1
500
3
-
https://clinton.presidentiallibraries.us/files/original/f7b728e28a6c5820654c38c323f99f9d.pdf
9028fe02bddb235ecde9c9904a668330
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Hayes
Subseries:
3015
OA/ID Number:
FolderlD:
Folder Title:
Admin. Material on Constituency Groups & Ethics Working Groups-Folder 3
Stack:
Row:
Section:
Shelf:
Position:
S
56
3
5
1
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
IW
�5:50-
PANEL TEN-LABOR-TESTIMONY BEGINS
[MEG ARRIVES ]
[NOTE: SECRETARY REICH HAS TO LEAVE MIDWAY THROUGH
THIS PANEL.]
We asked the next panel of labor representatives to address the question: "In a rapidly
changing economic world, how do we ensure that all workers have the security of quality,
affordable health coverage?"
Benefits at the AFL-CIO.
Our first witness is Karen Ignani, Director of Employee
�PANEL TEN: LABOR
Question Posed:
In a rapidly changing economic world, how do we ensure that all workers have the
security of quality, affordable health coverage?
Groups:
AFL-CIO
Service Employees International Union
American Federation of State, County, and Municipal Employees
Teamsters
Building Trades Council
United Auto Workers
M^jor issue concerns:
The six testifiers are evenly split between those unions who are historically single payer
advocates (UAW, AFSCME, Teamsters ~ see Message Sheet for Panel Eleven:
Consumers) and those are more comfortable with a managed competition approach
(AFL-CIO, SEIU, Building Trades.) All share a strong opposition to taxing employee
benefits and to allowing some companies to opt out of the HIPCs. They will likely push
for HIPCs to compete on quality and outcomes instead of on price. They will all push
for a more rather than less comprehensive package.
/Talking points:
1.
It's important to workers more than anyone to keep health care costs under
control.
2.
We need to eliminate job lock by making sure every American has coverage.
3.
Our benefits package will be comprehensive.
�AFL-CIO
MEMBERS:
88 u n i o n s , 14 m i l l i o n members
REPRESENTS:
Unions r e p r e s e n t i n g i n d i v i d u a l s employed i n
m a n u f a c t u r i n g , t h e p u b l i c s e c t o r , s e r v i c e and
b u i l d i n g and c o n s t r u c t i o n
TODAY'S SPEAKER:
Karen I g n a g n i , D i r e c t o r o f Department o f
Employee B e n e f i t s (See a t t a c h e d b i o g r a p h y )
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Strong e f f e c t i v e grassroots network;
i n f l u e n t i a l w i t h Congress; l a r g e campaign
contributors
Support e s t a b l i s h m e n t o f p u r c h a s i n g
cooperatives
Support u n i v e r s a l access t h r o u g h r e g i o n a l
p u r c h a s i n g and d e l i v e r y system w i t h
e n f o r c e a b l e budget. Community r a t i n g f o r
a l l . Consumer c h o i c e among p l a n s .
Quality
assurance system i n c l u d i n g development o f
p r a c t i c e g u i d e l i n e s , h e a l t h outcomes,
r e s e a r c h and t e c h n o l o g y assessment.
POSITION ON
PLAN:
Supportive.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n , Mrs. C l i n t o n , I r a Magaziner.
PET
ISSUES:
HOT BUTTON ISSUES:
Finance r e t i r e e h e a l t h c a r e by u n i f i e d
p u r c h a s i n g and d e l i v e r y system. Medicare
e l i g i b i l i t y t o 60. Finance system
t h r o u g h broad and e q u i t a b l e mechanisms.
No employers c a n o p t o u t o f HIPCs; no
t a x a t i o n o f employer-provided b e n e f i t s .
�RCV BY:
; 3-25-93 ;12:55PM i
AFL-CIO-
SOCIAL OFF ICE Jft2
Testimony by Karen Ignagni
Director, Employee Benefits Department
AFL-CIO
before the White House Task Force on Health
March 29, 1993
Q-
In a rapidly changing economic world, how do we ensure that all workers have the
security of quality, affordable health care coverage?
A.
We should do five things:
1.
Change the word "workers" in the question to "Americans." When we change
that word, we change a key concept. We then assume that no matter what
happens to your job, no matter what happens to the economy, no matter
whether you are a full-time, part-time, temporary worker or retiree, you and
your family still has a right to quality health care. By removing health care
from the employment equation, we free workers and their employers to focus
on pay, pensions, and productivity - the three variables that ultimately
determine whether we remain competitive and secure in a rapidly changing
economic world.
2.
Ensure universal access to quality services and a comprehensive set of benefits
with an emphasis on preventive care, as well as mechanisms to support
families who are caring for those with long-term illness.
3.
Restructure health care delivery, reducing fragmentation, cost shifting and
administrative waste by establishing a unified purchasing and delivery system
to negotiate with providers and contract with plans. We should require all
purchasers to participate fully in the system so that costs can be distributed
fairly across the entire population.
4.
Control costs by establishing global budgets through negotiations with
purchasers and providers. This will create competition where it belongs - on
service to coasumers and performance of plans.
5.
Pay for universal health care through taxes that distribute the costs fairly
across the entire spectrum of economic activity, rather than taxing the benefits
of millions of working people who have already given up wage increases to
preserve their health care benefits.
Building a plan on these fundamental principles will create a New Deal of the
sort that all Americans can be proud.
�SERVICE EMPLOYEES INTERNATIONAL UNION (SEIU)
MEMBERS:
More t h a n one m i l l i o n members i n U.S.,
Canada, and Puerto Rico
REPRESENTS:
P u b l i c employees make up o n e - h a l f o f
membership. With more t h a n 400,000 members
w o r k i n g i n h o s p i t a l s , n u r s i n g homes, and
HMOs, l a r g e s t u n i o n o f h e a l t h c a r e w o r k e r s .
TODAY'S SPEAKER:
John J. Sweeney, P r e s i d e n t (See a t t a c h e d
biography)
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
HOT BUTTON ISSUES:
Large, f a i r l y i n f l u e n t i a l ,
in California.
Largest union i s
Support e s t a b l i s h m e n t o f p u r c h a s i n g
cooperatives
Same as AFL-CIO (Support u n i v e r s a l access
t h r o u g h r e g i o n a l p u r c h a s i n g and d e l i v e r y
system w i t h e n f o r c e a b l e budget.
Community
r a t i n g f o r a l l . Consumer c h o i c e among p l a n s .
Q u a l i t y assurance system i n c l u d i n g
development o f p r a c t i c e g u i d e l i n e s , h e a l t h
outcomes research and t e c h n o l o g y assessment)
S u p p o r t i v e , assuming key concerns
in plan.
addressed
T r a n s i t i o n , Mrs. C l i n t o n , I r a Magaziner
No employer o p t o u t o f HIPC; no t a x a t i o n o f
employer-provided b e n e f i t s
�Services Employees International Union
Representative
John J . Sweeney
President
I n 13 years as president o f the Service Employees I n t e r n a t i o n a l
Union, John J. Sweeney has bucked n a t i o n a l trends t o b u i l d a
union which i s growing i n influence as w e l l as membership. When
Sweeney was f i r s t elected i n 1981, SEIU was a union o f 600,000
w i t h a t h i r d o f i t s membership i n healthcare, a t h i r d i n p u b l i c
employment and a t h i r d i n i t s t r a d i t i o n a l membership base,
b u i l d i n g s e r v i c e workers. Today SEIU, w i t h more than a m i l l i o n
members i n t h e United States, Canada and Puerto Rico, i s t h e
f o u r t h - l a r g e s t and f a s t e s t growing a f f i l i a t e of the AFL-CIO.
With p u b l i c employees now making up h a l f i t s membership, i t i s
the second-largest non-teaching p u b l i c employee union i n t h e U.S.
And w i t h more than 400,000 members working i n h o s p i t a l s , nursing
homes, and HMOs, i t s t h e biggest union o f healthcare workers i n
North America. Sweeney i s a v i c e president of the AFL-CIO and as
chair o f the labor f e d e r a t i o n ' s i n f l u e n t i a l h e a l t h care committee
he's l a b o r p o i n t man f o r n a t i o n a l healthcare reform.
�John J. Sweeney
Health Care Task Force
Oral Statement
March 29,1993
We are grateful for this opportunity to share our experiences negotiating health benefits for
our members who work in diverse industries and occupations.
SEIU is organizing workers in industries like janitorial services, home care and nursing
homes where wages are low and health benefits are scarce, Once they join the union, it's often
impossible to negotiate health coverage. Or if the employer does offer coverage, the plan is too
expensive for the workers to use.
In some cities, we have established multi-employer insurance funds which are affordable for
small employers and provide good benefits to our members. We work closely with employers to
control costs. In New York City, where I'mfrom,our local union operates its own health clinic and
uses provider panels to better control costs. In spite of these efforts, health costs continue to escalate
out of control and remain a sore spot in negotiations. It's clear to us that plan-by-plan, company-bycompany efforts at cost containment cannot bring relief.
Throughout the service industries, we have seen an explosion of contingent workers: parttime, temporary and contract workers, Some estimates show a quarter of the total U.S. work force
is in this category. And probably the main reason is that employers want to avoid the cost of health
benefits that they provide to regular, full-time workers.
�MAR 26 '93 13:18 SEIU ORGANIZING
P.2
The upward spiral of health costs continues. So does the downward spiral of shrinking
employer coverage. We cannot afford to delay comprehensive reform for a single day longer than
necessary.
Popular support for comprehensive reform is overwhelming because even people with
coverage find themselves paying more and more. Cost containment doesn't mean making people
pay more.
Proven methods of controlling costs do exist. A survey of our industrial competitors shows
that while their healthcare systems vary greatly, all rely on some form of global budgeting and ratesetting to control costs. During the 1980s, they had the tools to stabilize health spending as a share
of GDP. Meanwhile, we in the United States stood by and watched as health care increased its
"bite" of the economy, paralyzed by the lack of leadershipfromthe federal government.
Working families also want security against the loss of coverage when they change jobs or
retire. The cornerstone of reform must be a federal guarantee of health coverage to all Americans,
similar to the universal promise of Social Security and public education.
Finally, health care refonn presents a unique opportunity for building-in to the reformed
system the kind of quality improvement strategies that have proved so successful in other industries.
We must focus on upgrading the skills offrontlinehealthcare workers and involving them in the
process of reorganizing the service delivery system. Only by giving healthcare workers a greater
-2-
�MPR 26 '93 13:18 SEIU ORGANIZING
P. 3
voice in their workplaces can we ensure that cost cutting doesnt undermine the quality of care.
But the critical ingredient for successful reform remains what it has always been: strong
federal leadership. SEIU fully supports the urgent quest of the Health Care Task Force to prepare
and submit to Congress a plan for comprehensive reform.
Thank you.
-3
�AMERICAN FEDERATION OF STATE, COUNTY AND MUNICIPAL EMPLOYEES
(AFSCME)
MEMBERS:
More than 1.3 m i l l i o n p u b l i c employees and
h e a l t h care workers throughout t h e U.S.
REPRESENTS;
Employees o f s t a t e , county, and municipal
governments, school d i s t r i c t s , p u b l i c and
p r i v a t e h o s p i t a l s , u n i v e r s i t i e s and nonp r o f i t agencies who work i n a cross s e c t i o n
of jobs ranging from blue c o l l a r t o c l e r i c a l ,
professional and paraprofessional. White
c o l l a r employees account f o r o n e - t h i r d o f the
membership.
TODAY'S SPEAKER:
Gerald W. McEntee, I n t e r n a t i o n a l President
(See attached biography)
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
The l a r g e s t and most i n f l u e n t i a l AFL-CIO
union
Historically
s i n g l e payer, but f l e x i b l e
Single payer but are w i l l i n g t o work w i t h us
and AFL-CIO. Very concerned t h a t p u b l i c
sector not be used t o create " c r i t i c a l mass"
f o r HIPCs.
POSITION ON
PLAN:
Generally supportive
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n , Mrs. C l i n t o n , I r a Magaziner
�AFSCME
Representative
Gerald W. McEntee
International President
Gerald W. McEntee, I n t e r n a t i o n a l President, began h i s career
i n 1958 as an AFSCME organizer i n Philadelphia, McEntee went on
t o become t h e successful a r c h i t e c t of the major p u b l i c sector
organizing d r i v e t o unionize Pennsylvania's more than 75,000
s t a t e employees. McEntee was elected I n t e r n a t i o n a l President o f
AFSCME i n 1981. He i s v i c e President and member of t h e AFL-CIO
Executive Council. He c h a i r s the AFL-CIO Work and Family
Committee. He i s also a member of the Democratic N a t i o n a l
Committee and the DNC's Labor Council.
�03/25/93
13:56
®202 429 1084
^1002
AFSCME/PUBPOLICY
®
American Federation of State, County and Municipal Employees, AFL-CIO
1625 L Street N.W Washington, D.C20036-5687
Telephone (202} 429-1000
Telex89-2376
Facsimile (202)429-1293
TOO (202) 659-0446
V
CertJdW.Mtfntee
WiTUamUicy
Secretary-Treasurer
Vex Residents
Ronald OUexaixler
Co/uxnbtm. Ohio
Statement
of
DoomarJ.Bidobto
Newffntan^Conn.
Hefl/yLBiycr
aiago.in.
PeterJ-Benner
SostccMss.
OoriaCCobbif)
Gerald W. McEntee
I n t e r n a t i o n a l President
American Federation o f S t a t e ,
County
and
Municipal Employees, AFL-CIO
Stephen M-Coten
AtbcftA.Di(»
Danny Donohue
Albany, NX
WSHamtEiKlsiey
Columbus, Ohio
Stanley W.HiU
Can)MiJ,Hoimes
to
WIIHamS.HiKisoiMr.
SyfejvSfeMd
BIoiK&eP.Jardan
The White House Health Caxe Task Force
fdwatdj. Keller
JoKahE-McOerrortt
Donald & MdCee
DesA*o«ies,/owa
Guy Moan:
Ofycapia. wai/i.
MdaeiaMunitnr
Henry NidraUs
BussdlCOIata
HonohUuHanaB
kxephF.fuaa
March 29,
1993
VedadE-RhyiuaySr.
Ji«phP.
KithyJ.Sadnun
Pocnoni,CM
Buriunan D.Smith
LtnyRSniidi
UndzQmex-Thooiplon
Sin/totomtv Tex
inthepubUc service
�03/25 '93
13:57
© 2 0 2 429 1084
AFSCME/PUBPOLICY
1
Members of the Healtli Care Task Force, I am Gerald w.
McEntee, president of the American Federation of State, County
and Municipal Employees.
Our members work on the front l i n e s of
the health care c r i s i s , i n hospitals and c l i n i c s and home health
care agencies around the country.
They know from the patients
they t r e a t , and the governors and mayors they work for, that
national health care i s America's number one p r i o r i t y .
Regardless of whether they work or not, every American must
be able to get the health care he or she needs.
And the only way to do that ~ and control skyrocketing
health care costs with a budget, as President Clinton has said —
i s to require every employer and every individual — with no
exceptions —- to participate.
Anything l e s s than t h i s , any opt-outs for companies l i k e
General E l e c t r i c or Marriott, or any other business, i s t o grant
special favors for the few at the expense of a l l the people.
The problem with health care i n America i s that the system
works f o r the businesses who can figure how to s h i f t t h e i r costs
to t h e i r workers or to government, or to some other business.
As the F i r s t Lady and I r a Magaziner have said throughout
these meetings, a l l the micro-management i n the world hasn't
11003
�0.V25''93
13:57
©202 429 1084
AFSCME/PUBPOLICY
2
stopped hospitals, doctors and insurance companies from r a i s i n g
prices and people from losing coverage.
Let's face facts, an employment-based system of health
insurance has no place in the competitive world of the 1990s.
The l a s t thing we need i s a health insurance system that
treats workers differently based on who t h e i r employer i s , or
requires more costly micro-management to track what i s spent on
health care.
The l a s t thing we need i s more market segmentation where
employers with young, healthy workers opt-out, creating
incentives f o r age and health status discrimination in the
workplace.
The l a s t thing we need i s to single out public sector
workers, once again, just to subsidize the costs of a l l the
employers who
opt out of the purchasing cooperative i n t h e i r
area.
Members of the Health Care Task Force, we can succeed i n
1993 i f we a l l join together to solve our health care c r i s i s . No
special deals and no special interests —
choice for a l l Americans.
Thank you.
one system of free
l&OOi
�INTERNATIONAL BROTHERHOOD OF TEAMSTERS
MEMBERS:
1.4 m i l l i o n workers and 400,000 r e t i r e d
workers
REPRESENTS:
Very diverse union representing people i n
p r i v a t e i n d u s t r y and s t a t e and l o c a l
government i n c l u d i n g t r u c k i n g , brewery, food
processing, c l e r i c a l work and h e a l t h care.
TODAY'S SPEAKER:
Cindy Zehnder, I n t e r n a t i o n a l Representative
(See attached biography)
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
Large union w i t h s i g n i f i c a n t p o l i t i c a l c l o u t ,
increased since Ron Carey became President
Single payer
Single payer supporters who have seen major
labor-management disputes a r i s e due t o r i s i n g
h e a l t h care costs. They are supportive o f
systemic reform and w i l l l i k e l y accept an
employer-mandate c o n s t r u c t , but could be
concerned about any tax-cap p r o v i s i o n t h a t
l i m i t s t h e i r a b i l i t y t o negotiate f o r a r i c h
b e n e f i t s package, o r t h a t r e s u l t s i n reduced
b e n e f i t s f o r t h e i r members.
Mrs. C l i n t o n , I r a Magaziner
�Teamsters Union
Representative
Cindy Zehnder
International Representative
Cindy has been a leader i n the d r i v e f o r h e a l t h care reform
i n Washington State. She was a member o f the Executive Committee
and Vice Chair o f the Cost Control Committee o f the Washington
State Health Care Commission, which recently submitted a
comprehensive proposal t o the s t a t e l e g i s l a t u r e on h e a l t h care
reform. She was co-chair o f Governor Mike Lowry's t r a n s i t i o n
team task f o r c e on health care reform. Cindy Zehnder i s an
i n t e r n a t i o n a l Representative f o r the Teamsters f o r Washington and
Oregon. She i s also Coordinator f o r the J o i n t Council o f
Teamsters No. 28, which covers 20 Local Unions and 60,000 members
i n t h e State o f Washington. Cindy began her career w i t h t h e
Teamsters as a t r u c k d r i v e r and dock worker, and has worked as an
organizer and business representative f o r several Teamsters Local
Unions. She's a founding member and Secretary-Treasurer o f t h e
I n t e r n a t i o n a l Teamster Women's Caucus and a member o f t h e
Teamster Human Rights Commission. She has a masters degree from
the U n i v e r s i t y o f Washington i n Educational Psychology.
�Mar 26,1993
li:56flM
FROM driye
TO 94566241
P.02
STATEMENT OF
CINDY ZEHNDER
INTERNATIONAL REPRESENTATIVE
INTERNATIONAL BROTHERHOOD OF TEAMSTERS
AFL-CIO
TO
THE WHITE HOUSE HEALTH CARE TASK FORCE
MARCH 29, 1993
MADAME CHAIRMAN, MEMBERS OF THE TASKFORCE, MY NAME I S CINDY
ZEHNDER AND I AM AN INTERNATIONAL REPRESENTATIVE WITH THE
TEAMSTERS UNION. THE 1.5 MILLION TEAMSTER FAMILIES ACROSS THE
COUNTRY HAVE DEEP CONCERNS ABOUT WHAT HAS HAPPENED TO HEALTHCARE
- AND THEY ARE LOOKING TO TASKFORCE TO FIND A SOLUTION.
I WAS ASKED BY OUR GENERAL PRESIDENT, RON CAREY, TO
REPRESENT THE TEAMSTERS HERE TODAY BECAUSE I HAVE BEEN WORKING IN
THE TRENCHES FOR HEALTHCARE REFORM FOR MANY YEARS. MOST
RECENTLY, I HAD THE PRIVILEGE OF SERVING ON WASHINGTON STATE'S
HEALTH CARE COMMISSION AND AS CO-CHAIR OF GOVERNOR MIKE LOWRY'S
TRANSITION TEAM TASK FORCE ON HEALTHCARE REFORM.
