in our homes right 
now, out of the goodness of their hearts and their kin relationship? 
Would they not like to have $1,000 deduction on the tax form? We 
believe we should have it on the tax form. We sent it to the President. 
He vetoed it. We think it is important enough to give it to the 
American people.
  That is what this access bill is all about. It is access in ways 
people can use. We voted on them, we sent them out of the House, we 
sent them to the President, and he vetoed it. The problem was, it was 
in a larger bill that contained a number of other items. Now, these are 
very specific access issues for people. We think they are important 
enough. They stand alone. The American people should get them. If we 
vote for this, they will.
  Mr. SANDLIN. Mr. Speaker, the Republicans are again playing games 
with the American people. They are telling the public what they want to 
hear, hoping no one will read beyond the title of their bill, the 
Quality of Care for the Uninsured Act.
  Well, Mr. Speaker, I read the bill and it doesn't provide access to 
health insurance to those who need it most. According to the General 
Accounting Office, nearly one-third of all uninsured Americans would 
not be helped by this bill. Why? Because they make so little income 
that they do not pay income taxes. How will the Republican tax breaks 
help these families? It will not help them one cent.
  Of the 44 million uninsured Americans, of whom 5 million live in the 
State of Texas, the people this bill aims to really help are the 
600,000 uninsured healthy families that make almost $100,000 per year 
and can afford the risk to opt out of the broader insurance pool. The 
effect of this would be to drive up costs for those most in need of 
coverage. In addition, the Ways and Means Committee has also determined 
that only 160,000 people of those 600,000 families would qualify for 
access to insurance under this bill. Yet we would be spending 48 
billion dollars on this phony access package. Even worse, the bill is 
not paid for within the budget or by offsets.
  Mr. Speaker, my Republican friends on the other side of the aisle 
continue to ignore budgetary reality in order to push through a 48 
billion dollar access bill, the funds for which will come directly from 
the Social Security trust fund. Like the supporters of this bill, I 
want to give more Americans a range of options for their health care--
they should have at least as many choices in their health care plan as 
Federal employees. However, this bill does not deliver on what its 
supporters are promising. The Republican access bill will benefit a 
small group of people and is simply intended to kill the Norwood-
Dingell managed care reform bill that so many of my colleagues on the 
other side of the aisle are trying to derail.
  Republicans have already spent over $25 billion over the Social 
Security surplus, but here they are again with a tax bill they can't 
pay for. I urge my colleagues not to raid Social Security. I urge them 
to vote against this fiscally irresponsible poison pill to the Norwood-
Dingell managed care reform bill.
  Mr. FRELINGHUYSEN. Mr. Speaker, more than 16 percent of the people of 
my home State of New Jersey don't have health insurance. The national 
figure is even more staggering--44 million uninsured in America, one in 
six Americans goes without health care coverage. Mr. Speaker, these 
numbers are a wake up call and today we are taking steps to respond to 
the needs of the uninsured.
  The Quality Care for the Uninsured Act (H.R. 2990) improves access, 
affordability and individual choice for the 44 million Americans who 
lack health care insurance.
  H.R. 2990 includes measures designed to ensure that the nation's 
health care system is accessible and affordable for all Americans.
  Highlights of the tax incentives found in H.R. 2990 are:
  100 percent deduction for health insurance premiums--for the second 
time this year, we will send the President a bill that allows each and 
every American to deduct every penny they pay for health insurance 
premiums--hopefully he won't veto it the second time, 100 percent 
deduction of health and long-term care insurance costs for self-
employed Americans, and 100 percent deduction for long-term care 
premiums for all Americans, relief for taxpayers caring for elderly 
family members at home, cafeteria benefit plans will now be permitted 
to include long-term insurance, expands medical savings accounts for 
more Americans to allow more of our families to save for emergency 
medical needs.
  Helping more Americans obtain health insurance is a top priority and 
this bill will do just that. I urge my colleagues to support H.R. 2990.
  Mr. HILL of Montana. Mr. Speaker, it is clear that a growing number 
of Americans are looking to Congress and their state legislatures to 
address their concerns facing our health care system.
  They are concerned of the number of uninsured working adults and 
their dependents. They are concerned about the rising costs of health 
care. They are concerned about the lack of choice in health plans. They 
are concerned that important decisions involving their health care are 
being made by government bureaucrats or insurance company adjusters 
rather than their physician.
  While we enjoy the highest quality health care in the world, our 
system of financing health care often frustrates patients, providers 
and employers. People are deeply concerned that their health plan may 
not deliver the care they need when they are sick.
  I believe that we need to promote the three A's in reforming the 
system--Accessibility, Affordability and Accountability.
  Mr. Speaker, today we will be taking up the first two important parts 
to ensuring patient protection--Accessibility and Affordability.
  The best patient protection of all is access to quality, affordable 
health care. Yet, there are more than 43 million Americans who are 
currently uninsured. Nineteen percent, or nearly one in every five 
Montanans are uninsured. More than 60 percent of the uninsured have one 
thing in common--they are either self-employed, or their family is 
employed by a small business that cannot afford to provide health 
benefits.
  H.R. 2990 promotes accessibility and affordability by requiring basic 
protections to ensure high-quality health care coverage. This 
legislation accomplishes this in three major ways.
  First, we accelerate the phase-in of the 100 percent deduction for 
the health insurance of self-employed individuals to become effective 
in 2001.
  Secondly, the bill establishes a process for certifying association 
health plan (AHPs). AHPs empower small business owners who currently 
cannot afford to offer health insurance to their employees, to access 
health insurance through trade and professional association.
  Third, this legislation expands medical savings accounts (MSAs) to 
increase access to health care services and patient control of health 
care expenditures.
  Through these three and many other provisions in H.R. 2990, today the 
House will pass a common-sense approach to providing affordable choices 
and reliable access to health care for consumers.
  Again, I urge all of my colleagues to support this bill.

[[Page H9468]]

  Mr. BARCIA. Mr. Speaker, I rise today in opposition to H.R. 2990. 
This bill, while ostensibly aimed at expanding access to healthcare for 
those who are currently uninsured, in reality fails to provide access 
to health insurance for those who need it most. The authors of this 
bill have been very creative in drafting this legislation. They tout 
Association Health Plans, Tax Deductions for the Self-Employed and 
Uninsured and expanding Medical Savings Accounts. And unlike some of my 
Democratic colleagues, I have supported versions of these proposals in 
the past. I have worked with small businesses and local chambers of 
commerce in Michigan to allow them to form Association Health Plans. I 
have supported tax deductions for the self-employed and allowing 
individuals open tax free savings accounts for the purpose of covering 
their medical expenses. However, I must oppose this bill because of the 
many clever exemptions included by the authors of this legislation that 
will ultimately undermine any hope of increasing access to healthcare 
or providing important patient protections for our constituents.
  Under this bill, Association Health Plans will be exempt from 
important consumer protection, insurance and benefit regulations. 
Consumers in 33 states that require mental health benefits could lose 
this protection. Women in 49 states could lose mammography screening. 
Children in 29 states that require well-child care could face new 
financial barriers. These new plans intended to increase access will 
actually open new barriers to much needed health care.
  In addition, H.R. 2990 spends $48 billion federal on tax breaks that 
do more to help the healthy and the wealthy than the uninsured. 
According to the General Accounting Office, nearly one third of all 
uninsured Americans are at the lowest end of the income bracket. New 
tax deductions or medical savings accounts will not help them to 
purchase health insurance. These hardworking families are completely 
ignored by this bill.
  This morning I received a postcard from the National Federation of 
Independent Business which I submit for the record. It stated:

       Dear Representative: On behalf of the 600,000 members of 
     the National Federation of Independent Business, I urge you 
     NOT to help the 44.3 million uninsured Americans by voting 
     for H.R. 2990.