YOU ASKED US TO OFFER OUR IDEAS ON HOW TO MAKE SURE THAT ALL
WORKERS CAN HAVE THE SECURITY OF QUALITY, AFFORDABLE HEALTHCARE
COVERAGE IN OUR RAPIDLY CHANGING ECONOMIC WORLD.
FIRST, WE BELIEVE THAT ACCESS TO BENEFITS MUST BE SEPARATED
FROM AN INDIVIDUAL'S EMPLOYMENT STATUS.
TKE REASON IS ALREADY IMPLIED BY YOUR QUESTION. THIS IS
INDEED A RAPIDLY CHANGING ECONOMIC WORLD AND THAT MEANS THAT OUR
EMPLOYMENT STATUS IS ALSO SUBJECT TO RAPID CHANGE - ON THE
AVERAGE OF 5 TIMES IN EACH OF OUR WORKLIVES.
�Mar 26.1993 11:57PM
FROM driue
TO 94566241
P.03
ONE DAY WE ARE EMPLOYED WITH CADILLAC BENEFITS, THE NEXT WE
CHANGE EMPLOYERS AND HAVE VERY FEW BENEFITS OR WE ARE LAID OFF
AND HAVE NOTHING.
OUR NEED FOR HEALTHCARE DOESN'T CHANGE, HOWEVER, AND THE
ONLY WAY TO PROVIDE REAL SECURITY IS TO GUARANTEE TO EVERY
AMERICAN, REGARDLESS OF THEIR EMPLOYMENT STATUS, COVERAGE UNDER A
SINGLE NATIONAL HEALTHCARE SYSTEM.
SECOND, WE SIMPLY MUST GET CONTROL OF HEALTHCARE COSTS I F A
NATIONAL HEALTHCARE PLAN IS TO SUCCEED.
OUR CURRENT SYSTEM IS A PRIME EXAMPLE OF HOW CRAZY THINGS
CAN GET WHEN THE PROFIT MOTIVE IS ALLOWED TO RUN UNCHECKED. I F
THERE I S A WAY TO INCREASE THE PROFIT MARGIN BY ADDING A LITTLE
EXTRA HERE AND THERE OR BY OVER-COMPLICATING SIMPLE PROCEDURES OR
BY GETTING SOMEONE ELSE TO COVER YOUR COSTS, THE HEALTHCARE
ENTREPRENEURS HAVE FOUND IT. VERY OFTEN THE "SOMEONE ELSE" WHO
HAS TO PAY IS THE EMPLOYEES - WHO ARE ALREADY SUFFERING FROM A
DROP IN REAL INCOME AND A DECLINING STANDARD OF LIVING.
WE CAN NO LONGER AFFORD SO MUCH BUSINESS SUCCESS.
BANKRUPTING THE REST OF US.
IT IS
THE ONLY WAY TO EFFECTIVELY CONTROL COSTS IS TO BRING
EVERYONE INTO THE SYSTEM AND MAKE US ALL PLAY BY THE SAME RULES.
NO OPT OUTS SHOULD BE ALLOWED OR WE WILL CONTINUE TO HAVE A
HEALTHCARE SYSTEM THAT REWARDS PEOPLE FOR FIGURING OUT HOW TO
BEAT IT.
FINALLY, WE MUST PROVIDE ADEQUATE FUNDING FOR A
COMPREHENSIVE SET OF HEALTHCARE BENEFITS. THIS I S NO PLACE FOR
SMOKE AND MIRRORS.
�Mar 26.1993 li:57RM
FROM driue
TO 94566241
P.04
OUR MEMBERS ARE WILLING TO PAY THEIR FAIR SHARE OF ANY
INCREASED COSTS I F THEY ARE GUARANTEED THEY CAN MAINTAIN THEIR
EXISTING BENEFITS LEVELS AND GET REAL COST CONTROL. WHAT THEY
WILL NOT BE WILLING TO ACCEPT IS BEING FORCED TO PAY MORE TO GET
LESS.
AFTER LOOKING AT ALL THE HEALTHCARE PROPOSALS NOW BEING
CONSIDERED. THE TEAMSTERS UNION BELIEVES THAT THE MCDERMOTTWELLSTONE PLAN MAKES THE MOST SEHSE.
TEAMSTER MEMBERS CHERISH HEALTHCARE FOR THEMSELVES AND THEIR
FAMILIES. MANY HAVE WALKED A PICKET LINE AND SOME HAVE PAID THE
ULTIMATE PRICE, THE LOSS OF THEIR JOBS, TO MAINTAIN BENEFITS THAT
SHOULD BE THE RIGHT OF ALL AMERICANS.
WE BELIEVE THAT THE WORK YOU ARE DOING IS THE SINGLE MOST
IMPORTANT TASK BEFORE US AS A NATION AND WE ARE WILLING TO DO
WHATEVER IS NEEDED TO HELP YOU SUCCEED.
THANK YOU.
�BUILDING AND CONSTRUCTION TRADES DEPARTMENT
MEMBERS:
5 m i l l i o n members
REPRESENTS:
15 a f f i l i a t e d i n t e r n a t i o n a l unions i n t h e
construction industry
TODAY'S SPEAKER:
Robert A. Georgine, President (See attached
biography)
APPROACH TO
REFORM:
Supportive
SUMMARY OF
POSITION:
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
Same p o s i t i o n as AFL-CIO generally. Believe
Taft-Hartley plans should continue t o perform
administrative functions.
Supportive as long as b e n e f i t s package i s
comprehensive and as long as T a f t - H a r t l e y
can continue t o f u n c t i o n .
Mrs. C l i n t o n , I r a Magaziner
�Building and Construction Trades Department, AFL-CIO
Representative
Robert A Georgine
President
Robert A. Georgine has been the President o f the B u i l d i n g
Trades Department, AFL-CIO since 1974. Since 1990, he has served
as the Chairman and CEO of Union Labor L i f e Insurance Company.
Mr. Georgine i s t h e Vice President and Member o f the Executive
Council o f t h e AFL-CIO. Mr. Georgine attended the U n i v e r s i t y of
I l l i n o i s and DePaul U n i v e r s i t y .
�riAR-26-1993
14:06
FROM B.C.T.D.
TO
4566241
P.02
CLINTON ADMINISTRATIONS'S
HEALTH CARE REFORM CAMPAIGN
AND
TAFT-HARTLEY, MULTIEMPLOYER
HEALTH PLANS
BY
BOB GEORGINE, PRESIDENT
BUILDING AND CONSTRUCTION TRADES DEPARTMENT, A F L - C I O
AND
CHAIRMAN OF TEE NATIONAL COORDINATING COMMITTEE
FOR MULTIEMPLOYER PLANS
SUMMARY
Health Care Task Force
The issue i s how do we ensure that a l l workers have the security
of quickly affordable health coverage i n a rapidly changing
world.
1.
For the most part, employees whose health benefits are
provided by j o i n t l y administered plans (multiemployer now
plans) have the security of quality health coverage.
However, they are paying f o r that coverage through
continuing, escalating cost increases. Indeed, most
employees have forgone wage increases i n order t o ensure
continued, quality health care coverage.
2.
Whatever system i s developed f o r ensuring that a l l workers
have q u a l i t y health coverage should not be a t the expense of
the e f f e c t i v e system now i n place f o r the m i l l i o n s of
workers covered by labor-management multiemployer plans.
The system should b u i l d on the successes of those j o i n t l y
administered funds. Indeed, the Hawaii system does j u s t
that.
3.
Effective cost controls can be achieved through increased
consumer bargaining strength. We have proven that i n
j u r i s d i c t i o n s where j o i n t l y administered funds represent a
substantial segment of the consuming public, they have
achieved affordable health coverage through the acquisition
of managed-care programs. Any system f o r coverage of aill
workers should enhance that bargaining strength.
�, M^R-26-1993 14:07 FROM B.C.T.D.
TO
4566241 P.03
4.
Controls must be imposed to protect multiemployer plans from
undue shifting of expenses. That shifting of expenses
occurs when institutions such as the Government impose
limitations on reimbursable medical expenses which the
health care community then shifts to multiemployer plans,
among others.
5.
I t has been estimated that the administrative costs of
competing systems adds an overburden of 15 percent to the
cost of health care. Incentives should exist for the
development of a unitary health care program covering the
health care aspects of workers compensation, personal injury
recoveries, and emloyment-based health care programs. This
would obviate the costs of disputes among providers of
health care with respect to the sharing or shifting of
liability.
6.
Incentives should be created so that the private sector
would be encouraged to establish fee reimbursement schedules
which compensate lewer-cost primary care more favorably at
the expense of higher-cost specialty care, similar to the
resource-based relative value scale (RBRVS) system now in
place for Medicare.
�UNITED AUTO WORKERS (UAW)
MEMBERS:
1.4 m i l l i o n .
REPRESENTS:
Active and r e t i r e d workers throughout t h e
U.S. Automobile, Aerospace & A g r i c u l t u r a l
implement and parts i n d u s t r y .
TODAY'S SPEAKER:
Alan Reuther, L e g i s l a t i v e D i r e c t o r
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
One o f the l a r g e s t and most powerful unions.
Particularly influential i n industrial
midwest.
H i s t o r i c a l l y single payer, but f l e x i b l e .
Single payer union, but w i l l i n g t o work w i t h
us. Very concerned about r e t i r e e s h e a l t h
care coverage.
POSITION ON
PLAN:
Have not committed.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
Mrs. C l i n t o n , I r a Magaziner, OPL
�SENT BYiXerox Telecopier 7C21 ; 3-25-93 !10!16AM ;
2022933457-*NAT ECONOMIC COUNCIL!* 2
Alan Reuther
i s Legislative
Director
for the
International Union, United
Automobile, Aerospace &
Agricultural Implement Workers of America (UAW).
As
Legislative Director, he i s responsible for supervising a l l
aspects of the UAW's legislative program, including
development of issues, presentation of testimony, lobbying
Members of Congress, and grass roots a c t i v i t i e s .
In
addition, he i s responsible for managing the UAW's
Washington Office.
Mr. Reuther graduated magna cum laude from the
University of Michigan Law School in 1977.
He was a Note
and Comment Editor for the University of Michigan Journal of
Law Reform, and published several articles in the Journal
dealing with labor law topics.
After graduating from law school, Mr. Reuther joined
the UAW's Legal Department in Detroit, Michigan as an
Assistant General counsel.
He was involved in litigation
and also advised the officers and staff of the Union in
various areas, including the National Labor Relations Act,
the Landrum Griffin Act, ERISA, and federal and state
campaign laws.
In 1982 Mr. Reuther transferred to the UAW's Washington
Office to handle legislative matters.
He became an
Associate General Counsel, and was responsible for handling
legislative matters iri a variety of areas, including taxes,
social security, health care, pensions, and the National
Labor Relations Aot.
On May 1, 1991, he became Legislative
Director for the UAW.
AR:car
opeiu494
(27)
�6:50-
PANEL TEN--LABOR--TESTIMONY ENDS
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
) <~
�6:55-
PANEL ELEVEN—CONSUMER—TESTIMONY BEGINS
I would like to welcome another panel of consumer groups. This panel will be
answering the question: "How can we ensure that all Americans have the security of quality,
affordable health coverage?" Thefirstwitness is: Cathy Hurwitt, Legislative Director for
Citizen Action.
�PANEL ELEVEN: CONSUMERS
Question Posed:
How can we ensure that all Americans have the security of quality, affordable health
coverage?
Groups:
Citizen Action
Children's Defense Fund
National Council of Churches
Mental Health Liaison Group
Campaign for Women's Health
American Council for Health Care Reform
M^jor issue concerns:
This too is a pretty diverse group. National Health Care Council is one of the plaintiffs,
and is likely to be very conservative. Citizen Action will push very hard for single payer.
National Council of Churches is historically single payer as well, but their statement will
likely reflect their flexibility and supportiveness as long as we provide universal coverage.
Children's Defense Fund, Mental Health Liaison Group, and Campaign for Women's
Health will likely focus on their special issues.
Talking points:
1.
Our plan will insure universal coverage.
2.
Comprehensive reform means doing something about every facet of health care,
at every age.
3.
Single Payer: We support the goals of single-payer legislation ~ cost containment,
simplification, reduced paperwork, high quality health care, a guaranteed benefit
package - and these will be a central part of our May proposal.
A single payer proposal, however, relies on dismantling much of the current
system ~ good and bad together. Americans enjoy the highest quality health care
in the world, based on state of the art technology. We are committed to
maintaining a uniquely American system ~ one that is rooted in the private sector,
builds on our employer-based system, and preserves the right of Americans to
choose their doctors.
�CITIZEN ACTION
MEMBERS:
5 m i l l i o n consumers
REPRESENTS:
I n 32 s t a t e s , membership comprised o f w o r k i n g c l a s s ,
m i d d l e c l a s s , employed i n w h i t e c o l l a r and s e r v i c e
i n d u s t r i e s , a c t i v i s t s , c r o s s g e n e r a t i o n l i n e s and
h a l f a r e below t h e age o f 45.
TODAY'S SPEAKER:
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Cathy H u r w i t t , L e g i s l a t i v e D i r e c t o r
Some s t r o n g s t a t e a f f i l i a t e s , broad based c a n v a s s i n g
e f f o r t s , a b i l i t y t o m o b i l i z e , a l t h o u g h n o t as
p o w e r f u l o r i n f l u e n t i a l n a t i o n a l l y as numbers m i g h t
indicate.
S i n g l e payer
Supports s i n g l e - p a y e r approach because o f i t s
a b i l i t y t o meet p r i n c i p l e s o f a f f o r d a b i l i t y ,
u n i v e r s a l i t y , comprehensiveness, c h o i c e and p u b l i c
accountability.
Views managed c o m p e t i t i o n as approach which w i l l
s h i f t c o s t s t o t h e i r own f a m i l i e s w h i l e l i m i t i n g
t h e i r c h o i c e o f p r o v i d e r s . Fear o f b e i n g f o r c e d
i n t o a substandard p l a n . M i d d l e c l a s s f a m i l i e s
t h i n k they w i l l have fewer c h o i c e s t h a n low income
persons.
W i l l be more s u p p o r t i v e i f s t a t e s have o p t i o n t o
experiment w i t h s i n g l e payer system o r i f s e v e r e l y
l i m i t a b i l i t y t o o p t o u t o f HPC.
T i e s t o l a b o r make them l e s s r e c e p t i v e t o t a x cap.
POSITION ON
PLAN:
I f p l a n meets needs o f c o s t s and c h o i c e , w i l l come
w i t h t h e A d m i n i s t r a t i o n on our p l a n . Want t o work
w i t h us.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n , OPL, I r a Magaziner, A l Gore, HRC
PET
State
ISSUES:
HOT BUTTON ISSUES:
flexibility
Lack o f good c o s t c o n t r o l , drawn our p h a s e - i n o f
u n i v e r s a l access
�C i t i z e n Action
Representative
Cathy Hurwit
L e g i s l a t i v e Director
Cathy Hurwit has been l e g i s l a t i v e d i r e c t o r o f C i t i z e n A c t i o n from
1982 t o 1987 and from 1990 t o the present. As l e g i s l a t i v e
d i r e c t o r , she i s responsible f o r C i t i z e n Action's s t a t e and
n a t i o n a l h e a l t h care program. Previously, she served as
l e g i s l a t i v e d i r e c t o r f o r Representative Toby M o f f e t t (1976-1979);
as an advisor t o the House Government Operations Committee
Subcommittee on Environment, Energy and Natural Resources; and as
a l e g i s l a t i v e d i r e c t o r f o r Representative Ed Markey (1987-1989).
She has co-authored "Insuring t h e Uninsured: Options f o r State
A c t i o n , " and "National Health Care: An American P r i o r i t y . " Ms.
Hurwit received a B.A. from Brown U n i v e r s i t y i n 1974.
�03/25/93
15:52
©202 296 4054
CITIZEN ACTION
00
® ?-
ORAL PRESENTATION OF CATHY L . HURWIT, CITIZEN ACTION
BEFORE THE PRESIDENT'S HEALTH CARE TASK FORCE
March 29, 1993
Question: How can we ensure t h a t a l l Americans have t h e s e c u r i t y
of q u a l i t y , a f f o r d a b l e h e a l t h coverage?
Tn order to meet the goal stated in the above question, the American health care
system must be. completely redesigned. It is no longer possible to make minor
changes or to build on an employer-based, private insurance dominmed structure
that is deteriorating further every day.
Unlike citizens of other industrialized countries, Americans have neither the health
security of knowing that they can get access to the medical services they need or
the financial security of knowing that a serious illness or injury will not result in
bankruptcy. Today, millions of Americans cannot afford medical care, whether
they are uninsured, underinsured or even relatively well-insured. Tomorrow, any
one of the rest of us could face the same nightmare.
It is critical that, in preparing its plan, the members of the Task Force distinguish
between access to insurance and access to health care. We at Citizen Action
understand the difference, as every day we hear from people around the country
who have iiad their insurance company deny payment for physician-ordered
treatment. One such person is Joan Ravenna from Evanston, Illinois, who met
with Vice President Gore last week to tell her story. When her son was in a
school bus accident and was taken by the Fire Department paramedics to the
nearest emergency room, her HMO refused to pay for his treatment. She was told
by the service representative at Micliael Reese HMO, "You'll have to cover this
one yourself, honey."
The nightmare facing millions of low-income and middle-income Americans is that
they cannot "cover this one" themselves.
The failure of the private insurance industry and market competition requires tfie
creation of a national health insurance system based on the following five
principles:
Universality.
must:
Everyone must be covered. To be t r u l y universal, i t
•Break the l i n k between employment and insurance, so t h a t
changes i n employment, retirement, or part-time/seasonal
�03/25/93
15 = 53
©202 296 4054
CITIZEN ACTION
eaployment does not r e s u l t i n breaks i n coverage or
d i s c o n t i n u i t y i n the source of care.
Employers should be
required t o c o n t r i b u t e t h e i r f a i r share t o the f i n a n c i n g of a
n a t i o n a l h e a l t h insurance system, but they should not bear the
r e s p o n s i b i l i t y of p r o v i d i n g coverage nor should they be
allowed t o decide on t h e i r employees' behalf issues such as
b e n e f i t packages, cost-sharing requirements, or choice of
providers.
•Cover a l l Americans equally under the same system operating
under uniform r u l e s , regardless of income, h e a l t h or
employment s t a t u s , age or l o c a t i o n . I f employers or others
are able t o purchase coverage on t h e i r own i n s t e a d of through
a single-payer or r e g i o n a l purchasing e n t i t y , the current
problems of adverse r i s k s e l e c t i o n , c o s t - s h i f t i n g , and m u l t i t i e r e d , d i s c r i m i n a t o r y care w i l l remain unresolved.
Comprehensiveness. I t must cover a l l needed h e a l t h care.
t r u l y comprehensive, the plan must:
To
be
•Provide coverage f o r a l l necessary s e r v i c e s , i n c l u d i n g
preventive t o long-term care, mental h e a l t h services and
p r e s c r i p t i o n drugs. This i s not j u s t sound h e a l t h p o l i c y but
sound economic p o l i c y ; since the l a r g e r the package of
b e n e f i t s included under the cost containment r u l e s of the
plan, the more e f f e c t i v e i t w i l l be i n meeting o v e r a l l
budgets.
•Allow p a t i e n t s and t h e i r providers t o determine what services
are medically needed — not insurance companies. As the case
of Joan Ravenna so c l e a r l y demonstrates, h e a l t h s e c u r i t y
cannot be achieved i f consumers know t h a t p r i v a t e insurance
companies can set up access roadblocks and a r b i t r a r i l y deny
payment f o r treatment ordered by medical p r o f e s s i o n a l s .
Affordability.
I t must be
i n d i v i d u a l s and f o r f a m i l i e s .
must:
a f f o r d a b l e f o r t h e country, f o r
To be t r u l y a f f o r d a b l e , the plan
•Be financed based on a b i l i t y t o pay.
"While f i n a n c i a l
p r o t e c t i o n f o r low-income i n d i v i d u a l s and
families i s
e s s e n t i a l , the concept of progressive f i n a n c i n g must extend t o
middle-class f a m i l i e s as w e l l .