  Now I realize this is probably not the argument the NFIB intended to 
make in an attempt to garner support for this bill, however, the 
statement does have merit.
  H.R. 2990 does not help the millions of Americans who are uninsured. 
It does not improve their access to healthcare. It does not provide 
important patient protections. Instead, it grants tax breaks to the 
healthiest and wealthiest. Instead, it divides the insurance market 
between the healthy and the sick, undermining state efforts designed to 
spread health risks broadly. Instead of improving access to health 
care, this bill ignores millions of Americans who cannot afford the 
high cost of health insurance.
  Mr. Speaker, I urge my colleagues to vote no on this bill.
       Dear Representative: On behalf of the 600,000 members of 
     the National Federation of Independent Business, I urge you 
     not to help the 44.3 million uninsured Americans by voting 
     for H.R. 2990, which will expand access to affordable health 
     care coverage for small businesses and their employees.
       Specifically, H.R. 2990 would lower health care costs for 
     small business while increasing their choices in the health 
     care marketplace. Here's how:
       Association Health Plans (AHPs) would give small business 
     the administrative cost savings, economies of scale, and 
     bargaining power now enjoyed by big business;
       Tax-Deductible Premiums for the Self-Employed and Uninsured 
     would offer tax equity to level the playing field between the 
     ``haves'' and ``have nots;
       Medical Savings Accounts (MSAs) would allow families to 
     exercise control over their individual health care dollars to 
     address their particular needs.
       Don't turn your back on the uninsured, the majority of 
     which (3 out of 5) are small business owners and their 
     employees. Increase their access to affordable health care 
     coverage. Vote for H.R. 2990! This will be an NFIB Key Small 
     Business Vote for the 106th Congress.
           Sincerely,
                                                       Dan Danner,
                            Vice President, Federal Public Policy.
  Mr. VENTO. Mr. Speaker, I rise today in opposition to H.R. 2990, the 
Quality Care of the Uninsured Act.
  While I am concerned by the burgeoning numbers of uninsured, I am not 
convinced that this legislative initiative will provide relief to those 
who most need health care coverage. I am also disappointed that the 
Republican leadership has used this important forum for debate on 
managed care reform to resuscitate discredited tax proposals that are 
not even offset. Last week, the Congressional Republicans promised once 
again not to use Social Security trust funds; this week, they are 
advancing H.R. 2990 with no offset. Last week, the Congressional 
Republicans promised once again not to use Social Security trust funds; 
this week, they are advancing H.R. 2990 with no offsets, and once again 
breaking their promise not to spend Social Security funds.
  Unfortunately, Medical Savings Accounts (MSAs) are predicated 
primarily on greater cost-sharing and reduced health care use by 
beneficiaries. While this may be feasible for the wealthy and healthy, 
it does not help the sick and poor, and could lead to adverse selection 
by health plans. Essentially, MSAs are just another tax break for those 
who need it least.
  While I have supported full tax deductibility for small business 
health insurance in the past, I question policies to promote further 
segmentation of health care consumers. Association Health Plans and 
HealthMarts would not only separate the healthy from the sick, but they 
would allow certain health plans to circumvent state regulation. It is 
ironic that H.R. 2990 would actually create a more expansive ERISA 
shield at a time when Congress is trying to close the current ERISA 
loophole.
  Mr. Speaker, while the individual market may offer healthy people 
affordable coverage, people with substantial health risks will be 
burdened with disproportionate costs or limited access under this 
proposal. Disguised by popular bromides such as access and choice, 
these proposals would only serve to create further disparities in 
health care utilization in our society.
  It is unfortunate that we continue to allow a slow erosion of health 
care coverage at the expense of some of our most vulnerable workers and 
their families. Congress should seek comprehensive and responsible 
measures to reduce the number of uninsured. However, H.R. 2990 will not 
accomplish that goal. I urge my colleagues to reject this legislation 
and work towards substantial managed care reform that does not include 
costly tax breaks which blatantly expend Social Security trust funds.
  Mr. STEARNS. Mr. Speaker, I am pleased to support H.R. 2990, the 
Quality Care for the Uninsured Act. The legislation promotes access to 
health coverage for the estimated 43 million Americans who are 
currently lacking health insurance.
  Approximately 85 percent of these individuals are employed and either 
opt to forego such coverage (healthy young individuals) or work for 
companies who cannot afford to provide such benefits to their 
employees.
  Most people who have health insurance are covered by a health 
insurance policy chosen for them by their employers. If they work for 
small companies/businesses that cannot afford to pay for health 
coverage, they often have no coverage at all. If they are fortunate 
enough to have employer provided coverage, the possibility remains that 
if they lose their jobs or decide to change jobs, this valued benefit 
can be lost. Individuals who are self-employed currently get a 60% tax 
credit for purchasing their own health insurance, unlike the major 
corporations who get a 100 percent credit for purchasing health 
coverage for their employees.
  Tax benefits should be moved out of the workplace and shifted over to 
the individual or family. Everyone--the self-employed as well as those 
who work for small firms--should get a tax credit to enable them to 
purchase coverage for themselves and their families. These credits 
should be larger for those whose medical expenses make up a greater 
share of their income. These credits should be refundable so that low-
income individuals and families should get assistance if they have no 
tax liability.

  Under current tax law, third-party insurance is subsidized and self-
insurance is penalized. Every dollar an employer pays for third-party 
insurance is excluded from employee income. When employee's try to save 
that money it is taxed.
  If we are to have true health care reform, we must provide 
individuals with the option of being allowed to create Medical Savings 
Accounts (MSAs). These Medical IRA would enable consumers to use tax-
free savings accounts to self-insure for routine, out-of-pocket medical 
expenses.
  By empowering consumers with choice and individual responsibility, a 
healthy competition among insurance companies to compete for the 
consumers' health care business would be generated.
  One of the proposals in H.R. 2990 to expand access to health coverage 
is through the establishment of HealthMarts which would shift the 
decision making power over to the individual or family. Everyone--the 
self-employed as well as those who work for small firms--should be 
allowed to purchase coverage for themselves and their families. The 
consumers would be given the ability to making their own choices. This 
gives consumers a sense of empowerment and a sense of responsibility 
which will encourage them to wisely use medical services.
  H.R. 2990 provides for the establishment of Association Health Plans 
(AHPs) to allow national trade and professional associations to

[[Page H9469]]

sponsor plans. This would also allow them to buy into plans and pool 
together for themselves and their employees.
  This bill also allows Community Health Organizations to form networks 
to give community health centers greater control of their resources and 
to provide comprehensive coverage to the people they assist.
  Community health centers offer a valuable service by providing 
primary health care in our rural and urban communities. I have toured 
these community health care centers and know full well the valuable 
services they provide and it is one of the most cost-effective programs 
in which our government invests to meet the growing demands of the 
uninsured and underinsured.
  I support this important bill that would provide those individuals, 
many of whom are the working poor, who do not currently have access to 
health care insurance an opportunity to purchase such care for 
themselves and their families.
  Ms. MILLENDER-McDONALD. Mr. Speaker, the nation continues to cry our 
for reform of the managed care system. However, I must rise in strong 
opposition to this bill and the rule that has brought this important 
issue to the floor. As legislators, we must stop playing games with 
healthcare. I have great respect for my colleague Mr. Talent, but I do 
not believe that H.R. 2990 provides the access to quality health care 
that our constituents really need.
  When we talk about access to health care, those that are most in need 
are children and those with limited means. This bill does nothing to 
provide access to those people. Instead it contains ``poison pill'' 
provisions in an effort to pander to campaign contributors. One-third 
of the currently uninsured will still not have access to health care. 
This bill spends federal dollars on tax breaks--when is the last time a 
tax break benefited the poor and low-income?
  I urge my colleagues to vote no against this special interest poison 
pill package disguised as an ``access'' bill to health care.
  Mr. WELDON of Florida. Mr. Speaker, I believe strongly that any 
discussion of improving the quality of care for those with health 
insurance must also include a discussion of ways to make health 
insurance more affordable. Earlier this week, the Census Bureau 
released the latest figures showing that nearly one million additional 
Americans were added to the ranks to the uninsured last year. We must 
take steps to ensure that these Americans have greater access to 
affordable health insurance.
  There is no doubt that the managed care reform legislation that we 
are considering today will result in higher insurance premiums for 
Americans. There is significant difference of opinion about how much 
those premiums will go up. Will it be one percent, three percent, or 
ten percent? Study after study has indicated that with every one 
percent increase in insurance premiums 300,000 additional Americans 
lose their insurance. That is why I believe it is so critical that 
these issues be considered together.
  H.R. 2990 will expand insurance options for uninsured Americans. I am 
particularly pleased that the bill provides a 100 percent deduction for 
health insurance premiums and long-term care premiums if the taxpayer 
pays more than 50 percent of the premiums. This is long overdue. For 
too long, Americans who pay for their health insurance out of their own 
pockets have not had the same opportunity to deduct these expenses as 
do large corporations. This bill fixes that problem.
  I am also pleased that the bill provides families with an additional 
exemption ($2,750) if they care for an elderly family member in their 
home. This is important in helping families who have made a decision to 
care for an elderly family member in their own home, rather than 
placing them in an expensive long-term care facility.
  Association Health Plans (AHPs), which are encouraged in this bill, 
will play a critical role in helping those who work for small 
businesses have access to affordable insurance. This is the largest 
segment of uninsured Americans. AHPs enable small employers to pool 
together to obtain the economies of scale, purchasing clout, and 
administrative efficiencies enjoyed by employees of larger firms.
  H.R. 2990 expands Medical Savings Accounts (MSAs) to increase access 
to health care services and patient control of health care 
expenditures. It (1) allows both employers and employees to make 
contributions to MSAs: (2) makes MSAs a permanent health care choice 
under the law; (3) eliminates the cap on the number of taxpayers 
(currently 750,000) that may benefit annually from MSA contributions; 
(4) reduces the minimum deducitble to $1,000 for individual coverage 
and $2,000 for families; and (5) allows MSA contributions equal to 100 
percent of the deductible;
  The bill also allows for the creation of HealthMarts, which are 
private, voluntary, and competitive health insurance ``supermarkets'' 
that transfer choice within the current employer-based health insurance 
market from small employers to their employees and dependents. 
HealthMarts are similar to the Federal Employee Health Benefits Plan 
(FEHBP) which gives federal employees greater choice among a host of 
different plans. They will be established and run by private sector 
partnerships consisting of providers, consumers, small employers, and 
insurers.
  Finally, the bill permits Community Health Organizations (CHOs) to 
offer health insurance coverage in a state in which they are not 
licensed under certain conditions. This change is designed to make it 
easier for providers to form health care networks to meet needs in 
medically under served areas.
  Again, I believe that this bill, combined with patient protection 
legislation will play an important role in improving the quality of 
health care and giving Americans greater access to affordable insurance 
plans.
  Mr. HAYES. Mr. Speaker, over the August recess, I had the opportunity 
to meet with a number of health care providers in my district, the 8th 
district of North Carolina. Without exception, these care givers share 
a common concern. Hospitals and clinics in rural America appear to 
shoulder a disproportionate share of the spending reductions agreed to 
in the Balanced Budget Agreement of 1997. Now why do I bring up this 
subject today. Because our hospitals are currently providing health 
care for the more than 43 million uninsured Americans and have to 
absorb the cost.
  Hospitals and clinics are faced with the untenable position of having 
to scale back services or closing their doors altogether. In fact, many 
of our providers have trimmed services to such an extent that in the 
near future they may be forced to turn away critically ill patients. As 
you can imagine, further cuts in Medicare spending expected for next 
fiscal year will only exacerbate the current problem, leaving our 
hospital administrators braced for the worst, but financially unable to 
respond to needs.
  If we do not address the desperate situation in which our health care 
providers find themselves, my constituents, both individuals and 
businesses, will not have any choice when it comes to health care--
hospitals, doctors, nursing homes. I am hearing from hospital and 
nursing homes that they will be closing their doors within the next 
year if immediate relief for these budget cuts are not addressed.
  Elements of all three health care bills that are being debated later 
today will become obsolete if our hospitals and clinics begin to close, 
including: Rural Americans diminished access to health care because 
they will have to drive too many miles to see a primary care physician; 
emergency care that will be so far away that patients could die before 
ever reaching a hospital; and less access to local pediatricians, 
obstetricians, and specialists.
  Bottom line the health care services will be unavailable. I support 
the intentions of the underlying health care bills, but at what cost? I 
cannot pass along these costs to the consumer.
  Let's pass H.R. 2990--Quality Care for the Uninsured to give small 
businesses, individuals and early retirees the access to affordable 
health care. But, let's please be careful how we pass along the cost to 
consumers. Let's allow patients to speak freely with their doctors. 
Let's be sure there is accountability. Let's provide choice in primary 
care physicians and specialists, and give employers the opportunity to 
provide affordable benefits to their employees. But, if we pass costly 
new mandates--won't we be passing along the cost to the consumer that 
we are trying to help with H.R. 2990?
  I would also like to urge the Speaker--Let's address Medicare reform 
this year--so that both of these bills do not become null and void in 
Rural America.
  Mr. RYAN of Wisconsin. Mr. Speaker, I am here today to speak in favor 
of the Quality Care for the Uninsured Act.
  You are going to hear a lot of discussion later today about 
protecting individuals who are enrolled in health plans in this 
country; but we have a much bigger problem in this country. A problem 
that this act provides solution for--the problem of the uninsured.
  It is important to make sure individuals who have health care are 
receiving quality care, but it even more important to find a solution 
for the growing number of uninsured. The Census Bureau reported that 
currently 44 million people in this country do not have health 
insurance--that number has been steadily rising during this 
administration. We must find a way to provide a better system for 
them--a system that makes health care affordable and accessible.
  This bill does that with healthmarts, medical savings accounts, tax 
deductions for the self-employed and the uninsured, tax deductions for 
long-term care premiums, and association health plans. These provisions 
will help small businesses find a way to offer health insurance for 
their employees.

[[Page H9470]]