•Eliminate copayments and deductibles t h a t act as f i n a n c i a l
b a r r i e r s t o care and add t o a d m i n i s t r a t i v e costs.
costsharing i s not an e f f e c t i v e method of reducing unnecessary
care, much of which i s p r o v i d e r and not consumer d r i v e n .
Cost-sharing i s too o f t e n a disguised f i n a n c i n g mechanism i n
which the cost of paying f o r h e a l t h care i s imposed on those
needing medical services, a " s i c k t a x " which i s regressive and
which w i l l block access t o needed care.
•Meet o v e r a l l g l o b a l budget caps by e l i m i n a t i n g a d m i n i s t r a t i v e
�03/25/93
15:53
© 2 0 2 296 4054
CITIZEN ACTION
waste,
unnecessary care, and expensive,
duplicative
technology. Any proposal must i n c l u d e a publicly-accountable
mechanism t o address the problem o f the medical arms race
which i s not j u s t c o n t r i b u t i n g t o the cost c r i s i s but t o the
erosion of q u a l i t y .
Freedom of Choice. I t must l e t American consumers choose t h e i r own
p r o v i d e r s . To provide r e a l freedom of choice, the p l a n must:
•Permit everyone t o choose t h e i r own providers w i t h o u t having
t o pay more f o r t h e r i g h t t o do so. M i l l i o n s of working class
Americans lack t h e disposable income t o pay an a d d i t i o n a l
premium every month i n order t o get the r i g h t t o choose, y e t
t h a t choice may be necessary t o them i n g e t t i n g access t o the
q u a l i t y p r o v i d e r s best able t o meet t h e i r h e a l t h care needs.
•Eliminate eaiployer c o n t r o l over h e a l t h plans which r e s t r i c t
access t o h e a l t h care providers.
•Ensure t h a t primary care providers and f a c i l i t i e s are located
i n medically underserved urban and r u r a l areas. P r o v i s i o n of
an insurance card i s an i n s u f f i c i e n t guarantee o f choice i f
t h e r e are no p r o v i d e r s w i t h i n t h e community from which t o
choose.
P u b l i c l y Accountable.
I t must l e t consumers and p r o v i d e r s shape
the system t o r e f l e c t t h e i r needs. To be p u b l i c l y accountable, the
plan must:
•Be administered by a n o n - p r o f i t , p u b l i c e n t i t y which i s both
responsive and responsible t o the community i t serves.
•Guarantee r o l e s f o r consumers and providers i n making a c t u a l
decisions.
For consumers t o be e f f e c t i v e i n representing
t h e i r own views, they need t o be given the i n f o r m a t i o n and
t e c h n i c a l assistance necessary t o be e f f e c t i v e p a r t i c i p a n t s .
C l e a r l y , t h e r e a r e many other important issues o f concern t o
C i t i z e n A c t i o n , but the above p r i n c i p l e s are a b s o l u t e l y e s s e n t i a l
components i n any comprehensive reform proposal.
We appreciate the Task Force's commitment and e f f o r t s t o solve the
nation's h e a l t h care c r i s i s and look forward t o working w i t h you.
11004
�Extended Page 1. 2
employment does not result i n breaks i n coverage or
discontinuity in the source of care.
Employers should be
required to contribute their f a i r share to the financing of a
national health insurance system, but they should not bear the
r e s p o n s i b i l i t y of providing coverage nor should they be
allowed to decide on their employees' behalf issues such as
benefit packages, cost-sharing requirements, or choice of
providers.
•cover a l l Americans equally under the same system operating
under uniform rules, regardless of income, health or
employment status, age or location. I f employers or others
are able to purchase coverage on their own instead of through
a single-payer or regional purchasing entity, the current
problems of adverse r i s k selection, cost-shifting, and multitiered, discriminatory care w i l l remain unresolved.
Comprehensiveness. I t must cover a l l needed health care.
t r u l y comprehensive, the plan must:
To be
•Provide coverage for a l l necessary services, including
preventive to long-term care, mental health services and
prescription drugs. This i s not j u s t sound health policy but
sound economic policy; since the larger the package of
benefits included under the cost containment r u l e s of the
plan, the more effective i t w i l l be in meeting overall
budgets.
•Allow patients and their providers to determine what services
are medically needed — not insurance companies. As the case
of Joan Ravenna so clearly demonstrates, health security
cannot be achieved i f consumers know that private insurance
companies can set up access roadblocks and a r b i t r a r i l y deny
payment for treatment ordered by medical professionals.
Affordability.
I t must be affordable for the country, for
individuals and for families. To be truly affordable, the plan
must:
•Be financed based on a b i l i t y to pay.
While f i n a n c i a l
protection for low-income individuals and families i s
e s s e n t i a l , the concept of progressive financing must extend to
middle-class families as well.
•Eliminate copayments and deductibles that act as f i n a n c i a l
b a r r i e r s to care and add to administrative costs.
Costsharing i s not an effective method of reducing unnecessary
care, much of which i s provider and not consumer driven.
Cost-sharing i s too often a disguised financing mechanism i n
which the cost of paying for health care i s imposed on those
needing medical services, a s i c k tax" which i s regressive and
which w i l l block access to needed care.
w
•Meet overall alobal budqet caps by eliminating administrative
�03/25/93
15:44
O202 296 4054
CITIZEN ACTION
21002
waste,
unnecessary care, and expensive,
duplicative
technology. Any proposal must include a publicly-accountable
mechanism t o address the problem o f the medical arms race
which i s not j u s t c o n t r i b u t i n g t o the cost c r i s i s but t o the
erosion o f q u a l i t y .
Freedom o f Choice, i t must l e t American consumers choose t h e i r own
providers. To provide r e a l freedom o f choice, the plan must:
•Permit everyone t o choose t h e i r own providers w i t h o u t having
t o pay more f o r t h e r i g h t t o do so. M i l l i o n s of working class
Americans lack t h e disposable income t o pay an a d d i t i o n a l
premium every month i n order t o get the r i g h t t o choose, y e t
t h a t choice may be necessary t o them i n g e t t i n g access t o the
q u a l i t y providers best able t o meet t h e i r h e a l t h care needs.
•Eliminate employer c o n t r o l over h e a l t h plans which r e s t r i c t
access t o h e a l t h care p r o v i d e r s .
•Ensure t h a t primary care p r o v i d e r s and f a c i l i t i e s are located
i n medically underserved urban and r u r a l areas. P r o v i s i o n of
an insurance card i s an i n s u f f i c i e n t guarantee o f choice i f
t h e r e are no providers w i t h i n t h e community from which t o
choose.
Publicly Accountable. I t must l e t consumers and providers shape
the system to r e f l e c t t h e i r needs. To be publicly accountable, the
plan must:
•Be administered by a n o n - p r o f i t , p u b l i c e n t i t y which i s both
responsive and responsible t o t h e community i t serves.
•Guarantee r o l e s f o r consumers and providers i n making actual
decisions.
For consumers t o be e f f e c t i v e i n representing
t h e i r own views, they need t o be given the i n f o r m a t i o n and
t e c h n i c a l assistance necessary t o be e f f e c t i v e p a r t i c i p a n t s .
C l e a r l y , t h e r e are many other important issues o f concern t o
C i t i z e n A c t i o n , but the above p r i n c i p l e s are absolutely e s s e n t i a l
components i n any comprehensive reform proposal.
We appreciate the Task Force's commitment and e f f o r t s t o solve the
nation's h e a l t h care c r i s i s and look forward t o working w i t h you.
�CHILDREN'S DEFENSE FUND
MEMBERS:
O r g a n i z a t i o n ' s i n t e r e s t e d i n C h i l d r e n ' s i s s u e s . Fund
research f o r children.
REPRESENTS:
50
TODAY'S SPEAKER:
C a r o l Regan, D i r e c t o r , H e a l t h A f f a i r s
(see a t t a c h e d b i o g r a p h y )
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
states
Respected i n media, e f f e c t i v e l o b b y i n g group on
c h i l d r e n ' s i s s u e s , s t r o n g grass r o o t s , s t r o n g
advocates f o r c h i l d r e n ' s i s s u e s
Managed C o m p e t i t i o n
The p r i o r i t i e s o f t h e CDF are as f o l l o w s .
C h i l d h e a l t h b e n e f i t s , i n c l u d i n g mental h e a l t h
u n i v e r s a l access; access t o m e d i c a l c a r e ;
comprehensive coverage-primary and p r e v e n t i v e
s e r v i c e s ; phase i n f i r s t , pregnant women and
c h i l d r e n ; a f f o r d a b l e premium based o f f a m i l y income
w i t h no c o s t s h a r i n g ; c o n t i n u i t y o f coveragep o r t a b l e ; ensure a v a i l a b i l i t y o f s e r v i c e s , i n v e s t i n
p u b l i c h e a l t h ; M e d i c a i d , poor peoples program;
t r a n s i t i o n i n t o a new system takes a number o f y e a r s
t o put i n place, put c h i l d r e n f i r s t
P o s i t i v e , w i l l p l a y around w i t h s t r u c t u r e as long as
i t meets needs o f c h i l d r e n , c o n t r i b u t o r s t o
campaign.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
Ira
PET
Children
ISSUES:
HOT BUTTON ISSUES:
Magaziner, OPL, T r a n s i t i o n
b e n e f i t s , p r i m a r y and p r e v e n t i v e
services
Opposed r a t i o n i n g aspects o f t h e Oregon P l a n .
�MPlR-26-1993
10:28
FROM CDF F&P 662-3553
TO
94566241
P.03
CAROL REGAN, M.P.H.
Carol Regan has been involved in health care policy and grassroots edvocacy
work for nearly twenty years. She is currently the Director of the Health Division at
the Children's Defense Fund in Washington, D.C, where she is responsible for the
Division's research, state and local technical assistance, policy development and
legislative activities for a broad array of health financing and maternal and child health
issues. Before joining the Children's Defense Fund in 1992, Ms. Regan worked for
the American Federation of State County and Municipal Employees and the Service
Employees International Union on a variety of health policy, research and organizing
projects. She also founded and directed a statewide health advocacy center in Rhode
Island from 1977 to 1981.
Ms. Regan has authored numerous publications, reports and journal articles and
has served on many health commissions, including the Medicaid Task Force of the
Health Policy Agenda for the American People, the National Leadership Coalition for
Health Care Reform, and the AFL-CIO Health Care Task Force. She received her B.A.
from the University of Rhode Island and her M.P.H. from the University of Michigan.
�MAR-26-1993 10:27
FROM CDF P8,P 662-3550
TO
94566241
P.02
Statement before the President's Task Force on Health Care Reform
Carol Regan, Health Director, Children's Defense Fund
March 29, 1993
Panel 11: "How can we ensure that all Americans have the security of quality,
affordable health coverage?"
SUMMARY America's failing health care system wastes resources and inflicts
unnecessary suffering, disease, and disability on far too many children and families.
The Children's Defense Fund shares the Task Force's goals to contain rising health
care costs, provide universal coverage and guarantee quality, accessible health
services to all Americans. Guaranteeing every American health insurance is essential
to cost containment and overall restructuring of the health care system.
To get a healthy start in life, all children and families must have financial access to
health care,
•
Coverage, if phased in, must begin with children and pregnant women;
•
Coverage must be comprehensive -- similar to the range of services
covered through the Medicaid EPSDT program emphasizing primary and
preventive care;
•
Coverage must be continuous and easily transportable;
•
Coverage must be affordable, with no copayments for preventive
services such as immunization, and with financial protection for lowincome families;
To ensure that coverage is affordable, reform must promote systemwide cost controls
which address not only provider fees but administrative complexity, red tape and the
increasing financial burden on families.
To provide security of coverage, the new plan must invest in the thousands of
medically underserved communities across the country in dire need of funds and staff
for the most basic primary care services.
�NATIONAL COUNCIL OF CHURCHES OF CHRIST IN THE USA
MEMBERS:
45 m i l l i o n C h r i s t i a n s i n the US
REPRESENTS:
32 member church bodies, i n c l u d i n g P r o t e s t a n t ,
Orthodox and Anglican churches. Of t h e 141,000
congregations across the country, the membership
includes 6 h i s t o r i c black churches, Quaker meeting
houses, Korean-Americans, and Orthodox churches.
Member o f t h e I n t e r r e l i g i o u s Health Care Access
Campaign.
TODAY'S SPEAKER:
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Mary Cooper, Associate D i r e c t o r
Found i n p r a c t i c a l l y every community, s t r o n g
grassroots network, they l i n k i n the nation's
ecumenical network—working r e l a t i o n s h i p s w i t h Roman
Catholic Church, Evangelical, Pentecostal
communities, Jewish and Muslim groups, foundations
and other n o n p r o f i t groups.
Single payer, s h i f t e d p o s i t i o n s t o look a t a v a r i e t y
of approaches.
C r i t e r i a f o r support on any h e a l t h care program
includes u n i v e r s a l access and a comprehensive
package o f b e n e f i t s . P u b l i c l y - f i n a n c e d through
income and corporate taxes; q u a l i t y o f care;
comprehensive b e n e f i t s package i n c l u d i n g preventive
care, h e a l t h promotion, education; primary and acute
care; extended care and r e h a b i l i t a t i v e services a t
home and i n i n s t i t u t i o n s ; mental h e a l t h ; cost
savings; simple f i n a n c i n g ; p a t i e n t choice; s t a t e
flexibility.
POSITION ON
PLAN:
Supportive, but wait and see
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n , OPL
PET ISSUES:
Universal access and comprehensive package o f
benefits
HOT BUTTON ISSUES: R e s t r i c t e d access, high costs.
�RCV
: 3-23-93 I 3:31PM :
BY:
CCITT 33*
SOCIAL OFFICE'.8 2
Biographical Information
Mary AndarsoD Cooper
Associate Director
Washington Office
National Council of the Churches of Christ in the U.S.A.
At the Council:
Mary Cooper serves as NCC liaison to officials i n the legislative and executive branches of federal governnent. She
shares Council views on domestic legislative concerns with
federal legislators and son!tors issues of interest to NCC
staff, member commmione and local ecumenical agencies,
keeping them updated on what government is doing.
An important part of her work i s writing and editing MARKUP, & monthly legislative newsletter for constituents of
the NCC, which provides in-depth analysis of iasuas before
Congress and regular status reports on a wide range of
legislative matters of concern to the religious ccmmunity.
Ms. Cooper represents the NCC i n a number of religious and
seculsr coalitions, campaigns and projects working or
priority issues. She represents the Council as a member of
the Emergency Food and Shelter National Board, a federally
funded program which provides emergency aid to victims of
economic difficulties.
Through i t , six private sector
nations! religious and social service agencies decide how
to channel millions of dollars i n federal funds annually
through local agencies (soup kitchens, church-run shelters,
food pantries, etc.) to those i n need.
Other examples of the groups with which Ms. Cooper works
include The Interreligious Health Care Access Campaign (of
which she i s Secretary), Interfaith Impact for Justice and
Peace(a social education and action network), Washington
Interreligious Staff Council, and The Ecumenical Decade:
Churches i n Solidarity with Women.
Previous
Pcsitions:
™ Acting Director, NCC Washington Office, 7/89-8/91.
— Assistant Director, NCC Washington Office, 5/77-6/89.
~ Various appointed staff positions at the NCC, 5/65-5/77— Secretary, St. Mark's Church, Washington, DC 5/62-4/65.
~ Secretary to Rep. John J. Riley (D-SC) 2/59-4/65.
Recent
Publications:
— Frequent articles for the IMPACT network.
— Chapter on "The Role of Religious and Nonprofit Organizations in Combating Homelessness" i n The Homeless i n
Contemporary Society. Sage Publications, for the Urban
Research Center, Univ. of Wisconsin, Milwaukee), 1986.
— Article on "The Working Poor," SEEDS Magazine. 8/87.
Chapter on "Overview of Homelessness", United Church
Board of Homeland Ministries resource manual, 198&.
-- Article on The Ecumenical Decade for Christian Social
Action magazine (United Methodist Church), October 1990.
�RCV BY:
: 3-23-S3 ; 3:32PM ;
CCITT G3-
SOCIAL OFFICE;*
Article on "Women as Heads of Households" in
Presbyterian Church magazine Church in Society, 1993Education:
— University of South Carolina, B.A. in English and 3.S.
in Business Administration, 1959.
-- George Washington University, Washington, D.C,, M.A. ir.
Legislative Affairs. 1978.
Affiliation:
Ms. Cooper i s an Episcopal layperson and attends St. Mark's
Episcopal Church on Capitol Hill, Washington, D.C.
At Hoae:
Ms. Cooper and her husband, Bert, live in Washington, D.C,
In her spare time she enjoys photography, gardening,
needlework, cocking and travel.
Issues:
Poverty (homelessness, welfare, uneoploynent, food
assistance)
Health Care
Children's issues
Women's issues
Church-state issues
Civil rights
3/93
�SENT BY: NCC WASH INSTON
; 3-25-93
1:53PM i
-i
2024567739; 8 2
National Council of the Churches of Christ in the USA
STATEMENT TO THE PRESIDENT'S HEALTH CARE TASK FORCE
on behalf of
the National Council of the Churches of Christ in the USA
March 29, 1993
I an Mary Andersen Cooper, Associate Director of the National
ngton
Jij!5?Jj
Council of Churches (NCC) Washington Office. I am also Secretary of the
Interreligious Health Care Access Caapaign, a national organization
which i s a cooperative project with the National Council of Churches.
Although the NCC was asked to be part of a panel representing
consumers, our
32 member communions and
their agencies
are also
employers, providers of health care, and advocates on behalf of those
whose health needs are unmet.
The National Council of Churches and the Interreligious Health Care
Access Campaign both support a publicly financed approach to health care
reform.
We have come to this conclusion after surveying our member
organizations and, in some cases, even local congregations to determine
their views on the matter. The message that has come back to us is one
of strong support for public financing.
The National Council's policy calls for creation of a health care
system that i s :
— universal, providing quality care as a matter of right to every
person living in the U.S.:
~
accessible, providing services without restrictions based on
place of residence, citizenship, or ability to pay; and
—
comprehensive, including: preventive, prenatal and maternity,
diagnostic, dental and long-term care; treatment for illnesses;
rehabilitation; mental health services; and drug and substance
abuse treatment.
110 Maryland Avenue, N.E.
•
Waahington, D.C. 20002
•
202-544* 2350
�SENT BY:NCC WASHINQTON
; 3-25-93
1:54PM ;
^
2024567739;8 3
Such services should include continuity of care, removing barriers that
now prevent patients from moving easily among providers to access whatever
service is appropriate for them at any point in their illness.
We believe that the health of our nation's people has deteriorated to
such a point
that we cannot wait any longer
for universal access to
comprehensive health services. Incremental reform of the system, in our view,
would not be adequate to meet the needs of the people in this nation.
believe that this is the time for systemic reform.
We
This nation is paying
enough now for every man, woman and child in the country to have adequate
health care. The problem is distribution.
We believe that payment for the health care system should be on the basis
of ability to pay, and that lack of funds should not prevent people from
having access to service.
We know that poverty often keeps people from
seeking medical help until their conditions have become both life-threatening
and extremely expensive to treat.
We know this through the experiences of
hospitals, nursing homes and rehabilitation facilities operated by our member
communions, and because our local parish churches are extensively involved in
providing health services in their communities. But we know i t also through
the experiences of our church members who are victims of the present system's
inadequacy, people whose poverty or unemployment leaves them outside the
system and makes them become subjects of charity in order to receive the
health care services which they should have by right.
We are convinced that the national treasury i s now bearing massive costs
associated with the failure to provide adequate health care to all our people.
There are the direct expenses of maintaining people on welfare. Supplemental
Security Income, Social Security Disability, Medicaid and Medicare whose
physical or mental conditions are allowed —
by lack of access to health
�SENT BY:NCC WASHINGTON
care ~
; 3-25-93
1:54PM ;
2024567739;8 4
to deteriorate to the point that they are now unable to be self-
supporting.
There are other massive, but less clearly identifiable, costs to
the society that result from foregone productivity and lost tax revenues and
purchasing power. The prevention of such waste of human potential would help
to reduce the cost of a universally accessible and comprehensive health care
system.
I t would also be good stewardship.
However, we believe that
universal access to health care should be provided because i t is in the best
interest of the nation and because i t is morally the right thing to do, not
because i t could save money.
The National Council of Churches and the Interreligious Health Care
Access Campaign support a publicly financed health care system because of
their commitment to social justice. I t is the NCC's belief that in matters of
health the rights and well-being of one group in society cannot be secured
without securing them for a l l .
Consequently, we believe that a health care system which makes the same
quality of services available to every person living in the U.S. is the only
just system for this nation; and we believe i t should be funded through taxes
on Individuals and corporations, gathered on the basis of ability to pay.
FOR FURTHER INFORMATION: Contact Mary Anderson Cooper, National Council of
Churches Washington Office, 110 Maryland Ave., N.E., Washington. D.C. 20002
(202-544-2350).
�MENTAL HEALTH LIAISON GROUP
MEMBERS:
C o a l i t i o n o f more t h a n 33 n a t i o n a l o r g a n i z a t i o n s
across t h e U n i t e d S t a t e s t h a t share c o n c e r n f o r
mental h e a l t h i s s u e s i n c l u d i n g N a t i o n a l M e n t a l
Health Association, National A l l i a n c e f o r t h e
M e n t a l l y 111, American P s y c h i a t r i c A s s o c i a t i o n
REPRESENTS:
Grassroots, Consumers, Family Advocacy, and
P r o v i d e r s O r g a n i z a t i o n s i n 50 s t a t e s .
TODAY'S SPEAKER:
Leslie Scalett,
SCOPE OF
INFLUENCE:
Coordinated message p r o v i d e s r e l a t i v e
APPROACH TO
REFORM:
Concerned about coverage more t h a n approach
SUMMARY OF
POSITION:
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
HOT BUTTON ISSUES:
Chair
influence.
The Mental H e a l t h L i a i s o n Group seeks t o promote a
p l a n t h a t s u p p o r t s mental h e a l t h s e r v i c e s , i n c l u d i n g
b o t h acute and r e h a b i l i t a t i v e s e r v i c e s , i n a system
which p r o v i d e s access f o r a l l Americans.
Wait and see, dependent on b e n e f i t package
S e v e r a l meetings w i t h members o f t h e M e n t a l
Task Group, Mrs. Gore
Health
D i s c r i m i n a t i o n i n b e n e f i t package a g a i n s t m e n t a l
illness
�Mental Health Liaison Group
Representative
Leslie Seallet
Chair
L e s l i e J. S c a l l e t graduated from Washington U n i v e r s i t y i n
St. Louis w i t h a degree i n h i s t o r y and received her law degree
from the U n i v e r s i t y of Pennsylvania. During the 1970s she served
as law c l e r k t o Chief Judge David L. Bazelon o f the U.S. Court of
Appeals f o r t h e D i s t r i c t of Columbia, and as Special Assistant t o
the D i r e c t o r o f the National I n s t i t u t e of Mental Health. She was
the f i r s t d i r e c t o r of the p o l i c y advocacy program o f the Mental
Health Law P r o j e c t . A f t e r several years as a consultant i n
mental h e a l t h and human services p o l i c y , she founded the Mental
Health P o l i c y Resource Center, a n o n p r o f i t o r g a n i z a t i o n , i n 1987.
Ms. S c a l l e t has served as the elected c h a i r o f the Mental Health
Liaison Group since 1991.
�mR 25 '93 14:21
10:4566241
5505
FROM: POL ICY RESOURCE CTR
T-486 P. 03
ORAL PRESENTATION BY LESLIE J. SCALLET
CHAIR, MENTAL HEALTH LIAISON GROUP
EXECUTIVE DIRECTOR, MENTAL HEALTH POLICY RESOURCE CENTER
Panel 11, Health Care Task Force
March 29, 1993
I am pleased to have this opportunity to discuss an area of healthcare that touches the
lives of nearly every American at one time or another—mental health. We are grateful to this
Administration for being so responsive to the mental health needs of our people and for the
leadership both Mrs. Clinton and Mrs. Gore have demonstrated in bringing about this long
overdue change in attitude.
There is a question of simple, elemental fairness confronting this Task Force as it goes
about the design of a healthcare reform package: How can we ensure all Americans the security
of quality, affordable health coverage? Our message to you today is that it is impossible to reach
that goal unless mental healthcare is fully integrated into the benefit package on the same terms
as other healthcare services.
One out of every five adults has a diagnosable mental disorder, yet fewer than 20% of
those needing care ever receive it. Only about two million of the seven million children and
adolescents who need some type of help for a mental or emotional disorder receive it. Total
direct and indirect costs of mental disorders in 1990 were estimated at $148 billion. Many
people are surprised to hear these statistics. They believe that mental disorders only happen
"to someone else." But mental illness knows no class, sex, race, or age limitations.
37 million Americans have no health insurance, and probably 50 million are
underinsured. But those who do have some form of coverage are all too often shockedtofind that
when mental illness strikes, just when they need it most, their insurance falls short.
How does this happen? First is the rank discrimination which pervades private
insurance coverage and public programs alike—which imposes limits on mental health services
not applied against comparable services for physical healthcare. Examples abound. In private
insurance higher copayments and deductibles, separate annual and lifetime caps on mental
health coverage, pre-existing condition exclusions, severe special limitations on days or visits
for treatment
aH descend on the person seeking help like huge iron gates blocking access to
needed care. Just three examples will make the point.
A young woman who once worked for me had received short-term treatment for
depression while she was in college—not an uncommon problem. She was told that she was
disqualified—completely—-from our health insurance plan because actuarially she was a high
risk. Another example: a friend had a serious episode of manic depressive illness, was
hospitalized and successfully treated, and returned to work. Several years later, feeling
another depression coming on, he sought help. But this time my friend was told that his first
episode had used up his lifetime limit for "nervous and mental disorders" and he had no
coverage. Finally, there was the woman who was told that she would have to pay the full cost of
outpatient care out of pocket, because under her policy the need for hospitalization was the only
way tc demonstrate that her condition was "serious" enough to justify coverage.
�MAR 25 '93 14:21
10:4565241
5505
FROM:POLICY RESOURCE CTR T-486 P.04
If this happened to someone with, say, heart disease, people would be outraged. Heart
conditions range from mild to severe, yet sometimes minor symptoms can mask serious
disorders, and some serbus conditions like hypertension may have no overt symptoms. Some
conditions become worse over time, while others remain relatively static. No one suggests
waiting until after a heart attack to be sure that the condition is "serious enough* to warrant
insurance coverage. And even though heart attacks certainly are expensive to treat, no one sets
a special, lower lifetime limit for this treatment.
Obviously, these horror stories strongly discourage many people from ever seeking
mental health services, even if they know they need them. They, and their employers, and our
whole society pay a hidden price for that. Others find themselves locked into jobs because they
know they will be turned down for health insurance (and not only mental health coverage) if
they try to move.
And these obstacles are not reserved for those fortunate enough to have some insurance
coverage. They are also found in the public programs intended to provide a safety net for
individuals locked out of the private insurance market Many people have the mistaken belief
that when their insurance runs out they can simply move over into the public mental health
system. In fact, one of the justifications offered for discrimination against mental health in
private insurance is that there is a public system. But it is now very difficult if not impossible
to access public mental health services unless one has been committed by a court or is eligible
for Medicaid. In other words, the cost of treatment is to forfeit your liberty or to spend down
all your assets. Families are faced with the reality that their child wili be eligible for services
if only they sign away custody to the state. And even then the services are limited.
Discrimination against mental healthcare also distorts the costs and structure of mental
health care. If coverage for hospitalization is favored over less restrictive (and less costly)
alternatives, we should not be surprised at the number of hospital beds devoted to mental health.
Limitations imposed with the intent to control costs produce the perverse effect of actually
increasing them. We know that emphasizing front-end care and early intervention will save
people from having to wait until their condition and their suffering reach crisis proportions
before they can obtain help, and will save the whole system the costs of expensive and
unnecessary hospitalization. We know that early identification and management of even the most
serious mental health problems can reduce high cost hospitalizations by maintaining persons in
more appropriate community settings. We know that people in need of treatment are in danger
of losing their job and often their housing. But denying or severely limiting access to less
intensive care creates a disincentive and often an Insurmountable obstacle to early treatment.
We cannot afford to be penny wise and pound foolish.
The answer to cost containment does not lie in denying access to needed care, but assuring
access to a comprehensive continuum of services so that people receive the appropriate and
effective treatment as early as possible. That's the best way both to save money and to prevent
needless suffering.
The opportunity now exists to eliminate discrimination against persons with mental
disorders once and for all. Two simple steps are necessary to provide Americans with the
Statement of Leslie J . Scallet
2
�MAR 25 '93 14:22
10:4566241
5505
FROM:POLICY RFSOURCE CTR
T-486 P. 05
security of quality, affordable mental health coverage: First—Integrate mental healthcare into
the mainstream of general healthcare, and Second—Wipe out those invidious insurance and
programmatic barriers to mental health sen/ices which have caused so much anguish,
impoverishment, and pain to persons with mental disorders and their families.
Research—as well as common sense—increasingly confirms the inter-relationship
between mind and body. There is little justification for continuing the historic mistake of
separating one from the other, and relegating mental health to a lower status.
Mental health in fact provides a great example of why it's important for ALL Americans
and all healthcare to be covered under the same rules. The state-run public mental health
system has been expected to fill the gaps in private sector coverage. And more than half of
mental health care is now provided by the general healthcare system, not by mental health
specialists. The separation of mental health treament andfinancingfromother elements of
health care has provided an irresistable temptation to game the system—to manipulate diagnoses
in order either to assure reimbursement or to push people and costs from one system to the
other. It has, in some respects, produced a shell game in which the person needing treatment
has been the inevitable loser.
Having urged a single integrated approach, however, my remarks should not be
construed as a condemnation of the public mental health system. That system has played a vital
and often pivotal role in providing care under the most difficult of circumstances. Any reform
initiative must encourage and retain an appropriate state role that builds upon their hard-won
learning and successes, particularly in developing comprehensive systems of care to serve
adults with serious mental illnesses and children with serious emotional disorders. The state
mental health systems will surely change under the new order, but that change must be focused
in a way that encourages and does not destroy these key elements of the delivery system for our
most vulnerable citizens.
We believe the experience of the mentai health field can be useful to you as you proceed
with the overall reform effort My colleagues in the Mental Health Liaison Group and I stand
ready to share that experience with you and to assist you in your monumental task of reforming
our healthcare system. We have provided the Administration with a Transition Briefing on
Mental Health, laying out seven key principles essential to mental health in healthcare reform.
A detailed set of Recommendations for how mental health can be built into the reform package,
based on those principles, has been endorsed by over thirty major mental health organizations
(and more are expected to join).
I have stressed the issue of discrimination in my remarks because so many of our fellow
citizens have borne the burden it imposes on them socially, financially, and therapeutically. A
separate system—even if it were a separate but equal system—is no better for mental health
today than it was for the civil rights of African Americans in the days of Plessy v. Ferguson.
This Task Force has set a goal to ensure quality as well as affordable care for ail Americans.
Integrating mental health within the overall healthcare system will not only end the invidious
discrimination against people with specific mental health needs. It will also save money by
reducing duplication and ending perverse incentives for high-cost care. And it will assure that
the overall system cares for the mental as well as the physical dimension of health.
Statement of Leslie J. Scallet
�CAMPAIGN FOR WOMEN'S HEALTH
MEMBERS:
Members o f a broad c o a l i t i o n of over 70
organizations committed t o ensuring t h a t women's
h e a l t h needs are addressed i n the debate o f h e a l t h
reform.
REPRESENTS:
8 m i l l i o n members nationwide representing women's
groups, unions, and health care organizations and
i n c l u d i n g Older Women's League, Planned Parenthood
Federation o f America, YMCA of the USA, NARAL, and
Black Women's Agenda.
TODAY'S SPEAKERS:
Joan Kuriansky,
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Executive D i r e c t o r
Active grass r o o t s , hot issue i n Congress, and
p o l i t i c a l clout
Not s p e c i f i c
Universal access and a comprehensive b e n e f i t s
package t h a t meets the needs o f women, i n c l u d i n g
maintenance and promotion i n c l u d i n g primary and
preventive services and primary and preventive
reproductive h e a l t h care; long term c a r e — r e s p i t e ,
spend down, e f f e c t i v e immediately, home care; h e a l t h
care d e l i v e r y i n a v a r i e t y of s e t t i n g s ; h e a l t h care
d e l i v e r e d by a v a r i e t y o f providers; community based
programs; f i n a n c i n g and a c c o u n t a b i l i t y .
POSITION ON
PLAN:
Wait and see, but ready f o r b a t t l e i f needs not met
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
O f f i c e o f Public Liaison and I r a Magaziner
PET ISSUES:
Preventative and reproductive h e a l t h care
HOT BUTTON ISSUES:
No v a r i a b i l i t y on b e n e f i t s package
�MAR 25 '93 18:54
OWL
139 P05
Profile of
Joan A. Kuriansky
J
o
a
^ J ^ f
n
s
k
y
i s
t
h
e
Executive D i r e c t o r of t h e o l d e r Women's
lolllt
, . "
membership o ^ g L i z a U o n
s o l e l y devoted t o improving the l i v e s and status of m i d l i f e and
0W
L
t
h
e
0 n l y
S
seven l l l Z s ™ ^
^
t
n a t i o n a l
e
S
'
0
W
L
h
a
S
1 2 0
c h
*P
t e r s
i n tSi?Sy
As D i r e c t o r of OWL, Ms. Kuriansky promotes changes i n p u b l i c
p o l i c y on f e d e r a l and s t a t e l e v e l s , she speaks before Congress, t o
the press, and l e c t u r e s extensively on such issues as h e a l t h care
reform, s o c i a l s e c u r i t y and pension e q u i t y , and employment
challenges facing m i d l i f e and older women.
employment
t h f t
o n v e n e r
o f
t h e
ic: * ™ i f ;
;
Campaign f o r Women's Health, which
i s a c o a l i t i o n of over seventy women and labor groups q i v i n q women
a powerful voice i n today's health care debate
V ^ i n q women
4
K u
i a n s k
tr-i^^?; ^
y received her law degree from t h e U n i v e r s i t y of
r i ^ S i ^ f
was awarded a CORO Fellowship i n Public A f f a i r i i n
C a l i f o r n i a , a t which time she earned a master's degree i n Urban
AH 9. UTS •
0
r C
l e
a S
C W L
S
E x e c u t
iSl^** ^
^
'
i v e D i r e c t o r , Ms. Kuriansky
T L ^
f
^ Against Abuse, a m u l t i - f a c e t e d
oST?^
°
Program serving over 20,000 b a t t e r e d women and
c h i l d r e n each year i n Philadelphia.
n
1 0
t
V
K
X
1
V
D l r e c : t o r
l
e
n
c
o f
W o B 1
e
r i a n s k
1.1' ^
y
served on numerous boards i n c l u d i n g Women's
Way, t h e Pennsylvania C o a l i t i o n Against Domestic Violence, t h e
Mayor's Commission f o r Women i n Philadelphia, t h e Women's Legal
Defense Fund, the center f o r E f f e c t i v e Public P o l i c y , and the
Consumer board of the American Health Care Association.
Ms. Kuriansky was named "A Woman of v i s i o n " by the MS
Foundation and was presented one o f s i x 1992 G l o r i a Steinmen
awards,
�MPR 25 ' 9 3 1 8 : 5 2
OWL
139 ?02
C/XIVIPAIGIM
TT A T
F O R
WOMENS
I IEALTI i
TESTIMONY OF JOAN A. KURIANSKY
Chair
The Campaign for Women's Health
before
The White House Health Care Task Force
March 29, 1993
Women's requirements for health and well being have largely been ignored by the current health
care system. Medical research, health care delivery and payment systems have failed to address
women's changing needs. Women's health is like the health of men in the importance of
maintaining good health, preventing disease and disability, treating illness and creating the
circumstances for the optimal well being of every individual. Women's health also includes
diseases and conditions which affect women differently than men or which are unique, more
prevalent or more serious in women. Any reform of the current health system must include a
renewed understanding of women's reproductive health. A number of often severe chronic and
acute diseases disproportionately affect women such as lupus, arthritis and osteoporsis. Women
are the fastest growing segment of the population with HIV, Women live an average of seven
years longer than men and are more likely to suffer from chronic diseases, thus, they are in
special need of adequate long-term care services.
In addition to biological differences, social and economic factors conspire to impede women's
access to quality care. Currently twelve million women have no health insurance of any kind.
Millions more have inadequate coverage tenuously based on either their marital status or
employment. Almost 60% of men have health coverage through their jobs whereas just 37%
of women have employment based health insurance. Women are more likely to be employed
in small business or low paying jobs in the clerical, administrative and service sectors which
offers few health care benefits. Only 19% of the thirty-five million women who worked for
businesses with fewer than 100 employees in 1989 had private group health insurance. Only
24% of women working in the service industry in 1990 had group health insurance. In addition
two-thirds of part-time workers are women. In 1990, 67% of the uninsured part-time midlife
workers were women.Health insurance through an employer is made even more tenuous because
women are more likely to go in and out of the workforce (an average of 11.5 years) primarily
because of caregiving responsibilities.
Thirty percent of women obtain group insurance as spouses or dependents yet many companies
have cut back on dependent coverage. And when a woman's marital status changes she faces
even greater barriers. Some women may become eligible for continued health insurance under
A Project of O W L
666 Eleventh Street, NW, Suite 700. Washington. DC 20001
(202).783-6686
FAX (202; 633-2356
�MRR 25 '93 IS:53
OWL
139 P03
COBRA, but such coverage is limited to a, miximum of 36 months- and one is only eligible if her
husband's employer employs 20 or more workers.
Affordability is also a barrier to care for many women. The mean income of a woman is about
half of that of men. Three-quarters of the elderly who are poor are women. The average
income of a woman over 65 average is $8,044. Despite the existence of Medicare, she already
spends up to 30% for out of pocket health care costs.
-Access
For all of these reasons, the Campaign for Women's Health (CWH), believes that universal
health care is a right of every individual in this country. It should not be based on employment
or marital status. A single tier of care shoulfl be available and it should include a comprehensive
benefits package. In a multi tier system, women will more often than not be ghettoized into the
lowest option plans. Either their employers, who currently'offer no insurance, will purchase the
least expensive and comprehensive plan or those women not in the workforce will only be able
to afford the lowest option plan.
The Campaign believes that the system should not permit large employers to opt out of the
national plan. Individuals must be guaranteed continuity of covergae regardless of thier
employment.
Further, it is our understanding that under a managed competitive model some cooperatives may
have to cover great physical distance to ensure the availability of a choice of plans. In such a
scenario poor women, struggling with child care or restrictive jobs, may be unable to access the
plans which they can afford.
The structure of such a plan should provide access to a variety of plans and providers
i
in various
settings including community-based care.
Bgngfils
Key to such a plan is a comprehensive benefits package for which a broad standard must be
developed. The CWH recommends the following language in establishing this standard:
AU services which are necessary or appropriate for the maintenance and promotion
of {women's) health. We do not recommend the application of a medically necessary standard
because we believes it contradicts the goal of comprehensive health reform particularly in the
provision of preventive and reproductive services, as well as long term care.
The CWH supports a system of preventive and primary care which includes periodic
history and physical exams. Such an exam would include blood pressure checks, urinalysis,
total blood and cholesterol tests, screening for osteoporsis, mental health, dental, vision care,
speech and hearing.. Access to affordable prescription drugs and devices should be included.
Evaluations also necessary for.nutrition, drug and substance use, harrassment and violence
prevention are also necessary. For instance, every 15 seconds a woman is beaten in her own
home. Routine domestic violence screening by health professionals, recently endorsed by the
AMA, is still uncommon but essential.
�MPR 25 ' 9 3 1 8 : 5 3
OWL
1
3
9
P
0
4
Reproductive health services are an insaperable part of primary and preventive services
for women. The full complement of reproductive services are linked to one another and a
continuum of services over the course must precede, include, and follow the child bearing years.