  I believe everyone in this country deserves quality, affordable 
health care. This bill provides that through tax incentives and market 
reform. I urge my colleagues to join me in voting in favor of the 
Quality Care for the Uninsured Act.
  Mr. BALLENGER. Mr. Speaker, I rise today in strong support of H.R. 
2990, an important and timely bill designed to help the 44.3 million 
Americans who have no health insurance whatsoever. These Americans will 
find little comfort from our debate later today and tomorrow over 
improvements to managed care plans. H.R. 2990 offers something for 
them--that is, accessible, affordable and accountable health insurance 
coverage.
  This week, Congress and the American people learned from a Census 
Bureau report that the ranks of the uninsured has swelled by another 
one million. I support the efforts of the Republican leadership to give 
these uninsured Americans more choice in the health insurance market 
instead of expanding big government plans which President Clinton has 
embraced.
  To this end, H.R. 2990 contains important changes in the tax code 
which we have championed in earlier tax relief packages, including 
expanding Medical Savings Accounts (MSAs). We have worked for years to 
convince President Clinton that expanded eligibility for MSAs is one 
solution to the problem of the uninsured. The facts are in: 42 percent 
of individuals purchasing MSAs this year were previously uninsured. In 
addition to the creation of association health plans and 
``HealthMarts,'' H.R. 2990 also accelerates to 2001 the phase-in of the 
100 percent deduction for the health insurance of the self-employed 
Americans. Last month, the President rejected an immediate 100 percent 
deduction of these costs when he vetoed the Taxpayer Refund and Relief 
Act of 1999.
  I believe we need to add common sense and tax relief to the health 
care access debate. H.R. 2990 does just that, and I urge my colleagues 
to vote for it.
  Mr. STARK. Mr. Speaker, this is a very tough week for the House 
Republican leadership. In an attempt to get the spotlight off of 
bipartisan attempts to curb the power of big managed care companies, 
the Republican leadership is finally willing to talk about helping the 
uninsured get access to health care. Unfortunately, while their 
proposals are expensive, their talk is cheap.
  In a very cynical attempt change to the topic from managed care 
reform, we will see Republicans on the floor today in the House of 
Representatives claiming to be trying to expand health insurance to the 
uninsured. Don't be fooled. Their proposal will not help the population 
the most likely to lack health insurance and it isn't financed at all. 
It would cost the federal government more than $48 billion over ten 
years without solving the very problem it proclaims to address.
  A record 44.3 million uninsured Americans live in our country today, 
hoping and praying they do not get sick or injure themselves. More than 
32 million of these families have income at or below the 15% income tax 
bracket. These are people who cannot afford to pay insurance premiums--
working families of modest means, people between jobs, students, 
unskilled workers who do not have the luxury of demanding employer 
coverage--or have a ``pre-existing condition'' that makes them persona 
non grata in the individual insurance market. The ``access'' provisions 
that the Republicans offer do little to nothing to help these people 
without insurance. Instead, they provide tax breaks to the wealthy and 
the healthy through a variety of tax changes that don't reach the 
uninsured.
  For example, one of their so-called access provisions would expand a 
demonstration project on medical savings accounts (MSAs) so that all 
employers could offer them. Generally, demonstration projects have to 
``demonstrate'' some success to be expanded but, in this case, the big 
insurance companies that offer MSAs have much more political clout with 
the GOP than the millions of uninsured. Instead of admitting that MSAs 
have failed, the Republicans are throwing more money into them. With 
bigger tax breaks, more healthy and wealthy people will use them, but 
that doesn't do anything for people too poor to afford insurance or 
benefit from MSAs.
  Another provision would expand the deductibility of health insurance 
that employers and the self-employed receive to people who purchase 
their own insurance. It would not provide people with up front funds to 
help them purchase health insurance. Again, since more than 32 million 
uninsured families are at the 15% or 0% income tax bracket, this 
provision does nothing to make insurance affordable to them.
  The Republicans also do nothing to address the inequities of the 
individual insurance market. Anyone with a pre-existing condition, 
anyone who is older, anyone with a genetic history of potential health 
problems will continue to find it impossible to purchase affordable 
insurance.
  There are also other Republican provisions that would preempt state 
regulation of insurance in favor of new federal regulations. These so-
called Association Health Plans and HealthMarts would undermine 
successful state-based small group market and individual insurance 
reforms. They are less comprehensive health insurance policies that 
would escape state consumer protections. The Republican proposal would 
let these plans ``cherry-pick'' the healthy, low-cost patients and 
result in higher health insurance premiums for people in traditional 
state-regulated insurance.
  If the Republicans were serious about providing access to the 
uninsured, there are a number of affordable, sensible solutions which 
they could be raising on the floor today, but aren't. Those provisions 
include items such as:
  Passing the Medicare Early Access Act. Introduced again this Congress 
as H.R. 2228, this bill would allow all people aged 62-64 to buy into 
Medicare program, people aged 55-64 who have lost their job to buy into 
Medicare, and would allow people whose employers' renege on retiree 
health coverage the option of staying in COBRA until they are Medicare-
eligible. This bill has only a small cost that can be fully covered by 
a number of small Medicare fraud and abuse revisions. Yet, we have seen 
no action on this legislation that would provide a new, affordable 
option for health insurance coverage for early retirees--the people who 
are the hardest to insure in the private marketplace and a significant 
growing portion of the uninsured.
  Enacting provisions to protect children whose parents are leaving the 
welfare rolls for low-income jobs so that they aren't inappropriately 
dumped out of Medicaid and left without health insurance. The number of 
people with Medicaid coverage in 1998 was the lowest it's been since 
1991, according to the Bureau's historical tables on insurance 
coverage.
  Improving the State Children's Health Insurance Program. This program 
was passed by Congress with great fanfare in 1997 as a means of 
extending health insurance to half of the then 10 million uninsured 
children. According to new census data, we now have 11 million 
uninsured children after that program has been in existence two years. 
Clearly, it isn't working as intended. Serious attention should be 
focused on making this program work or finding a new solution for 
covering these 11 million children. It's not rocket science to figure 
out who are low-income children. The Internal Revenue Service could run 
a match or we could utilize data from the free and reduced price school 
lunch program to presumptively enroll children.
  Passing H.R. 1180, the Work Incentives Improvement Act to allow the 
more than 8 million people receiving disability benefits return to work 
without fear of losing their health insurance. This bill has already 
unanimously passed the Senate and the Commerce Committee, but it has 
been stalled from reaching the House floor.
  These are real, concrete steps that would help the uninsured, but 
they are not part of the Republican bill. Instead, all of these 
Republican leadership provisions benefit the well-heeled rather than 
the uninsured. Essentially the Republican leadership has taken a tax 
break package for the wealthy and disguised it as a health access bill. 
But the Wolf's teeth show through the sheep's clothing when one looks 
at how the bill is financed. Instead of finding off-sets and living 
within tradition pay-go rules, the Republican leaders decided to tap 
the surplus needed to shore up Social Security and Medicare and pay 
down the debt.
  Not only are the Republican leaders not proposing a plan to help 
those who cannot afford health insurance, by using the surplus, they 
are putting the future of Social Security and Medicare in jeopardy and 
increasing the amount of debt we leave to future generations.
  H.R. 2990 is a poison pill to managed care reform and I urge my 
colleagues to join me in opposing this legislation.
  As further evidence of this point, I submit new data that we have 
received from the Joint Tax Committee.
  As you will see, the Joint Tax Committee has estimated how many 
people the Talent Access bill would help.
  The answer: Almost no one. The tax deduction for individuals paying 
for more than 50% of the cost of the health insurance will cost $31.2 
billion over 10 years and result in 200,000 uninsured people getting 
insurance. That's $156,000 per new insured person--$15,600 per year.
  The acceleration of the 100% tax deduction for the self-employed will 
help 120,000 previously uninsured and cost about $3 billion over 4 
years. That's $6,250 per person per year--a cadillac cost for sure.

                                  Joint Committee on Taxation,

                                  Washington, DC, October 6, 1999.
     Hon. Edward M. Kennedy,
     U.S. Senate, Washington, DC.
       Dear Senator Kennedy: This is in response to your letter of 
     October 4, 1999, requesting revenue estimates and other 
     information concerning several of the health care

[[Page H9471]]