Regular periodic gynecological history and exam is primary care for women. Family planning
services reduce the incidence of unplanned pregnancies. The availability of safe affordable
abortions is associated with decline in maternal mortality, low birth weight infants and neonatal
mortality, We will be unable to support a plan which does not include abonion as well as other
needed reproductive services. Infertility affects 1 in 12 couples in the U.S. and the majority of
infertile couples require conventional treatments. We also recommend evaluation and counseling
for sexually transmitted diseases and menopause.
A full range of long-term care services must be incorporated into one comprehensive benefits
package. The Campaign supports a program with its priority being the provision of home and
community based services and the protection from impoverishment for those families whose
members must go into an institution. Services should ultimately be available in all settings and
support people with cognitive and mental impairments as well as those having difficulty with one
or more ADL's or lADL's. While costs may initially prohibit the provision of a full range of
services in all settings, the financing and administrative mechanism must be put in place at the
onset.
Acountability
Lastly, the CWH recognises that health care needs will evolve with complementary treatments
and services. The health system must mandate a mechanism for the inclusion of representatives
of the women's health community in all decision-making boards, commissions and other
advisory and regulatory bodies. Women are no more monolithic than any other group and as
such, representatives must include those of different races, ages, income levels, and sexual
orientation.
Summary
In summation, we do believe America can offer its residents appropriate health care.
All Americans will have the security of health care coverage if access to health care is not tied
to employment or one's marital status.
Affordable health care can only be achieved through a system with little or no cost sharing.
Where cost sharing exists it must be tied to one's ability to pay and in a system that controls
costs. Such a system must be defined by regulator}' or legislative bodies that include broad
based comsumer representatives;
Quality health care will be achievable when a comprehensive set of benefits includes preventive,
reproductive, and long term care services.
We are grateful to be given an opportunity to present this testimony today. On behalf .of the
52% of the population which we represent, we thank you.
�AMERICAN COUNCIL FOR HEALTH CARE REFORM
MEMBERS:
Drawn from t h e g e n e r a l
REPRESENTS:
A g r a s s r o o t s consumer a s s o c i a t i o n t o p r o t e c t and
i n f o r m consumers.
TODAY'S SPEAKERS:
W i l l i a m Shaker, E x e c u t i v e D i r e c t o r
SCOPE OF
INFLUENCE:
Grass r o o t s a t t h e F e d e r a l l e v e l
APPROACH TO
REFORM:
Non-committed
SUMMARY OF
POSITION:
public—consumers.
The c o u n c i l s u p p o r t s e l i m i n a t i n g a d m i n i s t r a t i v e r e d
t a p e , changing i n s u r a n c e r e f o r m , r e f o r m i n g
m a l p r a c t i c e i s s u e s , and p r o v i d i n g g u a l i t y o f care t o
a l l Americans.
POSITION ON
PLAN:
Wait and see
PET ISSUES:
Health care reform
HOT BUTTON ISSUES: H e a l t h c a r e r e f o r m
�RCV BYiTne White House
; 3-26-93 ; 4:27PM ;
SOCIAL OFFICE-
1
nwv y i
AMERICAN
COUNCIL
FOE
HEALTH CASE
REFORM
AriiagtomVIniRiilZM?
Testimony prepared for meeting of
The Presidents Task Force on Health Care Reform
Presented on Monday, March 29* 1992
Health Care Reform Proposal of the
American Council for Health Care Reform
and
Analysis of other reform proposals under consideration
by the Task Force
*U 6
�RCV BYJThe White House
i 3-26-93 I 4:27PM !
1
SOCIAL OFFICE-
;« 8
Tho American Council for Health Care Reform
Ihe Americart Council for Health Care Reform (Amcrictn Council) vw established in 1 m
with ihe purpose of oonsumer protection, the elimination of government interference, and the costeffective dclivciy of quality health care, Werepresentthe public tntciest and believe infomuoion about
procedures and pracrjtioners should be fully available to the consumer and that medidne should operate
in a market environmentfreeof unnecenaiyregulations.We wen: asked by the President's Health Caiv
Task Force for our views on ccntiollmg health care costs and providing security to every Anwrican family white maintaining quality. This is our testimony, as presented to the Task Foree on March 29, !W
Wc believe that we can adapt certain provisions from the health delivery systems of other countries and borrow ihjm parts of "managed care" programs proposed fbr this country, Lets use only those
pans that do not limit individualfreedom,and ngect those jam that would ration care, create unneceswiy ;ind wastefulregulationand coerce consumers with oppressiverestrictionson individual choice.
As consumer advocates with only the public interest to protect, the American Council
troubled that legislation might move too rapidly to be properly thought out We are concern
ill-crtrKX'ived and shcrtsigfoed programs are installed, they will be impossible to eliminate
form farm subsidies are an example of what 1 mean. James Bovard, author of The Ftam Fi
mutus the farm program costs $30 billion a year in higher ft«J prices and taxes. But no way
ilkonucived program be eliminated We agree with Ross Perot in that yourrecommendationssh
not Iv implemented across the board without first conducting pilot tests. Ottrtesdtmty wMbe
recimtmcndatiom qf the American Councft fo&wed by a bfi^anafysis tfsotm cftht mmpopute
posals lo wliieh we think die Task Force may beghingserifmconsldtretkm.
imerican Council for Health Cm' Rtforn Recommendations-Summary
t iimin^rcdt^Elimingie Certificate of Public Need requirements, health planning agencies
, jytf utilizationreviewoiganizations. The skyrocketing cost of
health care (going irom some $70 billion in the early \vm to
approaching $1 thi lion today) combined withreducedacoww to
care leaves little doubt in anyone's mind that healthreformts
long overdue. The stifling regulation of health care began in curnest in 1973-1974 with passage of the National Health Planniitg
Act, Certificate of Public Need (COPN) legislation, the creaiion
of state health planning agencies and later with "proftssionaJ
standardrevieworjjaniations. I could All volumes with homv
HtoneH. but I'll give just a couple examples. It cost a 430 bed hospital in the San Ftancisoo Bay Area S7 x
millron uvefy year just to comply with bureaucraticregulations.276 people of the hospitais 734 person
vtaJVdevote full time toregulatorycompliance.
A IKTsonat exzmnWi Total Patient Care (TPC) provided
nursinii care to private and hospice patients in Northern Virginia,
The company provided excellent care at relative low cost.
Although services were desired by Medicare patients. I'PC was
prohibited from providing care to these patients because IPC was
not ii certified Medicare provider, The federallyftmdedHealth
™
^
Systems Agency told TPC not to bother tc submit an application CORN APPUCATIONO"'! it"
Paget
�RCV BY/The White House
i, 3-2(3-93. : v q n :
SOCIAL OFFKfr^
o y
,
1 M t
^.^^9
#
for cerrificition, linee no new aeency had been approved sinw the COPN lawforhome health
agencies had been passed some 5 years earlier. My wife (at the time president of Total Paiicm
Ca/e) said to the government planner, "watch m& " This is volume 1 of the three volume application After a 3-yew battle consisting of several legal appeals, the application was sventuaf ly
approvijd The attached WALL STREET JOURNAL uditorial highlights the government's urgument against allowing competition by my wife's compjny These are just two examples of how
government red tape increases the cost of health care to the consumer.
2.
lnHurrtncc Refonn: Much of this portion of our telorm recommendation presumes that insurance
thr high risk people will be subsidized by society in general. Wc propose mandating that all Insumnce
companies offer a defined package of standard benefits to anyone who applies for coverage. (The package should include high catastrophic limits on policies.) The American Council proposal would produce
outcomes similar to those envisioned by proposed "managed care" plans (in which consumers arc orjjaniwd into large pools in order to get better insurance rates) I Jnder our approach, this can be eccom<
piishod without the "red tape** and the poor quality of can uguafy associated with managed care
(llfvK >'* |. Insurance companies would be required to offer the same rates to all persons living within
"standard sttti.tbcal areas." All insumaoe plans must accept high cost, high risk individuals and families
These high ask people would be subsidized by the general i»pulation through slightly higher premium
rates for ewryhody, The healthier policy hota would raetverebatesvia the incentive system described below. Maximum freedom of choice is provided hv spreading the risk among all policy holders.
Competitors, playing by the same rules will tend to hold rates down. In addition, we would require msuram: companiestopay into a cemral reinsurance fund to protect individuals in the event that an insurance
company goes bankrupt (similar in concept to FDIC insurance paid by banks). Individuals who lose coverage would be allocated to other carriers, Insurance compimies would be:
Prohibitedfromdenying or limiting health oovemgei due to preexisting conditions.
Prohibited from canceling policies or raising individualratesdue to illness.
ttequiredtosell insurance tc all individuals at the same premium rates. Thus those who
lose a job could get insurance atreasonablerates,
Other aspects of our insurancereformproposal include:
1 Eliminating tax credits to both individuals and companies fbr insurance coverage above a specified amount By eliminating excessive tax subsidies, insurance will tend to become pure
insurance, as opposed to essentially''prepaid' medical coverage, By definition,
insurance is not intended to pay fbr routine expenses, such as tooth aches, and budgdahie
expenses. The present system hides the cost of health carefromthe consumer, and thi*
encourages excessive use of the health care system
An incentive system. Our proposal would be a projiram by which policy hokfcit would get
annualrebateswhen insurance claims fbr the ytsar are some specific percentage less than
overall experience for the insurance company (similar in concept to the Medicare I )R( i
scheme).
Allow tax-deduotible "Medi-save" accounts (similar to IRA's), This would allow individuais lo
become partially self-insured, over time. Withdrawalsfromthis account could only k
taken tax free for legitinme medical purposes,
1
P^2
�RCV BYJThe White House
; 3-26-93 ; 4:29PM ;
SOCIAL OFFICE-*
_
I M I
i i r r
,
L
iflO
1
KHiirm of Mwlicwre and Mcdicak) Medicare ancl Medicaid, as we know them would be diminatcd Ihe money saved by eliminating the bureaucracy andredtape would provide funds to greatly expend the universe of people covered The money budgeted for these programs could be used by the
governmenttopurchase private policies for those covered under the Medicare and Medicaid programs
Individuals could be offered the option of selecting their own insurance company by use of vouchers
Those not electing to shop for their own company could Iw assigned to an insurer by the government. Insurance companies in the various areas of the country would competeforthe business,forcinga downward pressure on the premiums the government would pay lor.
1
MHipmcticc I*gal Reform! An orthopedic surgeon in Canada pays $10,000 a yearformalpracticc insurance; the same coverage in the United States COM $45,000 a year. Malpractice legal reform
should be a part of therecommendationsof the Task Forec
5.
tMtKty uf CHTC. The vast msgority of medical practitioner are honest and provide good quality
canv 1 kiwever, the consumer must be protected against im-ompctent doctors. Physicians can lose their
heenst; in one state and move to another and continue practicing on unsuspecting patients, State reguluuv
ty agencies allow physicians and surgeons to practice, even after they have had multiple convictions lor
malpractice. The medical community has demonstrated that it cannotregulateand discipline itself, and it
is vital that health care consumers have the &cts on doctor competence so they can make infomed dovisiom Congressfondeda computer system (The National hactitioner Data Bank)tokeep track of all
malpmctice and disciplinary actions taken against doctors at an initial cost to taxpayers of $15.9 million
The annual operating cost is about $4 million. Congress has blocked consiaaer aeowtothis vital inibrmation. Some of therefonnproposal under consideration hy the Task Force, especially the managed
care pruposaJf will make it essential that legislation making this data base availabletoconsumers he
pUKSUi
Anufyshi t)f other Heahh Cm Reform Proposals
Along with providing ourrecommendationsforhealth care public policyrefonn,we had hoped
to provide specificrecommendationson ideas the Task Fon* is actively considering, Wefiledour law
suit to thai end:toopen up the process. Although we won the low suit fn Federal District Court, the HIXI
1 Jidv is uppealing. Ifs beenreportedthat the Task Force believes "giving the public accesstomemings
would lead to public interference in the taskforceactions" If true, this is troubling to the American
Council Without anything more specific, we oflTcr thefollowinganalysis of proposals which vre think,
based on scloctive press leaks, the Task Force may be actively considering:
MaiwiPsdC omiK-iitkm
At this point, a "managed competition" model seems the most likelyrecommendationof the I iwk
l orctf there are two basic approaches to so-called managed competition: (I) the "Starr" approach
(developed by Professor Paul Starr) and (2) the "Jackson Hole" approach (promoted by a private group
which holds meeting? in Jackson Hole, WY). The Stair modelrequiressomeformofwag&'pricc controls |ic. setting a national budget ("global budgetir^and/westaWishingspecifc
As we understand it, the Task Forcefevorsthe Starr mode! which would concentrate draconian authority
in a "national health board," which would set all health can: policy and prices.
Prkv ( nnimu.,- The Task Forcereportedlywould use giohal budgeting and extend the Medicare I3R( \
price control payment system to all medical services performed by private doctors and hospitals, 11,^
is I HI:I :I M>M V. cx)ERaoN -
NIMI rr««»i.»m i
lli^alf -i " uiDfa^ ItirttvfcHutl* wluu u> «fa i |
N
IMMIII*
UM
.rf i l d i i ^ to c o m * IVotu Udn THMK T O I
Page3
,^
TW*
hv "Bw
I**,*' life proposal w itoi fi.™-
�RCV BYiThe White House
; 3-25-93 ; 4:30PM :
SOCIAL OFFICE-*
,
L im
v i r r i
'\*}l
"CMobal budgeting" would have the same eftct as wa^pnce controls - to (fcny medica] services
to those who need them, Stanford University Professor Enthoven put it clearly: "Global budget and price
controls imposed at the national level are akin to "bombingfrom35,000feetPram very high Attitudes in
your Washington office you do not see the people you art k illing,"
Ihe Nixon wage priw controls did hold health can; cost inflation to 4,9%, which was less than
the general inflation (from August, 1971 to April, 1974). Once the controls
lifted, health care costs
shot up at 12,1 \ with pent up price pressure blowing the lid off the kettle. The DRG prospective appnuch has tended toreducecost increasesforMedicare - with the denial of needed services to Senior
Crti/ens i doubt that any serious student of health care problems will deny that DRG s have caused senous rationing of services to seniors, Who among the Task Force wants to spread such dangerous rationing of health care benefits even further? It's one thing to install such a system to control government
payments It would be a giant leap to extend this system ncrou the board. And it would not be effective
Providers will adopt the "come see me evety second day" syndrome (Le., increasing their volume of service ) Some may think that Volume "enfbreement" (restricting the number of medical procedures performed) could make the controls work; but what size bureaucracy increase would berequiredforth.s >
KMtkmiii|<: Ultimawly, prices under ihis managed eompetiiion approach will be controlle
global budgeting (i.e.. rationing). Theresultwould be toftveeconsumers toforgomedical care
"national health boanf deemed not worth the expense (thephilosophy here b the Individual
satifkeMthegoodtftkewlukqfwckty. h^lrottlcdthatwhentotaliuirianre^
arnurut the world, Ovxt such an appwach Is bemgtfven serbus com
imitf Were talking about bureaucrats making the hard choices about the qualify of peoples lives - ;ind
who gets to live and die - e.g., authorization for the Oregon Medicaid experiment
A personal axamnfo - my married daughter, a diabetic, almost died because her primary cartI !M() physician refused to refer her to a specialist She was given the referral when her primary care
physician on vacation, and her problem was corrected,
HMO-type organisations around the country would be allocated their own limited budget as
their share of the "global budget" Senior citizens, cancer pitients with a prognosis of less than 5 year*,
people with chronic back pain, and so on would be likely candidates to have their carerationed,in our
view, u Professor Paul Starr type managed care system would essentially be a Canadian style single ptver
system under another name (as discussed below).
RtoRl* Payer Syttoms (unKci wl hwlth care)
The single payer systems arcrelativelyinexpensive because they provide less care than whm the
Amcncnn consumer wouldfindappropriate, Canadians pay about 9% of their gross national pnxiud <
l>r
iheir universal heahh care, as compared to expenditures of Americans of about 13^ of ONP. This sumstic has galvamaed much debate and is cited try liberal activists as reasonforradicalchange in this uiuntry
(Our syxtcm has many problems - but their is nothing inherently wrongfora society to spend 13% «»
2?%) of its CINP on health care, if individuals so choose.] Ihe population of Canada is 26 million, less
than that of California (The U.S. population is 250 million v This couplod with toughrestrictionson
smoking in Canada and lifestyle difRsrences make statistical comparisons meaningless, Although Amencans dnnoi get their dollars vwth in health care purchases {because of lack of market competition).
Americans are getting a higher level of care than those served by single payer systems. As in other single
payer systems we havereviewed,cost control in Canada is accomplished by waiting lines and rationing.
The Canadians limitfreedomfurther by not allowing privafr medicine to compete with "government
Page 4
�RCV BYiThe White House
5 3-26-93 J i ^ P B i
S
0
0
1
, ^ ,
0
/ ^
1
W I N . WMCkA 1
medicine," and private insurance is limited to extras like private hospital rooms and plastic surgwy The
waif ibr elective surgety, such as a cardiac bypass is typically 3 to 6 months. (People wait 80 weeks Tor a
hip replacement in the United Kingdom). Based upon the number of people on waiting lists for elective
surgoy in Canada, the equivalent in the United States (should ue adopt a single payer system) would bu
24 million people, h is so bad that when the Premier of Quebec needed cancer treatment, he crosaed into
the O S. and obtained it at his own expense. Modem medical technology isrelativelyscarce in Canada.
Comparing the United States and Canada on a population basis, the U.S. has 3 times more open heart surgcrv units. 4 times more caniiac caiheterization units, 7 times more radiotherapy units, 8 times morv
Magnetic Resonance Imaging machines, and so on. One of the drivingforcesbehind the rapidly rising
cost ofheahh care is advancing medical technology. Government managed health care systems, such as
Canada's have "solved" this problem, they have essentially isolaied patientsfromthis new technology
Ask a person on the street if he or she would like to have a Canadian style health care
system in this country and you might get thefollowinganswer. Yes, if its not run by the govemmcm! f)ncc grassroots America understands ihe details of the single payer systems, I'm coniiden; it cannot be passed
Ihe Single payer systems and managed competition plans are unworkable and would create
chaus. if passed by the Congress. Both would ration care. During the campaign, BUI Ciinton was askud
if he favored rationing of health care and he said that we alnjady mtion health oare by keeping itfromthe
poor The answer is not to make the poorfodbettor by rauoning ore fbr everyone else, as well The answer is a consumer choice plan which eliminatesredtape and reintroduces marketforcesinto the health
care system, as summarized at the beginning of our testimony
I hope therecommendationsof the American Council will be usefbltothe Task Force and 1
hot* you will give our health carereformproposals serious consideration.
About (he Amtrknii ( ouncfl
The Amencan Council for Health Care Reform, a grass toots consumer association, was established in
lWasa(50l)(cX4) nonprofit organization, Our purpose is consumer protection. Werepresentthe
public interest and our members are drawnfromthe general public. We believe information about procedure and practitioners should befollyavailabletothe consumer, that medicine should operate in a market environmentfreeof unnecessaryregulations,and that certain insurancereformsmust be
implemented. Suchreformsshould eliminate "governmentredtape" broaden accesstohealth care ;iml
maintain freedom of choiceforthe public in the selection of their health care providers.
About WHftim Shakr
Voluntary President and voluntary Executive Director of the American CouncilforHealth Care Reform
(198.l.prcsen0 and President, Washington Marketing Group (1987-present), B.S.fromthe Univwmy of
Southern California and MS,fromthe Umveraity ofMichigan;registeredprofessional mdistrial engineer (California). Ucemcd health and life insurBrK-e agent (Virginia). Formeriy with National legal
Centerforthe Public Interest (Vice President, 1979); Total Patient Care (a Medicare certified home
health agency, vice president, 1980-1986); National Tax 1 .imitation Committee (Executive Vioe President 1980.1986); Voluraaiy chairman, Michigan Taxpayers United and principal draftsman of the Taxlimitation constitutional amendmem spearheaded by Taxpayers United and passed by Michigan voter* in
1076 riitor-m-chief. Electric Power Reform, a 400 page hook on delivery ahemattves published hy the
University of Michigan.
Pages
�^
^
7:55--
PANEL ELEVEN-CONSUMER-TESTIMONY ENDS
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
1
10
�^ ^
8.00--
PANEL TWELVE—BUSINESS —TESTIMONY BEGINS
Our final panel of business groups will be talking about the best way to ensure that
employees of large businesses get quality, affordable health coverage. Thefirstwitness is
Jerry Jasinowski from the National Association of Manufacturers.