     tax provisions in the conference agreement on H.R. 2488 and 
     two of the health care tax provisions in S. 1344.
       The conference agreement on H.R. 2488 contains an above-
     the-line deduction for health insurance expenses and long-
     term care insurance expenses for which the taxpayer pays at 
     least 50 percent of the premium. The deduction would be 
     phased in at 25 percent for taxable years beginning in 2002 
     through 2004, 35 percent for taxable years beginning in 2005, 
     65 percent for taxable years beginning in 2006, and 100 
     percent for taxable years beginning in 2007 and thereafter. 
     Taxpayers enrolled in Medicare, Medicaid, Champus, VA, the 
     Indian Health Service, the Children's Health Insurance 
     Program, and the Federal Employees Health Benefits Program 
     would be ineligible for the deduction for health insurance 
     expenses.
       The conference agreement on H.R. 2488 also contains a 
     provision that would allow long-term care insurance to be 
     offered as part of cafeteria plans, effective for taxable 
     years beginning after December 31, 2001.
       For the purpose of preparing revenue estimates for these 
     provisions in H.R. 2488, we have assumed that the provisions 
     will be enacted during calendar year 1999. Estimates of 
     changes in Federal fiscal year budget receipts are shown in 
     the enclosed table.
       We estimate that in calendar year 2002 about 9.1 million 
     taxpayers would claim the 25-percent deduction for health 
     insurance expenses. About 100,000 of these 9 million 
     taxpayers would be new purchasers of health insurance. 
     Assuming an average of two persons covered by each policy, 
     about 200,000 persons would be newly insured as a result of 
     the 25-percent deduction for health insurance expenses.
       We estimate that in calendar year 2002 about 4.7 million 
     taxpayers would claim the 25-percent deduction for long-term 
     care insurance expenses, and an additional 300,000 taxpayers 
     would use cafeteria plans to pay their share of premiums for 
     employer-sponsored long-term care insurance. About 80,000 of 
     these 5 million taxpayers would be new purchasers of long-
     term care insurance.
       S. 1344 contains a provision that would increase the 
     deduction for health insurance expenses of self-employed 
     individuals. Under present law, when certain requirements are 
     satisfied, self-employed individuals are permitted to deduct 
     60 percent of their expenditures on health insurance and 
     long-term care insurance. The deduction is scheduled to 
     increase to 70 percent of such expenses for taxable years 
     beginning in 2002 and 100 percent in all taxable years 
     beginning thereafter. S. 1344 would increase the rate of 
     deduction to 100 percent of health insurance and long-term 
     care insurance expenses for taxable years beginning after 
     December 31, 1999.
       S. 1344 also contains provisions that would eliminate 
     certain restrictions on the availability of medical savings 
     accounts, remove the limitation on the number of taxpayers 
     that are permitted to have medical savings accounts, reduce 
     the minimum annual deductibles for high-deductible health 
     plans to $1,000 for plans providing single coverage and 
     $2,000 for plans providing family coverage, increase the 
     medical savings account contribution limit to 100 percent of 
     the annual deductible for the associated high-deductible 
     health plan, limit the additional tax on distributions not 
     used for qualified medical expenses, and allow network-based 
     manage care plans to be high-deductible plans. These 
     provisions would be effective for taxable years beginning 
     after December 31, 1999.
       For the purpose of preparing revenue estimates for these 
     provisions in S. 1344, we have assumed that the provisions 
     will be enacted during calendar year 1999. Estimates of 
     changes in Federal fiscal year budget receipts are shown in 
     the enclosed table.
       We estimate that in calendar year 2000, about 3.3 million 
     taxpayers would claim the 100-percent deduction for health 
     insurance expenses of self-employed individuals. About 60,000 
     of these taxpayers would be new purchasers of health 
     insurance. Assuming an average of two persons covered by each 
     policy, about 120,000 persons would be newly insured as a 
     result of the 100-percent deduction for health insurance 
     expenses.
       We do not have an estimate of the numbers of individuals 
     who would be newly insured as a result of the medical savings 
     account provisions of S. 1344.
       I hope this information is helpful to you. If we can be of 
     further assistance, please let me know.
           Sincerely,
                                                   Lindy L. Paull.
       Enclosure: Table #99-3 206

                                                             ESTIMATED REVENUE EFFECTS OF VARIOUS PROVISIONS RELATING TO HEALTH CARE
                                                                            [By fiscal years, in millions of dollars]
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
              Provision                          Effective              2000      2001      2002      2003      2004      2005      2006      2007       2008       2009     2000-04    2000-08
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Health care provisions in the
 conference agreement for H.R. 2488:
    1. Provide an above-the-line       tyba 12/31/01................        --        --      -444    -1,379    -1,477    -1,803    -3,137    -5,878     -8,299     -8,848     -3,300    -31,264
     deduction for health insurance
     expenses--25% in 2002 through
     2004, 95% in 2005, 65% in 2006,
     and 100% thereafter.
    2. Provide an above-the-line       tyba 12/31/01................        --        --       -48      -328      -964      -417      -677    -1,315     -2,027     -2,146       -741     -7,324
     deduction for long-term care
     insurance expenses--25% in 2002
     through 2004, 35% in 2006, 65%
     in 2006, and 100% thereafter.
    3. Allow long-term care insurance  tyba 12/31/01................        --        --      -104      -151      -171      -190      -202      -204       -215       -247       -426     -1,484
     to be offered as part of
     cafeteria plans; limited to
     amount of deductible premiums
     [1].
                                                                     ---------------------------------------------------------------------------------------------------------------------------
      Total of health care provisions  .............................        --        --      -596    -1,858    -2,012    -2,410    -4,016    -7,397    -10,541    -11,241     -4,467    -60,074
       in the conference agreement
       for H.R. 2488.
                                                                     ===========================================================================================================================
Health care provisions in S. 1344, as
 passed by the Senate:
    1. Immediate 100% deductibility    tyba 12/31/99................      -245    -1,007    -1,040      -657  ........  ........  ........  ........  .........  .........     -2,949     -2,844
     of health insurance and long
     term care insurance premiums of
     the self-employed.
    2. Liberalization of conditions    tyba 12/31/99................       -93      -281      -326      -370      -414      -458      -502      -546       -590       -634     -1,483     -4,214
     for enrolling in MSAs.
                                                                     ---------------------------------------------------------------------------------------------------------------------------
      Total of health care provisions  .............................      -338    -1,268    -1,866    -1,027      -414      -458      -502      -546       -590       -634     -4,432    -7,164
       in S. 1344, as passed by the
       Senate.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Note.--Details may not add to totals due to rounding.
Legend for ``Effective'' column: tyba=taxable years beginning after [1] Estimate assumes concurrent enactment of the above-the-line deducation for long-term care Insurance (item 2.)
Source: Joint Committee on Taxation.

  The SPEAKER pro tempore. All time for debate has expired.
  Pursuant to House Resolution 323, the bill is considered read for 
amendment, and the previous question is ordered.
  The question is on the engrossment and third reading of the bill.
  The bill was ordered to be engrossed and read a third time, and was 
read the third time.


                Motion to Recommit Offered by Mr. Rangel

  Mr. RANGEL. Mr. Speaker, I offer a motion to recommit.
  The SPEAKER pro tempore. Is the gentleman opposed to the bill?
  Mr. RANGEL. I am, Mr. Speaker, in its present form.
  The SPEAKER pro tempore. The Clerk will report the motion to 
recommit.
  The Clerk read as follows:

       Mr. Rangel moves to recommit the bill, H.R. 2990, to the 
     Committee on Ways and Means with instructions to report the 
     same promptly back to the House with an amendment in the 
     nature of a substitute that--makes the bill consistent with 
     the President's demand to preserve the projected surpluses 
     until there is action on Medicare and Social Security 
     solvency.


                         Parliamentary inquiry

  Mr. ARCHER. Parliamentary inquiry, Mr. Speaker.
  The SPEAKER pro tempore. The gentleman will state his parliamentary 
inquiry.
  Mr. ARCHER. I have just listened to the motion to recommit. I have a 
copy of it in writing before me. I am curious as to what is the 
amendment that will make the bill consistent with the President's 
demand.
  This says to report the bill back with an amendment that will make it 
consistent with the President's demand. I am curious as to what the 
terminology and the wording of that amendment would be.
  The SPEAKER pro tempore. These are general instructions from the 
gentleman from New York contained in the motion to recommit, so they 
are general instructions and not instructions to report ``forthwith'', 
which could be taken up in the Committee on Ways and Means if the 
motion to recommit is successful.
  The gentleman from New York (Mr. Rangel) is recognized for 5 minutes 
in support of his motion to recommit.
  Mr. RANGEL. Mr. Speaker, I understand the problem that my chairman 
has in not understanding any amendment that preserves the projected 
surpluses in social security and Medicare. But this is what the 
President has been