�NATIONAL ASSOCIATION OF MANUFACTURERS
7 )
/AY''
" j y ,A) MEMBERS:
r
n
REPRESENTS:
Industries o f a l l sizes located i n every
s t a t e . Many mature i n d u s t r i e s w i t h o l d e r
workers. NAM member companies employ 85
p e r c e n t o f a l l workers i n m a n u f a c t u r i n g and
produce more t h a n 80 p e r c e n t o f t h e n a t i o n ' s
manufactured goods.
TODAY'S SPEAKER:
J e r r y J. J a s i n o w s k i , P r e s i d e n t (See a t t a c h e d
biography)
"h
/n
/
\
f'Y
6A
More t h a n 12,000 member companies and
subsidiaries
SCOPE OF
INFLUENCE:
I n f l u e n t i a l w i t h b o t h Congress and t h e media
APPROACH TO
REFORM:
Managed c o m p e t i t i o n
j SUMMARY OF
/ POSITION:
1
Conducted survey o f members i n 1992 w h i c h
found t h a t NAM members a r e more r e c e p t i v e t o
r e f o r m approaches t h e y p r e v i o u s l y opposed,
p r o v i d e d these approaches a r e p a r t o f a
comprehensive h e a l t h c a r e r e f o r m package.
Reform must i n c l u d e : u n i v e r s a l coverage,
medical l i a b i l i t y t o r t reform, a d m i n i s t r a t i v e
and q u a l i t y i n i t i a t i v e s , mechanisms t o
measure and d i s s e m i n a t e h e a l t h c a r e outcomes,
c o s t containment measures t o address
c o r p o r a t e c o s t i n c r e a s e s and c o s t - s h i f t i n g ,
i n t e g r a t i o n o f Medicare, m a i n t a i n s e l f i n s u r a n c e o p t i o n , and broad-based f i n a n c i n g
mechanisms.
POSITION ON
PLAN:
W i l l be f l e x i b l e i n r e v i e w i n g p r o p o s a l .
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n , I r a Magaziner, OPL
HOT BUTTON ISSUES:
Concerned about f u r t h e r t a x on t o p o f energy
tax i n economic package.
�RCV BY:
; 3-24-93 i l l :48AM ;
CCITT Q3^
SOCIAL CFFICE;# 2
JERRY J. JASINOWSKI
NATIONAL ASSOCIATION OF MANUFACTURERS
Jerry Jasinowski is president of the National Association of Manufacturers and
one of the nation's most frequently quoted authorities on the economy and the vital role
manufacturing plays in America.
Jasinowski has addressed audiences across the country - from The Commonweaith
Club of California to the Detroit Economic Club - focusing primarily on developments and
issues in the manufacturing environment. As industry's chief spokesperson on a broad range
of issues, from the state of the economy, to health care reform, from international trade to
workplace trends, he is widely quoted in the media and appearsfrequentlyon television news
and talk shows. His opinion editorials have run in The New York Times. Chicago Tribune
and other major publications.
Jasinowski became president of NAM in January 1990. He previously had served as
the association's executive vice president and chief economist. NAM, the largest broadbased national industrial trade association in the United States, represents more than 12,500
manufacturing firms and subsidiaries, large and small, located in every state. NAM is the
oldest and most requested industrial campaign in the nation.
Jasinowski began his career as an air force intelligence officer serving in the Far East
in the mid 1960s. He then became assistant professor of economics at the U.S. Air Force
Academy. In the early 1970s, Jasinowski came to Washington to manage research and
legislative activities for the Joint Economic Committee of Congress. In 1976, Jasinowski
served as director of the economic transition team of the Carter administration for the
departments of Treasury, Commerce, Labor, the Council of Economic Advisers and the
Federal Reserve. He later was appointed assistant secretary for policy at the U.S.
Department of Commerce.
A native of LaPorte, Indiana, Jasinowski received his A.B. in economics from
Indiana University, his master's degree in economics from Columbia University, and is a
graduate of the Harvard Business School's Advanced Management Program.
He resides with his wife and two children in Washington, D.C.
-NAM7/92
�RCV BY:
; 3-25-93 ;10:07AM !
2026373024*
SOCIAL OFFICE!* 2
Oral Statement of
Jerry Jasinowski, President
National Association of Manufacturers
before the President's Task Force on National Health Reform
March 29, 1993
Washington, DC
I am Jerry Jasinowski, President of the National Association of Manufacturers. The NAM
includes over 12,000 member companies both large and small~97 percent of whom, according
to a recent survey, provide health coverage. My topic: "ensuring that employees of large
businesses get quality, affordable health coverage" will address just one segment of our
membership. Small businesses present yet another complex set of issues.
The Task Force's question raises an essential poim-can large employers continue to provide
health benefits in view of annual health costs three times inflation? And can they do so while
remaining competitive with our trading partners? If we desire to maintain our present employersponsored system of health benefits, refonn legislation must deal with the following areas:
• Cost-shifting. Providers to public programs must be paid fairly to deter cost-shifting to
private employers. Of the 1991 employer bill for health care, 28 percent or $11.5 billion
(Lewin/ICF,Inc.) was due to cost-shifting resulting from underpayment by Medicare and
Medicaid to doctors and hospitals andfrommanufacturers' cost of providing care for workers'
dependents employed by non-providing employers. Comprehensive reform is essential to
�RCV BY:
; 3-25-93 ;iO:Q7AM ;
2G26373024*
SOCIAL OFFICER 3
address the broad system-wide problem of cost-shifting.
• Quality Improvement and Administrative Efficiencies, Develop and disseminate health
care outcomes on what works, on which hospitals and doctors provide what kind of care at what
price and other quality information to assist consumers and payers (employers) to buy costeffective quality health care. Uniform data systems on claims and outcomes that can be shared
nationally is also essential. The efficiency and productivity gains achieved by manufacturers
must now be adopted by the health care sector as well.
• Medical Liability Tort Reform. Defensive medicine-the extra tests and treatments ordered
by physicians to protect against lawsuits-add to the costs of medical care.
A 1993 study
reported that $36 billion could be saved over five years if we were to enact medical liability tort
reform. This sum of money would go a long way to helpfinancecoverage for the 37 million
uninsured.
• Employer Flexibility. A reformed system will create a new delivery infrastructure which
must be integrated with existing entities, including employer health plans. This new infrasture
with its local purchasing cooperatives and accountable health plans must permit employers
flexibility to assure that employees can continue to receive affordable, quality-based health care.
• ERISA and Employer Plans. The Employee Retirement Income Security Act (ERISA) has
encouraged self-insured employers to provide health benefits across multiple plant locations
regardless of conflicting state laws. System reform should continue the basic principles of this
�RCV BY!
; 3-25-93 ;1C:03AM !
202637302^
SOCIAL OFFICE!* 4
law to assure such coverage remains affordable for employees and employers.
• Tax Status of Health Benefits/Financing. limiting employer deductibility for health care
without a similar limit on the employee will do nothing to change consumer behavior, which is
essential to managing health costs. We mustfinancehealth care in a way that does not
aggravate buying decisions or reduce employment. Financing should be broad-based such as a
value added tax in lieu of a BTU tax or payroll tax.
• Improved Delivery System and Universal Coverage. We must move to a system of
universal coverage through managed competition with purchasing cooperatives and other
mechanisms to facilitate the delivery of affordable quality health care. Medicare must be brought
into the new system to deter cost-shifting and to ensure that Medicare beneficiaries enroll in
cost-efficient managed care plans just like those persons under 65.
The ability of large employers to continue providing quality, affordable health coverage depends
on a reformed system that addresses these important issues. Ultimately, we must fashion a health
care system that reduces the high rate of cost increases for American business and preserves our
future economic viability and capacity to support other essential national priorities.
�BUSINESS ROUNDTABLE
MEMBERS:
200 C h i e f E x e c u t i v e O f f i c e r s
REPRESENTS:
A s s o c i a t i o n o f business e x e c u t i v e s o f F o r t u n e
500 companies i n a l l f i e l d s
TODAY'S SPEAKER:
Robert C. W i n t e r s , C h a i r and CEO, The
P r u d e n t i a l (See a t t a c h e d b i o g r a p h y )
SCOPE OF
INFLUENCE:
Significant, but frequently
APPROACH TO
REFORM:
Pure managed
SUMMARY OF
POSITION:
competition.
C r e a t i o n o f group p u r c h a s i n g arrangements f o r
small groups and i n d i v i d u a l s . Large employer
o p t - o u t . Standard b e n e f i t package, incomebased s u b s i d i e s f o r i n d i v i d u a l s , l i m i t s on
tax f r e e p o r t i o n o f h e a l t h b e n e f i t s f o r
employees, outcomes r e s e a r c h and m e d i c a l
m a l p r a c t i c e r e f o r m . Pre-emption o f s t a t e
laws t h a t mandate s p e c i f i c b e n e f i t s and
r e s t r i c t managed c a r e .
POSITION ON
PLAN:
Support managed
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
Transition.
HOT BUTTON ISSUES:
overestimated.
competition.
No employer mandate,
controls.
Budget o r p r i c e
�RCV BY:
; 3-23-33 ;12:22PM i
202 293 1658-»
SOCIAL OFFICE!* 3
Robert C. Winters
Chairman and Chief Executive Officer
The Prudential Insurance Company of America
Robert C. Winters became Chairman of the Board and Chief Executive Officer of
The Prudentiai in Februaiy, 1987.
Before his election to Chairman, Mr. Winters had been Vice Chairman since
September, 1984. In that capacity, he headed the Company's Central Corporate and
Financial Operations.
Mr. Winters joined the Company in 1953 in the Newark headquarters. Subsequenily,
he held actuarial positions in both group and individual insurance, as well as
assignment in the Company's regional home offices in Boston, Chicago and Fort
Washington, PA. In Fon Washington, he was Senior Vice President in charge of The
Prudential's Central Atlantic Operations from 1975 to 1978. In 1978, Kir, Winters
was promoted to Executive Vice President and became a member of The Prudential's
Executive Office,
Mr. Winters graduated from Yale University in 1953, and received his MBA from
Boston University in 1963. He became a Fellow of the Society of Actuaries in 1957.
He was awarded the Chartered Life Underwriter designation by the American
College m 1977 and the Chartered Properly and Casualty Underwriter designation by
the Amencan Institute for Property and liability Underwriters, Inc. in 1982. He
served in the Army from 1954 to 1956.
Mr, Winters is a past President of the American Academy of Actuaries and a former
member of the Board of Governors of the Society of Actuaries. He is a past Director
of both the Regional Plan Association and the life Office Management Association.
Mr. Winters served as Chairman of the United Wav of Tri-Staie Campaign for 198990, aod has served as Chairman of the Board or the Metro Newark Chamber of
Commerce.
Mr. Winters is past ChairmaTi of the board of the American Council of Life Insurance
and is on the board of the United Way of Tri-State. He is a member of the Business
S
? « Busmess Roundtable and its PoHcy Committee, and Chairman of its
Health, Welfare and Retirement Income Task Force. Mr. Winters is a member of
the Services PoKcy Advisory Committee to the US Trade Representative's Office, the
Committee for Economic Development, the Partnership for New Jersey, and the New
Jersey State Chamber of Commerce. He is also a member of the Securities Exchange
Commwsioas l ^ t e t Oversight Advisory Commince. Mr. Winters currently servls
on the Board of AlhedSignal, Inc. and also on the Mayo Clinic Foundation Board.
0
1
1
Mr. Winters is married to the former Patricia Martini of Minneapolis. They have two
daughters and reside in Rumson, New Jersey.
2/93
�MfiR 25 '53 19:35 PRUDENTIAL INSURANCE
P.2/4
ORAL STATEMENT OF ROBERT C. WINTERS
CHAIRMAN/ THE BUSINESS ROUNDTABLE HEALTH, WELFARE AND RETIREMENT
INCOME TASK FORCE
THE WHITE HOUSE HEALTH TASK FORCE
MARCH 29 1993
GEORGE WASHINGTON UNIVERSITY
8:00 P.M. - PANEL TWELVE
AS CHAIRMAN OF THE BUSINESS ROUNDTABLE HEALTH, WELFARE, AND
RETIREMENT INCOME TASK FORCE, I AM PLEASED TO BE ABLE TO SPEAK WITH
VOU THIS EVENING.
THE BUSINESS ROUNDTABLE APPLAUDS THE TASK
FORCE'S INTEREST IN MANAGED COMPETITION AS THE WAY TO BRING
FUNDAMENTAL REFORM TO THE AMERICAN HEALTH CARE SYSTEM.
YOUR QUESTION ASKS FOR THE BEST WAY TO ASSURE THAT EMPLOYEES OF
LARGE BUSINESSES GET QUALITY, AFFORDABLE HEALTH CARE. WELL, LET ME
START BY SAYING THAT LARGE EMPLOYERS HAVE BEEN GRAPPLING WITH THAT
ISSUE FOR YEARS. THE ANSWER I S REALLY TWO-FOLD.
FIRST, I BELIEVE LARGE BUSINESSES ARE ALREADY PROVIDING QUALITY
CARE FOR THEIR EMPLOYEES * AND, WE'VE BEEN WORKING HARD OVER THE
PAST DECADE TO GET THE COSTS OF THAT QUALITY CARE UNDER CONTROL.
WE'VE SEEN RESULTS. WE KNOW THAT GOOD SYSTEMS OF MANAGED CARE ARE
HIGHLY COST-EFFECTIVE.
THE DIFFERENCE IN AVERAGE PREMIUM PER
EMPLOYEE BETWEEN HMOS AND INDEMNITY PLANS I S NOW OVER $700 PER
YEAR. THAT'S NEARLY 25 PERCENT LOWER COSTS. EMPLOYERS WHO ARE
USING MANAGED COMPETITION PRINCIPLES NOW, SUCH AS XEROX AND
CALPERS, REPORT DRAMATICALLY REDUCED RATES OF COST INCREASE. LAST
YEAR CALPERS HEALTH CARE COSTS ROSE ONLY 1.5 PERCENT.
THE ADMINISTRATION NEEDS TO CREATE AN ENVIRONMENT WHICH NOURISHES
MANAGED COMPETITION. YOUR POLICIES NEED TO ALLOW US TO BUILD ON
THE SUCCESSES OF THE LAST FEW YEARS SO THAT, THROUGH PURCHASING
COOPERATIVES, SMALL BUSINESS EMPLOYEES RECEIVE THE SAME BENEFITS
THAT OUR EMPLOYEES HAVE NOW.
�MPR 25 '93 19=35 PRUDENTIAL INSURANCE
P-3/4
BEYOND THAT, WE BELIEVE THAT ALL AMERICANS SHOULD HAVE COVERAGE, NO
MATTER THEIR HEALTH OR WEALTH.
WE BELIEVE WE SHOULD REFORM MEDICAL TORT LAWS TO SAVE BILLIONS.
FINALLY, WE STRONGLY BELIEVE THAT HEALTH CARE IS A MARKETPLACE LIKE
ANY OTHER. COMPETITION CAN DRIVE COSTS DOWN AND MAKE HEALTH CARE
MORE AFFORDABLE — IF THE INCENTIVES ARE STRUCTURED CORRECTLY.
WITH THE RIGHT POLICIES AND A POSITIVE ENVIRONMENT, WE CAN GO A
LONG WAY TOWARD CONTROLLING COSTS. BUT WE NEED HELP FROM THE
GOVERNMENT IN CONTROLLING THE COST SHIFTING THAT GOES ON —
SHIFTING THAT DRIVES UP OUR COSTS.
WE URGE THE TASK FORCE TO AVOID SEEKING A SILVER BULLET. QUICK
FIXES OR ILLUSORY SAVINGS THROUGH PRICE CONTROLS, OR GOVERNMENTIMPOSED LIMITS ON HEALTH CARE SPENDING WILL NOT WORK. PRICE
CONTROLS HAVE FAILED TO CONTAIN COSTS IN THIS COUNTRY — WHETHER IN
HEALTH CARE, OIL AND GAS, OR THE ECONOMY AS A WHOLE.
IN HEALTH CARE PARTICULARLY, FEE CONTROLS HAVE FAILED. ALL YOU
HAVE TO DO IS LOOK AT MEDICARE AND YOU'LL SEE THAT YOU CAN'T
CONTROL UNNECESSARY PROCEDURES SIMPLY BY CONTROLLING THEIR COST.
WE BELIEVE THAT WHEN OUR HEALTH CARE SYSTEM HAS COSTLY PROBLEMS
LIKE UNNECESSARY SURGERY, THE SOLUTION IS NOT TO CONTROL THE PRICE
OF THAT SURGERY. THE SOLUTION I S TO ELIMINATE I T .
AND PRICE
CONTROLS WILL FREEZE INVESTMENT IN MEDICAL CARE SYSTEMS AT THE VERY
TIME WE NEED IT MOST.
IN DESIGNING YOUR PLAN, WE ALSO IMPLORE YOU NOT TO HURT EMPLOYERS
OR EMPLOYEES WHO HAVE ALREADY TAKEN THE DIFFICULT STEPS TO REDUCE
COSTS THROUGH MANAGED CARE. DO NOT PENALIZE THESE GROUPS FOR THEIR
EFFORTS TO CONTROL COSTS THROUGH NEW TAXES THAT PURPORT TO
"RECAPTURE" NON-EXISTENT SAVINGS ATTRIBUTED TO HEALTH CARE REFORM.
�MAR 25 '93 19=36 PRUDENTIAL INSURANCE
P.4/4
THE PRESIDENT HAS SAID HE WANTS TO REDUCE HEALTH CARE COSTS TO MAKE
OUR NATION MORE COMPETITIVE. BUT IF THE GOVERNMENT RAISES BUSINESS
TAXES WHILE EMPLOYER HEALTH CARE COSTS CONTINUE TO RISE, EVEN I F
MORE SLOWLY, THAT CAN ONLY HURT AMERICAN WORKERS.
WE SHARE THE ADMINISTRATION'S DESIRE TO CREATE A BETTER HEALTH CARE
SYSTEM. WE HAVE BEEN STRUGGLING FOR DECADES TO DESIGN A SYSTEM
THAT CHANGES THE INCENTIVES THAT NOW EXIST.
WE HAVE THROUGH
MANAGED CARE WORKED TO CONTROL OVER-UTILIZATION, AVOID DUPLICATION,
AND REDUCE COSTS•
NOW THE TASK FORCE HAS A UNIQUE OPPORTUNITY TO DESIGN A SYSTEM
BUILT ON THE MANAGED CARE MODEL THAT LETS BUSINESS DEVELOP
INCENTIVES TO CONTROL COSTS AND ELIMINATE COST-SHIFTING. THERE'S
MUCH KNOWLEDGE FOR YOU TO DRAW UPON. WE URGE YOU TO PUT THAT
KNOWLEDGE TO WORK.
�U.S. CHAMBER OF COMMERCE
MEMBERS:
215,000 businesses and o r g a n i z t i o n s
REPRESENTS:
The U.S. Chamber o f Commerce i s t h e l a r g e s t
o r g a n i z a t i o n o f businesses.
Over 90 p e r c e n t o f
Chamber members have l e s s than 100 employees.
TODAY'S SPEAKER:
Robert E. P a t r i c e l l i , P r e s i d e n t and CEO o f V a l u e
Health, I n c .
SCOPE OF
INFLUENCE:
S t r o n g Grassroots network,
APPROACH TO
REFORM:
Managed C o m p e t i t i o n
SUMMARY OF
POSITION:
i n f l u e n t i a l w i t h Congress
The Chamber's " G u i d e l i n e s f o r H e a l t h Care Reform"
s u p p o r t : employer " c o n t r i b u t i o n s " o n l y i f t h e r e i s
an a p p r o p r i a t e s u b s i d y f o r low-wage workers and
t h e i r employers; comprehensive managed c o m p e t i t i o n
s t r a t e g i e s , c o v e r i n g b o t h p r i v a t e and p u b l i c
programs; n a t i o n a l core b e n e f i t s package, s t r e s s i n g
i n d i v i d u a l c o s t s h a r i n g ; r e g i o n a l p u r c h a s i n g groups
f o r s m a l l businesses and i n d i v i d u a l s , w i t h
f l e x i b i l i t y t o a l l o w business c o a l i t i o n s t o s e r v e
t h i s f u n c t i o n and insurance market r e f o r m ; and c o s t
containment t o l i m i t c o s t i n c r e a s e s t o t h e g r o w t h o f
GNP.
L i m i t t a x d e d u c t i b i l t y o f premiums f o r employees
( b u t n o t f o r employers).
HIPC p a r t i c i p a t i o n l i m i t e d
t o f i r m s o f no more t h a n 100 employees.
POSITION
ON PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
HOT BUTTON ISSUES:
While n o t f u l l y s u p p o r t i v e , t h e y have n o t been
o v e r l y a n t a g o n i s t i c toward t h e A d m i n i s t r a t i o n .
However, a l r e a d y concerned about i n c r e a s e d t a x e s i n
t h e P r e s i d e n t ' s economic package.
T r a n s i t i o n , I r a Magaizner
Mandate w i t h o u t s u b s i d y ; U n d e r c u t t i n g s e l f - i n s u r a n c e
o p t i o n ; D e s t r u c t i v e r e g u l a t i o n o f premiums; Scale,
t i m i n g , and t a x - - l o o k a t i n c o n t e x t o f whole
economic package.
�RCV BY:
; 3-23-93 I 4:57PM ;
202 453 5500^
SOCIAL OFFICE!* 2
U.S. Chamber of Commerce
Washtogton, D.C. mti
BIOGRAPHICAL SUMMARY
Robert E. Patricelli
President and Chief Executive Officer
Value Health, Inc.
t
Robert E. Patricelli is founder, Chairman, President, and Chief Executive Officer of Value
Health, Inc., one uf the nation's leading providers of specially managed healdi care services.
Value Heallh now serves over 25 million people with managed care products in the areas of
mental health and substance abuse, prescription drugs, foot care, and health care mfonnation
services, and is publicly traded on the New York Slock Exchange.
Prom 1977 to 1987, Mr. Patricelli served in a variety of positions in Connecticut General
Corporation and ite successor, CIGNA Corporation, most recently as executive vice president
of the parent company and president of its l i billion health care group.
From 1965 to 1977, Mr. Patricelli held aFpoimments in numerous positions in the federal
government, Starting as a White Huuse Fellow in 1965, he served successively as counsel to
a U.S. Senate subcommittee. Deputy Under Secretary of the Department of Health, Education
and Welfare, and Administrator of the U.S. Urban Mass Transportation Administration.
i
Mr. Palrieelli is a member of the board of directors of the U.S. Chamber of Commerce and
chairman of the Chamber's Heahh and Employee Benefits Committee. He is vice chairman of
the Institute of Living (a psychiatric hospital), a board member of Northeast Utilities, Weslifyan
University, the Foundation for Health Services Research, and a member of the Institute of
Medicine of the National Academy of Sciences.
U.S. CHAMBER OF COMMERCE
The U.S. Chamber of Commerce is the world's largest federation of business companies and
�FROM U.S. CHAMBER OF COMMERCE
03.25,1993 12:19
NO. 4
P. 2
U.S. Chamber of Commerce
Washington, D.C. 20062
STATEMENT
ON GUIDELINES FOR HEALTH CARE REFORM
The Board of Directors of the United States Chamber of Comtnerce, the nation's largest
organization of independent businesses, encourages and offers its support to President Clinton
as he seeks an acceptable plan for national health care reform.
The Chamber will seek to play a constructive role in helping to forge a national consensus,
believing that all of the parties at interest in this important issue will need to make compromises
if we are to enact needed legislation.
As the Administration seeks to develop its proposal, the Chamber offers the following guidelines
as a foundation for an effective reform strategy.
1.
Managed competition and managed care offer the best opportunity for the nation to
achieve universal coverage at acceptable cost. It is critically important, however, for these
strategies to be applied to both private and public programs, mcluding Medicare and Medicaid,
to preserve equity and to prevent cost-shifting from public to private payers. Competition can
work in health care if given a chance, but it needs to be a truly comprehensive strategy.
2.
Universal coverage is a necessary objective of any acceptable reform plan. All
individuals should be required to have health insurance, which should be paid for through a
combination of public funding for the elderly, poor and near poor; employer/employee
contributions for all working people and dependents; and individual contributions. The inability
of many low-wage workers and their employers to pay the full cost of premiums must be
recognized through appropriate government subsidy and phasing of any plan. Workers should
not suffer interruptions in coverage by reason of waiting periods or underwriting rules when they
change jobs.
3.
A national core benefits package will need to be defined for universal coverage to be
made a reality . If such a core benefits package is to be affordable while at the same time
covering needed services, it will need to stress employee and individual cost sharing and
constraints on the provision of care which is medically or economically ineffective.
4.
Employer-driven innovation in the delivery of cost-effective services should be
encouraged by maintaining a self-insurance option for larger employers. Self-insurance permits
employers and employees to reduce their own premiums through effective cost containment and
prevention activities, whereas forcing such employers into largeriskpools defeats that incentive
for business and individual responsibility.
�FROM U.S. CHAMBER OF COMMERCE
83.25,1953 12:19
HO. 4
P, 3
5.
Purchasing groups should be created at the regional level to permit small businesses and
individuals to gain access to cost-effective core benefits. There should be considerable flexibility
in structuring these largely untested purchasing groups, mcluding permitting business coalitions
to serve this function. Insurance underwriting practices need to be reformed in this market to
ensure that competition will be based on the management of care rather than the selection of
risks.
6.
A wide variety of health plans operating under a range of funding arrangements must be
encouraged to compete on the basis of cost and quality for the business of both self-insured
employers and regional purchasing groups. Changes in health care delivery are currently
occurring at a rapid pace, and such innovation must be encouraged.
7.
Cost containment is a critical priority for all payers - government, employers and
consumers. Given the fact that the federal deficit cannot be brought under control without
constraining costs in federal health entitlement programs. Medicare and Medicaid must be early
targets for action. Cost shifting from government programs to private payers must end. There
is no reason why the elderly and the poor should not face the same constraints on unnecessary
care, and the same trade-offs between freedom of choice and out-of-pocket costs, as working
people would face under managed competition.
S.
Proposals to regulate health care premiums without addressing the underlying causes of
health cost inflation will not work and should be resisted. Limitations on the amount of
employer-paid health insurance premiums which employees can exclude from income may be
a useful support to the cost containment strategy we endorse. In no event, however, should
there be any limit on the employer's ability to deduct such premiums as a legitimate business
expense.
The preceding guidelines, approved by the Board of Directors on February 22, 1993, are
built on a foundation of longstanding Chamber policy. While some of the elements of that
earlier policy are updated by the new guidelines, other provisions remain in effect. The
Chamber continues to believe that health care refonn must incorporate the following principles.
1.
Self-employed persons and unincorporated firms should be given a 100 percent deduction
for health benefit costs.
2.
The federal government, working with the states, should develop a comprehensive
program to reduce costs associated with medical malpractice while at the same time protecting
the legitimate interests of patients.
3.
Providers, employers, and government should accelerate the development and use of
national medical practice guidelines and outcomes-based assessment tools. Such practice
guidelines should be tied to payer reimbursement and medical malpractice liability protection.
�FROM U.S, CHfiflBER OF COMMERCE
03,25,1993 12:20
HO. 4
P, 4
4.
Sustained public and private effort at the local, state, and federal levels is needed to
prevent the proliferation of excess equipment and facilities and to reduce excess capacity.
Excess capital spending should be constrained by reducing or eliminating government subsidies
for the acquisition of medical capital.
5.
Payers and providers working together must reduce the escalation of administrative costs
through standardization of processes and the introduction of improved information management
technologies, e.g., electronic claims filing, computer-based patient records.
6.
Providers should be required to make available to patients information on fees and
alternative treatment methods.
7.
State-level benefit mandates, as well as state and federal laws and regulations that impede
managed care and cost containment programs, should be repealed.
For more information, contact Kristin Bass or Lisa Sprague at (202) 463-5514.
�NATIONAL RETAIL FEDERATION
MEMBERS:
1.3 m i l l i o n r e t a i l
establishments
REPRESENTS:
The nation's l a r g e s t trade group encompassing
the e n t i r e spectrum of r e t a i l i n g i n c l u d i n g
department, chain, discount, s p e c i a l t y a t
independent stores and associations. Their
membership employs nearly 20 m i l l i o n people
and had r e g i s t e r e d sales i n excess o f $1.8
t r i l l i o n i n 1990. The large r e t a i l e r s
(Sears, Penny's) d r i v e the o r g a n i z a t i o n .
TODAY'S SPEAKER:
Tracy M u l l i n , President o f NRF's Government
and Public A f f a i r s D i v i s i o n
SCOPE OF
INFLUENCE:
Mixed, but not t o be underestimated
APPROACH TO
REFORM:
Support managed competition
SUMMARY OF
POSITION:
Oppose:
1) mandated coverage of p a r t - t i m e and
seasonal employees;
2) r e s t r i c t e d employee freedom t o s e l e c t
where they purchase health care coverage
( i . e . through employer, spouse's employer, o r
p r i v a t e insurance);
3) required s t a t e d percentage c o n t r i b u t i o n
from employers ( p r e f e r t o allow t h e f r e e
market t o set employer c o n t r i b u t i o n l e v e l s .
POSITION ON
PLAN:
L i k e l y t o oppose employer mandate.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
HOT BUTTON ISSUES:
Mandated coverage o f p a r t - t i m e r s .
�RCV BY:
; 3-23-93 I 4:22PM ;
CCITT Q3-»
SOCIAL OFFICE;* 2
NATIONAL RETAIL FEDERATION
701 PENNSYLVANIA WENUE, N.W. • SUfTE 710 • V*SHNGTOK DC 20004 • (202)
BIOGRAPHY OF TRACY MULLIN
PRESIDENT, GOVERNMENT AND PUBLIC AFFAIRS DIVISION
NATIONAL RETAIL FEDERATION
Tracy Mullin was named President of the Government and Public
Affairs Division of the National Retail Federation (NRF) on March 1, 1991.
The Government and Public Affairs Division, one of two divisions of NRF, is
responsible for developing, implementing and communicating all
governmental, public policy and public affairs positions of the retail
industry. NRF is the nation's largest organization representing the retail
industry. Prior to her appointment as President, Ms. Mullin served as
Executive Vice President of NRF, which was created in 1990 with the
merger of the American Retail Federation and the National Retail
Merchants Afisociation. Ms. Mullin had served in a variety of positions
with the National Retail Merchants Association which she joined in 1976.
Ms. Mullin served previously as Senior Legislative Assistant to the Senate
Minority Leader, the Honorable Hugh Scott of Pennsylvania. A native
Washingtonian, she is a graduate of Boston University where she majored
in political science.
�SENT BY-'
3-26-93 ;11:27AM : NATL RETAIL FEDERTN-N'AT ECONOMIC COUNCIL;* I t 4
NATIONAL R E T A I L F E D E R A T I O N
701 PENNSYLVANIA AVENUE. N.W. • SUITE 710 • WASHNGTON. D.C 20004 • (202) 783-7971
STATEMENT O F TRACY M U L L I N
NATIONAL R E T A I L F E D E R A T I O N
My name is Tracy Mullin, and I am President of the National Retail
Federation, an organization which represents almost 20 million
Americans employed i n over 1.3 million U.S. retail establishments. NRF
ie pleased to participate as part of this panol representing big businesses.
However, I'd like to underscore at the outset that while NRF represents the
nation's largest department, chain, discount and specialty stores, its
membership is predominantly comprised of small, independent retail
stores with annual sales of $1 million or less. Both large and small retail
firms have a vital interest in the outcome of the work of this task force.
Thp retail industry is the job machine of the U.S. economy. We
provide one out of every five jobs. We consistently create jobs - over 300,000
new jobs per year in the last two decades. We provide first-time work
experience for many Americans - one-fourth of all retail employees are
younger than 25. And, most important, we provide jobs to unemployed
Americans - more than one-fourth of all jobs provided to previously
unemployed workers.
A retail store is a unique American enterprise. Its doors are typically
open for business seven days a week and 12 hours a day - sometimes 24
hours a day. All stores experience peak buying periods, and as a result we
depend on a flexible work force with a high percentage of part time and
seasonal employees. Thirty percent of all retail employees work part time.
These flexible work hours are important to many American workers trying
to balance work and family responsibilities. I n fact, nearly three-fourths of
all part time retail employees specifically seek part time employment.
Retailing is a competitive industry. As a result profit margins are
narrow and the typical retailer faces intensive competitive pressures to
keep costs under control. Retail profit margins are approximately two
percent or less.
Retailing is labor intensive, yet most retail job opportunities do not
require expensive investments i n education and training. As a result,
wages i n retailing are not especially high. The hourly wage for forty-five
percent of all retail employees does not exceed $6.00.
RETAIL SERVICES DIVISION •
100 WEST 31ST STREET, NEW YORK, NY 10001 • (212)244-8780
�SENT BY:
3-26-93 ;11:27AM ; NATL RETAIL FEDERTN-NAT ECONOMIC COUNCIL;* 3/ 4
The retail industry was among the first to provide health care
benefits to its employees. In 1912, a landmark was established when a
major retailer voluntarily provided almost 3,000 employees with an
insurance package that included coverage for sickness, accidents, and old
age benefits. Even today, with health care costs rising out of control, fourfifths of retail employees have health inRurance, and one-third of those
without insurance simply have not worked long enough to qualify for the
coverage available through their employers. Nearly half of all uninsured
retail employees work infirmswith fewer than 25 employees. So, wo have a
unique and valuable perspective on the question we have been asked to
address this evening.
All consumers are having difficulty obtaining quality, affordable
health coverage. Why? Because health insurance premiums have been
rising dramatically, as high as 28 percent for conventional health
insurance plans and 18 percent for HMO plans.
To ermure that employees of large and small businesses get quality,
affordable health coverage, the rising price of coverage must be brought
under control, without destroying a business environment capable of
supporting wage, job and investment growth. The retail industry believes
this can be accomplished best through the following reforms to the U.S.
health care system:
o Reorganize the way health care is delivered by moving to a system
of managed competition with an individual mandate that requires that aU
Americans have access to care through broad risk pools. This access could
befinancedby a reasonable tax cap and by a recapture of indigent care
subsidies in Medicare and Medicaid that would be unnecessary in a system
that provides universal access.
o Empower consumers and providers with information on health
care costs and outcomes;
o Develop standards for appropriate care;
Retailers support health care reform efforts to reduce health care
cost inflation and provide universal access to care on a sustainable basis.
We strongly support reforming the health care delivery system by moving to
a reasonble form of managed competition. However, the costs of universal
access to care within a system of managed competition must be shared
fairly by all. An employer mandate to cover and pay the cost of employee
health care plans will unnecessarily burden retail employers and
employees.
�SENT BY:
3-26-93 :11:28AM ; NATL RETAIL FEDERTN-NAT ECONOMIC COLWCIL;* 4/ 4
In a recent study, Nathan Associates calculated that under an
employer mandate with no exemptions and a requirement that retail
employers pay 80 percent of the least costly health plan available to their
employees, the employers' direct cost of employee access to care will
increase $12.6 billion (81 percent) in the first year of managed competition,
and as much as $19 billion (84 percent) in the fifth year.
Retail employers will adjust to the heavier cost burden of an employer
mandate by shifting some of it tn their employees and restructuring their
work force. This increased cost could result in the loss of almost half a
million retail jobs in the first five years of managed competition. Nathan
Associates, Inc. predict that in the first year of managed competition with
an employer mandate, retail employee wages could fall $7 billion and
187,000 jobs could be lost. In the fifth year, wage losses could be as high as
$11 billion and an additional 280,000 jobs could be lost.
Therefore, we must anticipate a direct trade-ofF between an employer
mandate and loss of jobs at the lower end of the wage scale. The impact of
these losses will be felt most by retail employees who are currently
uninsured - the very group managed competition seeks to help.
The National Retail Federation shares your vision of affordable
health care for all Americans. We want very much to work with you to
realize genuine, long-lasting reform. We are not prepared, however, to
abandon this vision to an employer mandate that will result in wage and job
losses for many retail employees and an unnecessary financial burden for
many American families. NRF looks forward to assisting the task force in
working through the consequences and ripple effects of any health reform
plan on the retail industry in particular and on the economy in general.
�WASHINGTON BUSINESS GROUP ON HEALTH
MEMBERS:
180 Fortune 500 members
REPRESENTS:
One o f f i r s t business groups formed
s p e c i f i c a l l y t o examine health care issues.
Represent p r i m a r i l y l a r g e businesses.
TODAY'S SPEAKER:
Mary Jane England, President (see b i o )
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
HOT BUTTON ISSUES:
I n f l u e n t i a l on h e a l t h p o l i c y matters i n
Congress. Well known t o trade press as w e l l
as Washington-based media.
Form o f managed competition
Managed competition. Very comprehensive
b e n e f i t package. Allow HIPC opt out f o r the
s e l f - i n s u r e d . Believe managed care and
managed competition have great p o t e n t i a l t o
manage costs. Unlike many business groups,
very supportive o f mental h e a l t h b e n e f i t s
(President Mary Jane England, n o t
s u r p r i s i n g l y , i s a p s y c h i a t r i s t ) . Considered
one o f more progressive large business
groups.
Wait and see. Concerned about r a t e
r e g u l a t i o n , p a r t i c u l a r l y over long term.
T r a n s i t i o n , I r a Magaziner
concerned about HIPC opt out f o r s e l f - i n s u r e d
employers and s i g n i f i c a n t m o d i f i c a t i o n s t o
ERISA
�• 03/26/93
16:36
© 1 202 403 9332
WASH. BUS. ON HEAL
81003
THE WASHINGTON BUSINESS GROUP ON HEALTH (WBGH) was founded in 1974 to
give major employers a credible voice in the formulation of health care policy. WBGH is a nonprofit 501(c)(3) national health poUcy and research organization which serves as an effective
conduit for the flow of information between its members and health policy makers. WBGH
membership include all major segments of U.S. industry.
Representing the Washington Business Group oo Health will be:
PATRICIA M. NAZEMETZ is Director of Benefits for Xerox Corporation in Stamford, Conn.
Her responsibilities include setting the objectives and managing the direction of activities in the
corporate benefits department. These duties include management of the design, development and
operation of the company's United States benefit plans and programs. Ms. Nazemetz joined
Xerox in 1979 as benefits operations manager. She was named manager of benefits in 1987 and
assumed her present position in 1988. Before joining Xerox, Ms. Nazemetz worked for W.R.
Grace & Company as a benefits analyst. Ms. Nazemetz serves on the boards of the Kaiser
Health Plan of New York, the Matthew Thornton Health Plan, the National Committee for
Quality Assurance and the Washington Business Group on Health. She is also a commissioner
on the Physician Payment Review Commission and serves on several other boards and
commissions.
�-03/26/93
16:36
Q l 202 408 9332
WASH. BUS. ON HEAL
21004
Washington Business Group on Health
777 N.Copitoi Street N.E.
Suite 800
Washington, D.C. 20002 (202) 408-9320 TDD (202) 408-9333 FAX (202) 408-9332
STATEMENT OF THE WASHINGTON BUSINESS GROUP ON HEALTH
Ms. Rodham Clinton and Members of the Task Force:
My name is Pat Nazemetz, Director of Benefits for the Xerox Corporation. I am here today
representing 180 of the nation's largest employers who are members of the Washington Business Group
on Health. Large employers have worked hard to provide quality, cost-effective care to their employees.
Their experiences have made it clear that comprehensive reform of the delivery system is essential to
achieve universal access to affordable, quality care for all Americans.
We applaud you for the leadership and commitment to comprehensive nationwide health care
reform you have already demonstrated. And we urge you to continue your efforts to draft a plan to put
before the Congress and the American people by the beginning of May. While comprehensive reform
will require tradeoffs many American have yet to confront, we believe the potential is great to improve
the quality and affordability of health care overall and, ultimately, ensure consumer satisfaction.