[[Page H9472]]

 saying all along, that we can present bills that are paid for, we can 
reduce benefits and other things, but the bill has to be amended, 
amended, amended, amended, paid for, paid for, paid for, paid for; not 
bust the social security trust fund, not bust the Medicare trust fund. 
That is all the amendment means.
  I think we have had enough of partisanship for today. I think it is 
abundantly clear that the American people want a decent patients' 
rights bill. That is what they want. That is what Republicans want. 
That is what Democrats want. We cannot be effective as a body if we 
truly believe there is a Republican right way to do it or a Democratic 
right way to do it.
  The only way we can do it is putting the party labels behind us and 
sitting down like the gentleman from Georgia (Mr. Norwood) has and the 
gentleman from Michigan (Mr. Dingell) has to put together a bill that 
is not good for our parties, not good for our elections, but good for 
those people who need solid health care.
  That is what we are trying to do. That is why we have a motion to 
recommit, not to get rid of the bill, but to make certain that we pay 
for whatever we attach to what is a good bill.
  We do not know where Members got the access to health care to tax 
bills, but obviously if there is a little Republican bag of tricks, 
then come up with some money to pay for these things. That is all we 
are suggesting.
  It is just not fair to the American people to see that they have lost 
the support of their own party on a bill that is good for the American 
people, and instead of just taking it and working with it and seeing 
where the next struggle would be for bipartisanship, they had to come 
up with something that not even the Members of the tax-writing 
committees have seen.
  What they have done is to try to poison a good bill. It is not the 
right thing to do, it is not the fair thing to do, and it should not 
make Members proud, as Republicans, that they can kill a bill. They 
have the majority. The real question is, do Members have the 
determination to work with us so that we can work our will in providing 
the right thing for the American people?
  When people talk about a Patients' Bill of Rights, they are not 
talking about a tax bill, they are talking about something that we have 
created together with Republicans and Democrats working together. So I 
do not know why that side would object to the motion to recommit. It 
gives them the opportunity to be responsible. It gives them the 
opportunity to review the access to health care through using the tax 
system.
  If Members really believe we should use the tax structure, that is, 
no longer pull it up by the roots, no longer reduce it to the size of a 
postcard, but put another 30, 40, 50 pages there, which certainly the 
IRS would say that we would need in order to carry out the bill that 
Members just pulled up.
  If Members really want to use the tax code for that purpose, I do not 
think there would be serious objection on the Democratic side, and not 
by the President of the United States. But they have to pay for it. 
This message has been sent out so often that I think the American 
people understand it a lot better than some of my colleagues on the 
other side.
  All it says here is that the bill be recommitted to the Committee on 
Ways and Means. That means that we have to meet as a committee. I know 
that is difficult, but, Members know, no caucus, but Democrats and 
Republicans come together and report the same bill out promptly, which 
means all we have to do is to find ways to pay for this bill. Then we 
report it back to the floor. Then we can get on with the Patients' Bill 
of Rights.
  If Members have no concern about what happens to social security and 
no concern about what happens to Medicare, then they can say, let us 
deal with the projected surplus. They can even say, let us do it with 
smoke and mirrors, whatever makes them feel comfortable.
  But the whole thing is, let us not bring a bill to this floor and 
pass it because they have the numbers, only to have the President of 
the United States veto it. Do not send a bill like this over to the 
Senate, only to have them pile on whatever they wish to do in terms of 
loopholes for large corporations and probably donors to their party.
  In other words, it is not Christmas in September. It is time for us 
to come together as Members of Congress, cut out the partisanship, and 
work together as a team.
  The SPEAKER pro tempore. Is the gentleman from Texas (Mr. Archer) 
opposed to the motion to recommit?
  Mr. ARCHER. Mr. Speaker, I am opposed to the motion to recommit.
  The SPEAKER pro tempore. The gentleman from Texas is recognized for 5 
minutes.
  Mr. ARCHER. Mr. Speaker, I listened to the gentleman from New York, 
and I heard the rhetoric that we are invading the social security trust 
fund, that we are undermining Medicare. He knows that is not true. 
There is nothing in this bill that in any way invades the social 
security trust fund, and it is so certified by the Congressional Budget 
Office. I do not know why we have to listen to that kind of rhetoric, 
but, of course, we do.
  He says we have to save social security first. I agree with that. I 
have pushed for a plan to save social security, but I have not seen any 
specific plan come from the other side. We have been told recently in 
the media that the Chief of Staff in the White House has said that 
social security is not a priority anymore this year.
  Are we then faced with a standard which says, you have to save social 
security before you can give tax relief, and then on the other hand, 
but we will not let you save social security, in effect, just simply 
saying, we do not want tax relief?
  Why is this position being taken? Frankly, I do not know, because in 
1997 we had a tax bill that was passed when social security was in 
worse shape and we had no surpluses, and they voted for it. They made a 
big point of all of the relief that they had given to the American 
people. But today they want to stop children from being able to have 
access to vaccines, a new vaccine that can be an across-the-board 
preventer of many, many childhood diseases. Sixty-four million children 
will be denied access to that vaccine. He calls it, or my friend, the 
gentleman from New York (Mr. Rangel), calls it a poison pill. Who is 
poisoned is the children who will not be able to get a vaccination.
  What really this is all about, Mr. Speaker, I believe, sadly, is some 
type of political ploy to get to some end position on the part of the 
Democrats that might give them an advantage in the elections next year. 
I cannot imagine what it is, but clearly that must be what they feel.
  When the President vetoed our tax bill, he said it was too big. It 
was irresponsible, risky, too big. But we could have a $300 billion tax 
bill. Now we have tax relief for health care that will give more access 
to more people to health care, and it is $48 billion, and it still is 
not going to be accepted by the other side.
  I do not know what is happening. Perhaps it is really that the 
Democrats want to fight ferociously to keep this money in Washington 
because they know better how to spend it than the people do in taking 
care of their own health needs. Perhaps; I do not know. I have wondered 
about this effort to try to tie something that has no relationship to 
social security and Medicare into the social security-Medicare mix.
  But I do know that if this bill does not pass, we will have millions 
of Americans who will not have access to health insurance who would 
otherwise have it. We will have thousands and thousands of Americans 
who will not get tax relief for taking care of their elderly in their 
own homes.

                              {time}  1645

  We will have, again, millions of Americans who will not have access 
to long-term care insurance because they will not be given this tax 
deduction, and we will have a continuation of the inequitable and 
unfair treatment taxwise of different ways to provide health care; that 
big corporations get the deduction, the self-employed do not, and the 
individuals who have to buy their own insurance do not get it. That is 
wrong, Mr. Speaker. We cure that.
  Mr. THOMAS. Mr. Speaker, will the gentleman yield?
  Mr. ARCHER. I yield to the gentleman from California.
  Mr. THOMAS. Mr. Speaker, I understood that there would be a denial of 
a vaccine if this measure is voted down.

[[Page H9473]]

  Mr. ARCHER. That is correct.
  Mr. THOMAS. That vaccine is for America's children?
  Mr. ARCHER. Mr. Speaker, 64 million American children would have 
access to a new vaccine that will come on the market in November. But 
if this bill does not pass, it will not be put on the market.
  Mr. THOMAS. So on one hand, it is rhetoric about corporations; and on 
the other hand, it is vaccine for the America's children.
  Mr. ARCHER. Mr. Speaker, this motion is ill-conceived. It is vague. 
It should be opposed. I urge all of my colleagues to vote no on the 
motion to recommit.
  The SPEAKER pro tempore (Mr. Hastings of Washington). Without 
objection, the previous question is ordered on the motion to recommit.
  There was no objection.
  The SPEAKER pro tempore. The question is on the motion to recommit.
  The question was taken; and the Speaker pro tempore announced that 
the noes appeared to have it.


                             Recorded Vote

  Mr. RANGEL. Mr. Speaker, I demand a recorded vote.
  A recorded vote was ordered.
  The vote was taken by electronic device, and there were--ayes 211, 
noes 220, not voting 2, as follows:

                             [Roll No. 484]

                               AYES--211

     Abercrombie
     Ackerman
     Allen
     Andrews
     Baird
     Baldacci
     Baldwin
     Barcia
     Barrett (WI)
     Becerra
     Bentsen
     Berkley
     Berman
     Berry
     Bishop
     Blagojevich
     Blumenauer
     Bonior
     Borski
     Boswell
     Boucher
     Boyd
     Brady (PA)
     Brown (FL)
     Brown (OH)
     Capps
     Capuano
     Cardin
     Carson
     Clay
     Clayton
     Clement
     Clyburn
     Condit
     Conyers
     Costello
     Coyne
     Cramer
     Crowley
     Cummings
     Danner
     Davis (FL)
     Davis (IL)
     DeFazio
     DeGette
     Delahunt
     DeLauro
     Deutsch
     Dicks
     Dingell
     Dixon
     Doggett
     Dooley
     Doyle
     Edwards
     Engel
     Eshoo
     Etheridge
     Evans
     Farr
     Fattah
     Filner
     Forbes
     Ford
     Frank (MA)
     Frost
     Gejdenson
     Gephardt
     Gonzalez
     Goode
     Gordon
     Green (TX)
     Gutierrez
     Hall (OH)
     Hall (TX)
     Hastings (FL)
     Hill (IN)
     Hilliard
     Hinchey
     Hinojosa
     Hoeffel
     Holden
     Holt
     Hooley
     Hoyer
     Inslee
     Jackson (IL)
     Jackson-Lee (TX)
     Jefferson
     John
     Johnson, E. B.
     Jones (OH)
     Kanjorski
     Kaptur
     Kennedy
     Kildee
     Kilpatrick
     Kind (WI)
     Kleczka
     Klink
     Kucinich
     LaFalce
     Lampson
     Lantos
     Larson
     Lee
     Levin
     Lewis (GA)
     Lipinski
     Lofgren
     Lowey
     Lucas (KY)
     Luther
     Maloney (CT)
     Maloney (NY)
     Markey
     Martinez
     Mascara
     Matsui
     McCarthy (MO)
     McCarthy (NY)
     McDermott
     McGovern
     McIntyre
     McNulty
     Meehan
     Meek (FL)
     Meeks (NY)
     Menendez
     Millender-McDonald
     Miller, George
     Minge
     Mink
     Moakley
     Mollohan
     Moore
     Moran (VA)
     Murtha
     Nadler
     Napolitano
     Neal
     Oberstar
     Obey
     Olver
     Ortiz
     Owens
     Pallone
     Pascrell
     Pastor
     Payne
     Pelosi
     Peterson (MN)
     Phelps
     Pickett
     Pomeroy
     Price (NC)
     Rahall
     Rangel
     Reyes
     Rivers
     Rodriguez
     Roemer
     Rothman
     Roybal-Allard
     Rush
     Sabo
     Sanchez
     Sanders
     Sandlin
     Sawyer
     Schakowsky
     Scott
     Serrano
     Sherman
     Shows
     Sisisky
     Skelton
     Slaughter
     Smith (WA)
     Snyder
     Spratt
     Stabenow
     Stark
     Stenholm
     Strickland
     Stupak
     Tanner
     Tauscher
     Taylor (MS)
     Thompson (CA)
     Thompson (MS)
     Thurman
     Tierney
     Towns
     Traficant
     Turner
     Udall (CO)
     Udall (NM)
     Velazquez
     Vento
     Visclosky
     Waters
     Watt (NC)
     Waxman
     Weiner
     Wexler
     Weygand
     Wise
     Woolsey
     Wu
     Wynn

                               NOES--220

     Aderholt
     Archer
     Armey
     Bachus
     Baker
     Ballenger
     Barr
     Barrett (NE)
     Bartlett
     Barton
     Bass
     Bateman
     Bereuter
     Biggert
     Bilbray
     Bilirakis
     Bliley
     Blunt
     Boehlert
     Boehner
     Bonilla
     Bono
     Brady (TX)
     Bryant
     Burr
     Burton
     Buyer
     Callahan
     Calvert
     Camp
     Campbell
     Canady
     Cannon
     Castle
     Chabot
     Chambliss
     Chenoweth-Hage
     Coble
     Coburn
     Collins
     Combest
     Cook
     Cooksey
     Cox
     Crane
     Cubin
     Cunningham
     Davis (VA)
     Deal
     DeLay
     DeMint
     Diaz-Balart
     Dickey
     Doolittle
     Dreier
     Duncan
     Dunn
     Ehlers
     Ehrlich
     Emerson
     English
     Everett
     Ewing
     Fletcher
     Foley
     Fossella
     Fowler
     Franks (NJ)
     Frelinghuysen
     Gallegly
     Ganske
     Gekas
     Gibbons
     Gilchrest
     Gillmor
     Gilman
     Goodlatte
     Goodling
     Goss
     Graham
     Granger
     Green (WI)
     Greenwood
     Gutknecht
     Hansen
     Hastings (WA)
     Hayes
     Hayworth
     Hefley
     Herger
     Hill (MT)
     Hilleary
     Hobson
     Hoekstra
     Horn
     Hostettler
     Houghton
     Hulshof
     Hunter
     Hutchinson
     Hyde
     Isakson
     Istook
     Jenkins
     Johnson (CT)
     Johnson, Sam
     Jones (NC)
     Kasich
     Kelly
     King (NY)
     Kingston
     Knollenberg
     Kolbe
     Kuykendall
     LaHood
     Largent
     Latham
     LaTourette
     Lazio
     Leach
     Lewis (CA)
     Lewis (KY)
     Linder
     LoBiondo
     Lucas (OK)
     Manzullo
     McCollum
     McCrery
     McHugh
     McInnis
     McIntosh
     McKeon
     Metcalf
     Mica
     Miller (FL)
     Miller, Gary
     Moran (KS)
     Morella
     Myrick
     Nethercutt
     Ney
     Northup
     Norwood
     Nussle
     Ose
     Oxley
     Packard
     Paul
     Pease
     Peterson (PA)
     Petri
     Pickering
     Pitts
     Pombo
     Porter
     Portman
     Pryce (OH)
     Quinn
     Radanovich
     Ramstad
     Regula
     Reynolds
     Riley
     Rogan
     Rogers
     Rohrabacher
     Ros-Lehtinen
     Roukema
     Royce
     Ryan (WI)
     Ryun (KS)
     Salmon
     Sanford
     Saxton
     Schaffer
     Sensenbrenner
     Sessions
     Shadegg
     Shaw
     Shays
     Sherwood
     Shimkus
     Shuster
     Simpson
     Skeen
     Smith (MI)
     Smith (NJ)
     Smith (TX)
     Souder
     Spence
     Stearns
     Stump
     Sununu
     Sweeney
     Talent
     Tancredo
     Tauzin
     Taylor (NC)
     Terry
     Thomas
     Thornberry
     Thune
     Tiahrt
     Toomey
     Upton
     Vitter
     Walden
     Walsh
     Wamp
     Watkins
     Watts (OK)
     Weldon (FL)
     Weldon (PA)
     Weller
     Whitfield
     Wicker
     Wilson
     Wolf
     Young (AK)
     Young (FL)

                             NOT VOTING--2

     McKinney
     Scarborough
       

                              {time}  1707

  Messrs. SIMPSON, CUNNINGHAM, CASTLE, POMBO, and Ms. DUNN changed 
their vote from ``aye'' to ``no.''
  Mr. STUPAK, Ms. ROYBAL-ALLARD, Messrs. RODRIGUEZ, DAVIS of Florida, 
and SNYDER changed their vote from ``no'' to ``aye.''
  So the motion to recommit was rejected.
  The result of the vote was announced as above recorded.
  The SPEAKER pro tempore (Mr. Hastings of Washington). The question is 
on the passage of the bill.
  The question was taken; and the Speaker pro tempore announced that 
the ayes appeared to have it.
  Mr. ARCHER. Mr. Speaker, on that I demand the yeas and nays.
  The yeas and nays were ordered.
  The vote was taken by electronic device, and there were--yeas 227, 
nays 205, not voting 2, as follows:

                             [Roll No. 485]

                               YEAS--227

     Aderholt
     Archer
     Armey
     Bachus
     Baker
     Ballenger
     Barr
     Barrett (NE)
     Bartlett
     Barton
     Bass
     Bateman
     Bereuter
     Biggert
     Bilbray
     Bilirakis
     Bliley
     Blunt
     Boehlert
     Boehner
     Bonilla
     Bono
     Brady (TX)
     Bryant
     Burr
     Burton
     Buyer
     Callahan
     Calvert
     Camp
     Canady
     Cannon
     Castle
     Chabot
     Chambliss
     Chenoweth-Hage
     Coble
     Coburn
     Collins
     Combest
     Cook
     Cooksey
     Cox
     Cramer
     Crane
     Cubin
     Cunningham
     Danner
     Davis (VA)
     Deal
     DeLay
     DeMint
     Diaz-Balart
     Dickey
     Dooley
     Doolittle
     Dreier
     Duncan
     Dunn
     Ehlers
     Ehrlich
     Emerson
     English
     Everett
     Ewing
     Fletcher
     Foley
     Forbes
     Fossella
     Fowler
     Franks (NJ)
     Frelinghuysen
     Gallegly
     Gekas
     Gibbons
     Gilchrest
     Gillmor
     Goode
     Goodlatte
     Goodling
     Gordon
     Goss
     Graham
     Granger
     Green (WI)
     Greenwood
     Gutknecht
     Hansen
     Hastert
     Hastings (WA)
     Hayes
     Hayworth
     Hefley
     Herger
     Hill (MT)
     Hilleary
     Hobson
     Hoekstra
     Horn
     Hostettler
     Houghton
     Hulshof
     Hunter
     Hutchinson
     Hyde
     Isakson
     Istook
     Jenkins
     Johnson (CT)
     Johnson, Sam
     Jones (NC)
     Kasich
     Kelly
     King (NY)
     Kingston
     Knollenberg
     Kolbe
     Kuykendall
     LaHood
     Largent
     Latham
     LaTourette
     Lazio
     Leach
     Lewis (CA)
     Lewis (KY)
     Linder
     Lipinski
     LoBiondo
     Lucas (KY)
     Lucas (OK)
     Maloney (CT)
     Manzullo
     McCollum
     McCrery
     McHugh
     McInnis
     McIntosh
     McKeon
     Metcalf
     Mica
     Miller (FL)
     Miller, Gary
     Moran (KS)
     Moran (VA)
     Myrick
     Nethercutt
     Ney
     Northup
     Nussle
     Ose
     Oxley
     Packard
     Paul
     Pease
     Peterson (PA)
     Petri
     Pickering
     Pitts
     Pombo
     Porter
     Portman
     Pryce (OH)
     Quinn
     Radanovich
     Ramstad
     Regula
     Reynolds
     Riley
     Rogan
     Rogers
     Rohrabacher
     Ros-Lehtinen
     Roukema
     Royce
     Ryan (WI)
     Ryun (KS)
     Salmon
     Sanford
     Saxton
     Schaffer
     Sensenbrenner
     Sessions
     Shadegg
     Shaw
     Shays
     Sherwood
     Shimkus
     Shuster
     Simpson
     Skeen
     Smith (MI)
     Smith (NJ)
     Smith (TX)
     Smith (WA)

[[Page H9474]]


     Souder
     Spence
     Stearns
     Stump
     Sununu
     Sweeney
     Talent
     Tancredo
     Tauzin
     Taylor (NC)
     Terry
     Thomas
     Thornberry
     Thune
     Tiahrt
     Toomey
     Upton
     Vitter
     Walden
     Walsh
     Wamp
     Watkins
     Watts (OK)
     Weldon (FL)
     Weldon (PA)
     Weller
     Whitfield
     Wicker
     Wilson
     Wolf
     Young (AK)
     Young (FL)

                               NAYS--205

     Abercrombie
     Ackerman
     Allen
     Andrews
     Baird
     Baldacci
     Baldwin
     Barcia
     Barrett (WI)
     Becerra
     Bentsen
     Berkley
     Berman
     Berry
     Bishop
     Blagojevich
     Blumenauer
     Bonior
     Borski
     Boswell
     Boucher
     Boyd
     Brady (PA)
     Brown (FL)
     Brown (OH)
     Campbell
     Capps
     Capuano
     Cardin
     Carson
     Clay
     Clayton
     Clement
     Clyburn
     Condit
     Conyers
     Costello
     Coyne
     Crowley
     Cummings
     Davis (FL)
     Davis (IL)
     DeFazio
     DeGette
     Delahunt
     DeLauro
     Deutsch
     Dicks
     Dingell
     Dixon
     Doggett
     Doyle
     Edwards
     Engel
     Eshoo
     Etheridge
     Evans
     Farr
     Fattah
     Filner
     Ford
     Frank (MA)
     Frost
     Ganske
     Gejdenson
     Gephardt
     Gilman
     Gonzalez
     Green (TX)
     Gutierrez
     Hall (OH)
     Hall (TX)
     Hastings (FL)
     Hill (IN)
     Hilliard
     Hinchey
     Hinojosa
     Hoeffel
     Holden
     Holt
     Hooley
     Hoyer
     Inslee
     Jackson (IL)
     Jackson-Lee (TX)
     Jefferson
     John
     Johnson, E. B.
     Jones (OH)
     Kanjorski
     Kaptur
     Kennedy
     Kildee
     Kilpatrick
     Kind (WI)
     Kleczka
     Klink
     Kucinich
     LaFalce
     Lampson
     Lantos
     Larson
     Lee
     Levin
     Lewis (GA)
     Lofgren
     Lowey
     Luther
     Maloney (NY)
     Markey
     Martinez
     Mascara
     Matsui
     McCarthy (MO)
     McCarthy (NY)
     McDermott
     McGovern
     McIntyre
     McNulty
     Meehan
     Meek (FL)
     Meeks (NY)
     Menendez
     Millender-McDonald
     Miller, George
     Minge
     Mink
     Moakley
     Mollohan
     Moore
     Morella
     Murtha
     Nadler
     Napolitano
     Neal
     Norwood
     Oberstar
     Obey
     Olver
     Ortiz
     Owens
     Pallone
     Pascrell
     Pastor
     Payne
     Pelosi
     Peterson (MN)
     Phelps
     Pickett
     Pomeroy
     Price (NC)
     Rahall
     Rangel
     Reyes
     Rivers
     Rodriguez
     Roemer
     Rothman
     Roybal-Allard
     Rush
     Sabo
     Sanchez
     Sanders
     Sandlin
     Sawyer
     Schakowsky
     Scott
     Serrano
     Sherman
     Shows
     Sisisky
     Skelton
     Slaughter
     Snyder
     Spratt
     Stabenow
     Stark
     Stenholm
     Strickland
     Stupak
     Tanner
     Tauscher
     Taylor (MS)
     Thompson (CA)
     Thompson (MS)
     Thurman
     Tierney
     Towns
     Traficant
     Turner
     Udall (CO)
     Udall (NM)
     Velazquez
     Vento
     Visclosky
     Waters
     Watt (NC)
     Waxman
     Weiner
     Wexler
     Weygand
     Wise
     Woolsey
     Wu
     Wynn

                             NOT VOTING--2

     McKinney
     Scarborough
       

                              {time}  1724

  Mrs. ROUKEMA changed her vote from ``nay'' to ``yea.''
  So the bill was passed.
  The result of the vote was announced as above recorded.
  A motion to reconsider was laid on the table.

                          ____________________