Toward this end, we would like to suggest several principles that we believe are critical in moving
toward a new health care system:
•
Delivery system reform is essential:
We believe strongly that the key to creating incentives to manage costs and improve the
quality of care over the long run is to restructure the delivery system. Reform that
addresses access and financing but leaves the current delivery system intact cannot resolve
the inefficiencies and inequities that now plague the system.
In the future we envision that care will be provided through competing Organized Systems
of Care (OSCs). OSCs are vertically integrated health care financing and delivery systems
which offer comprehensive 24-hour care through a network of hospitals and practitioners.
Organized Systems of Care will oversee the provision of the full continuum of care, from
birth to long-term care, through delivery sites which range from the technologically
complex to an individual's home. OSCs would compete with each other and would be
Public Policy •
Insritute on Aoina Work and Health •
Institute for RehabSitation nnd Dknhilitv MnnmwmRnt •
Mnntnl Hwilth
�>03/26/93
16:37
© 1 202 408 9332
WASH. BUS. ON HEAL
12005
accountable to the purchasers and patients on the basis of cost and quality. OSCs would
incorporate continuous quality improvement techniques and incentives to provide only
appropriate, necessary, and effective care.
Although the concept and use of OSCs are evolving, several of the nation's largest health
care purchasers have ample experience with this model. We would be happy to provide
you with a more detailed definition of OSCs in our recently released report, A Vision of
the Future Healthcare Delivery System: Organized Systems of Care.
Multiple sponsors should continue to play a role:
We support the establishment of Health Insurance Purchasing Corporations (HIPCs) as the
exclusive health insurance purchasing agents for small businesses. Purchasing corporations
can provide small businesses with the market clout and technical expertise which have
enabled many large employers to contain costs and improve the quality of care offered to
their employees. Midsized and large employers can function as sponsors, contracting with
Accountable Health Plans and operating in compliance with the National Health Board.
To encourage competition among organized systems of care, it is important that no one
sponsor dominate the market. Market dominance by a single sponsor would raise barriers
for the entry of new delivery systems, encourage the concentration of existing systems,
and impede competition and innovation. Multiple sponsors can open the marketplace for
the delivery of care, and can encourage employers to remain engaged in efforts to improve
health status and health care.
It is important that employers have the incentive to remain actively involved in organizing
and managing health care for their employees. Many of them have the experience and
knowledge to operate as effective purchasing agents, with the capacity to evaluate quality
and costs. This involvement and talent will be lost to the system if employers are reduced
to simply paying the costs and are no longer sponsors of health benefits. We would be
happy to provide you with case examples of the best practices from employers such as
ALCOA, Digital Equipment Corporation, Xerox, and others.
AU segments of the market (including Medicare and Medicaid) should be included in
delivery system refonn from its inception:
Beneficiaries of Medicare and Medicaid should not berelegatedto a vanishing fee-forservice system nor excludedfromthe better quality that will come with a reformed
delivery system. It is equally important as a basis for controlling health care costs that
cost-shifting from these programs to the private sector end as soon as possible. For both
reasons, Medicare and Medicaid should be incorporated in the reformed system from its
inception, and not deferred.
�i'03/26/93
•
16:38
© 1 202 408 9332
WASH. BUS. ON HEAL
81006
A comprehensive uniform benefits package should apply nationwide:
Standard health care benefits should encompass medically necessary, appropriate, and
effective services along a full continuum of care. Cost control should be achieved through
the management of care rather than through arbitrary benefits limits. Practitioners should
have the freedom and incentives to choose from a full array of services to ensure costeffective and appropriate treatment.
•
Individuals should assume greater responsibility for their health and use of health
care services:
When health care consumers lack knowledge, they tend to view high prices and large
volume as proxies for quality. Thefinancialincentives in a reformed health care system
should encourage individuals to become more knowledgeable and more price-conscious as
consumers of health care services. Employers have found that, given choices, employees
and their families make wise health care decisions and can be encouraged to assume
greater responsibility for their own health. It is critical that reform provide outcomes
reporting, public report cards on providers, and better education on prevention and selfcare.
•
Malpractice liability should be reformed in the context of Organized Systems of Care:
The determination of malpractice liability should be completely restructured in the context
of a reformed delivery system and an improved ability to develop medical guidelines based
on outcomes research. Organized Systems of Care should assume malpractice liability,
and disputes about the quality of care should be subject to mandatory binding arbitration.
In closing, we would like to emphasize our willingness to continue to explore with you the difficult access
and financing issues that will come up in developing a reform package that can achieve these goals. We
are encouraged by your commitment to comprehensivereform,including the restructuring of the delivery
system. Employers are committed to working with the Administration to design effective reform and are
prepared to actively support efforts to enact a national package that will serve the needs of all Americans.
�ASSOCIATION OF PRIVATE PENSIONS AND WELFARE PLANS
MEMBERS:
Companies and i n d i v i d u a l s concerned a b o u t
f e d e r a l l e g i s l a t i o n and r e g u l a t i o n s a f f e c t i n g
a l l aspects o f p r i v a t e s e c t o r employee
benefits.
REPRESENTS:
APPWP members i n c l u d e employers o f a l l s i z e s
-- p r i n c i p a l l y F o r t u n e 500 major companies —
as w e l l as i n s u r a n c e c a r r i e r s and employee
b e n e f i t s c o n s u l t i n g f i r m s . T h e i r members
e i t h e r sponsor d i r e c t l y a d m i n i s t e r b e n e f i t
p l a n s c o v e r i n g 100 m i l l i o n Americans.
TODAY'S SPEAKER:
E l l e n L. G o l d s t e i n , D i r e c t o r o f H e a l t h
and Communications (see b i o )
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Policy
S i g n i f i c a n t , p a r t i c u l a r l y among c o n g r e s s i o n a l
members w i t h l a r g e employers i n s t a t e s . Have
some media i n f l u e n c e as w e l l .
Employer mandated.
I n December, t h e APPWP adopted a new s t a n c e ,
becoming t h e f i r s t employer o r g a n i z a t i o n t o
s u p p o r t an employer mandate and a l i m i t a t i o n
o f t h e employee t a x e x c l u s i o n f o r employerp a i d h e a l t h coverage. Employer mandate
c o u p l e d w i t h t a x c r e d i t s and s u b s i d i e s f o r
low-income i n d i v i d u a l s and employers w i t h
l a r g e numbers o f low-income w o r k e r s ; a l s o
i n d i v i d u a l mandate t o accept o r a c q u i r e
h e a l t h c a r e coverage.
L i m i t a t i o n o f employee t a x e x c l u s i o n f o r
employer-paid h e a l t h coverage t o t he c o s t o f
t h e b a s i c b e n e f i t s package.
I n t e g r a t i o n o f managed c a r e systems i n a l l
h e a l t h c a r e systems,both p u b l i c and p r i v a t e ,
t o c u r t a i l the p r a c t i c e of c o s t - s h i f t i n g ?
Support h e a l t h c a r e e x p e n d i t u r e t a r g e t s f o r
a l l h e a l t h system p a y o r s .
POSITION ON
PLAN:
May be s u p p o r t i v e i f s e l f - i n s u r e d a r e h e l d
harmless and s t a t e f l e x i b i l i t y does n o t
impose on t h e i r a b i l i t y t o a d m i n i s t e r p l a n s .
�INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
HOT BUTTON ISSUES:
Meetings during t r a n s i t i o n and a meeting w i t h
I r a i s scheduled.
Maintain option t o s e l f - i n s u r e o u t s i d e o f
HIPC s t r u c t u r e .
�A s s o c i a t i o n of P r i v a t e Pension and Welfare Plans
Representative
E l l e n L. Goldstein
Director
E l l e n L. G o l d s t e i n i s d i r e c t o r o f h e a l t h p o l i c y and
communications f o r t h e A s s o c i a t i o n o f P r i v a t e Pension and W e l f a r e
Plans. The APPWP i s t h e n a t i o n a l t r a d e a s s o c i a t i o n i n
Washington, D.C. f o r companies and i n d i v i d u a l s concerned about
f e d e r a l l e g i s l a t i o n and r e g u l a t i o n a f f e c t i n g a l l aspects o f t h e
v o l u n t a r y , p r i v a t e s e c t o r employee b e n e f i t system. I n t h a t
c a p a c i t y , she i s r e s p o n s i b l e f o r t h e development and c o o r d i n a t i o n
o f APPWP h e a l t h p o l i c y a c t i v i t i e s i n t h e h e a l t h area.
She a l s o
serves as t h e s t a f f d i r e c t o r f o r t h e new APPWP A c t i o n Center f o r
Q u a l i t y H e a l t h Care, and d i r e c t s t h e A s s o c i a t i o n ' s p u b l i c a f f a i r s
programs, i n c l u d i n g t h e annual l e g i s l a t i v e c o n f e r e n c e . She i s a
f r e q u e n t p u b l i c speaker on h e a l t h r e f o r m developments i n
Washington, and has appeared on CBS Morning News, Newsweek
n a t i o n a l r a d i o , and c a b l e t e l e v i s i o n .
P r i o r t o coming t o t h e APPWP i n 1985, Ms. G o l d s t e i n worked
on s t a t e r e g u l a t o r y p o l i c y MCI Communications i n Washington, D.C.
a f t e r s e r v i n g as an independent p o l i c y c o n s u l t a n t f o r a v a r i e t y
of public policy c l i e n t s .
From 1977 u n t i l 1981, Ms. G o l d s t e i n
served on t h e Domestic P o l i c y S t a f f a t t h e White House d u r i n g t h e
a d m i n i s t r a t i o n o f P r e s i d e n t Jimmy C a r t e r , and as an A s s i s t a n t
D i r e c t o r f o r Human Resources she was r e s p o n s i b l e f o r d e v e l o p i n g
budget p o l i c y , and l e g i s l a t i v e recommendations f o r t h e P r e s i d e n t
on a wide range o f f e d e r a l human s e r v i c e s programs.
P r i o r t o t h e White House, Ms. G o l d s t e i n served as r e s e a r c h
d i r e c t o r f o r t h e Democratic N a t i o n a l Committee and as an E n g l i s h
t e a c h e r . E l l e n G o l d s t e i n i s a 1970 g r a d u a t e o f Ohio S t a t e
U n i v e r s i t y and she r e c e i v e d h e r M.A. i n h i s t o r y from Georgetown
U n i v e r s i t y i n 1974 i n Washington, D.C.
Ms. G o l d s t e i n s e r v e s on t h e Board o f D i r e c t o r s o f t h e F a m i l y
& C h i l d S e r v i c e s o f Washington, D.C., as w e l l as t h e N o r t h
American F r i e n d s o f Kafka Center, Prague.
�03/25.'?3 13:28
8 202
289
4582
R.P.P.U.P.
AMQCirton o» Private Pension and Wdfara Plana
TESTIMONY 07 ASSOCIATION OF PRXTOT8 PENSIONfiWELFARE PLANS
TO TEE WHITS HOUSE HEALTH CARE TASX FORCE
given by ELLEN L. GOLDSTEIN, DIRECTOR OF HEALTH POLICY
Monday, March 29, 1993
On behalf of the Association of Private Pension & Welfare Plans I
want to thank you for inviting us to appear this evening before
this panel.
We've been asked to respond to the question, "What's the best way
to ensure that employees of large businesses get guality,
affordable health care?" Our answer i s simple: keep private
employers actively involved in the design, administration and
financing of health care benefits for their employees.
Our association firmly believes that a strong role for an employerbased, private system for health care and retirement income
benefits i s good for America overall, and good for the health of
American workers and their families. We believe that employer
involvement will provide a strong and steady driver of quality and
cost-effectiveness, without which health care would become less
affordable for more and more Americans.
Building upon the private system — and leveling the playing field
for a l l participants in the health care system — we believe to be
the wisest course and basis for reform, A health care system that
is basically private sector-based is more likely to sustain a high
quality and cost-effective delivery system.
The plurality and flexibility of an employer-based system are
highly valued by the American public because this system can best
tailor benefit programs to fit individual needs. This flexibility
permits technological and service-oriented developments that
provide the best medical care in the world. As the needs of our
employees change, so too do the programs we design and offer our
employees change.
Employers more than governments have the capacity to quickly design
or modify health benefits which contributes to the employers'
unique ability to experiment with new ideas in providing benefits,
to modify benefits to meet changing health care delivery patterns,
and to discover new ways to manage the cost of health benefits.
Employers bring a business perspective and concern about cost
effectiveness to the health care system, and can operate as
02
�__
^
Extended Page
knowledgeable purchases to gain the greatest value for patients
1212 New York Avenue, N.W. • Sulla 1250 • MsNngton, D.C. 200)5 • (202) 263-6700 • FAX (202) 289-4582
2.1
�& 202 289 4582
03/25/93 13:29
B.P.P.U.P.
03
from health services they purchase. While i t is also possible for
government t o act as a knowledgeable purchaser on behalf of
patients, i t i s a more d i f f i c u l t role for a political entity that
must be responsive to a variety of constituencies i n addition to
the patients themselves.
This i s not to say that government o f f i c i a l s are professionally
deficient or that p o l i t i c a l leaders are driven by less than noble
motives. But government's concerns about health care resource
limitations are often diluted by conflicting concerns about
provider opportunities, patient needs, and the public purse. We
have too many examples i n our public benefit programs where the
government has over-promised, but under-financed and underdelivered.
Absent a strong role for private employers, the American health
care system, we fear, would decline t o the lowest common
denominator of service as efforts are made t o treat everyone
equally within a p o l i t i c a l budget limited by the a b i l i t y to raise
taxes and strained by the costs of an aging population,
technological advances t o which everyone feels entitled, and
unlimited treatment of epidemics such as AIDS and substance abuse,
from the same public coffers as general health care.
The APPWP Health Reform Proposal
The APPWP already knows business is doing more than its fair share,
but has asked employers to do even more. Because we believe in the
employer-based system, the APPWP has approved a bold and detailed
health care reform proposal. The APPWP proposal makes us the first
major business organisation to come forward with an employer-based
comprehensive health care plan that provides universal coverage and
tough cost containment. Among other things, our integrated plan
includes an employer mandate to provide coverage to workers, a
basic benefits package based upon the HMO Act, aggressive managed
care for a l l Americans — even Medicare beneficiaries, a cap on the
employee tax exclusion, spending targets with a possible fall-back
rate regulation, and a federal health board.
By requiring a l l employers to participate in the health care system
through a mandate and guarantee of coverage of a basic yet broad
benefit package, the APPWP has called for an even stronger role for
employers i n the health care system, chiefly because of our
concerns over quality and costs. Employers a l l across the country
are leading the way i n innovative programs to drive quality and
cost-effectiveness.
Major employers acting alone, or i n
partnership with other employers i n large communities have
established bold and far-reaching arrangements that demand from
providers s t r i c t quality measures and t i e directly the provision of
quality to payment and participation.
The ultimate aim of employer managed care programs i s to wring out
• -
^
j .. j -
- J
j
^
•'
. > u J t ^
�Extended Page 3,1
from the system costly"inefficiencies and Inappropriate care while
striving to seek greater and measurable quality. These kinds of
-2-
�03/25/9313:30
82022894532
R.P.P.U.P.
34
programs are t y p i c a l of the energies and drive that a strong
employer r o l e can unleash on the health care system. This i s the
kind of energy and drive we need to not only encourage, but demand
from payers of health care.
Furthermore, the APPWP proposal includes tough insurance and
malpractice reforms which, along with universal managed care for
a l l programs including Medicare and Medicaid, can bring down the
seemingly unstoppable upward trend i n health care spending f o r the
last several decades. The APPWP does support the development of
spending targets and the p o s s i b i l i t y of fall-back regulatory
measures should these targets not be met i n a reasonable period of
time after managed care elements were introduced and required a l l
throughout the health care system.
Employees also have a role. Under the APPWP plan, a l l Americans
would be required to secure coverage; they must accept employer
coverage when offered. The unemployed, early retirees, and other
individuals not e l i g i b l e f o r an employer plan, Medicare, Medicaid,
or other public program, w i l l also be required t o secure coverage
through a new pool organized by private c a r r i e r s , covered under new
insurance reforms, and coordinated w i t h state authorities,
subsidies and vouchers would be available t o low income individuals
and part-time employees t o help secure t h i r d pool coverage. By
l i m i t i n g the employee tax exclusion to a f a i r value of a costeffective basic plan, the APPWP provides greater incentives for
employees t o demand cost effective care, make them f o r involved
consumers of care, and t o achieve equity across the system as to
the tax subsidy f o r health care.
Employers want a rational health care system that i s driven by
quality and cost-effectiveness. They also want a current, and
future workforce that i s healthy, one-size-fits-all, flat rate,
globally-budgeted systems are not the best ways to achieve these
ends.
In supporting mandates, spending targets and benefits tax caps the
APPWP has dramatically altered twenty-five years of Association
policy.
However we did so after careful deliberations which
produced a r a t i o n a l and comprehensive reform proposal that meets
the President's c a l l f o r shared s a c r i f i c e i n order t o achieve
meaningful reform. We believe our plan has the best chance of
preserving the employer-based system and we think i t merits your
close study.
The APPWP appreciates the d i f f i c u l t y of your task. I t took us over
f i f t e e n months t o develop our proposal with the input of our
diverse membership, comprised of firms that sponsor, design and
insure retirement and health plans covering more than 100 m i l l i o n
Americans. Unless sponsors of health plans are able t o benefit
from the cost savings of the changes i n the health care system
which you are c r a f t i n g , i t w i l l not represent true reform. We
stand ready t o assist you.
�^
9:00--
PANEL TWELVE—BUSINESS—TESTIMONY ENDS AND
THE VICE PRESIDENT CLOSES HEARING
[THE VICE PRESIDENT DEPARTS.
MEG DEPARTS ]
�TALKING POINTS DEFENDING PROCESS
»
T h i s i s t h e most open p o l i c y m a k i n g process i n h i s t o r y . Let's
p u t t h i s i n c o n t e x t . D e c i s i o n s i n government have
t r a d i t i o n a l l y been made by a few people s i t t i n g i n a room.
I n c o n t r a s t , we have b r o u g h t t o g e t h e r t h e r e a l - w o r l d
e x p e r t i s e o f more t h a n 500 people from a l l over t h e c o u n t r y .
These a r e people — d o c t o r s , nurses, s o c i a l workers,
a d m i n i s t r a t o r s and consumers — who know f i r s t h a n d t h e
problems i n o u r h e a l t h c a r e system.
»
D i f f e r e n t agencies a r e ^ w o r k i n g t o g e t h e r w i t h H i l l s t a f f t o
f o r m u l a t e a p r o p o s a l . T h i s e f f o r t i s unprecedented i n two
i m p o r t a n t ways: 1) I n s t e a d o f t h e u s u a l i n t e r a g e n c y
s q u a b b l i n g , people from a l l d i f f e r e n t agencies have come
t o g e t h e r t o g e t something done. 2) Over 90 H i l l s t a f f e r s a r e
i n v o l v e d , making t h i s a t r u l y c o l l a b o r a t i v e e f f o r t between
the e x e c u t i v e and l e g i s l a t i v e branches o f government.
<*
i n t e r e s t groups a r e b e i n g i n c l u d e d . Mrs. C l i n t o n , I r a
Magaziner and o t h e r White House o f f i c i a l s have met w i t h over
4 00 groups s i n c e t h e Task Force was formed. However, g i v e n
the p o s s i b i l i t y o f c o n f l i c t o f i n t e r e s t , we cannot l e t
i n t e r e s t groups make p o l i c y . For example, i f we were t o
g i v e t h e AMA a permanent r o l e , we would have t o do t h e same
f o r every drug company o r i n s u r a n c e f i r m t h a t wanted i n .
•
The one-hundred day d e a d l i n e i s necessary because o f t h e
u r g e n t need f o r a c t i o n . We've had enough s t u d i e s and
r e p o r t s . I t ' s time t o take a c t i o n t o fundamentally overhaul
our n a t i o n ' s h e a l t h c a r e system.
•
The people on t h e w o r k i n g groups have r e a l - w o r l d h e a l t h care
e x p e r i e n c e . I n f a c t , we have over 100 h e a l t h c a r e
p r o f e s s i o n a l s i n c l u d i n g 60 d o c t o r s , 20 nurses, 6 s o c i a l
workers.
[ I f pressed on d o c t o r s , almost h a l f o f them were
p r a c t i c i n g medicine b e f o r e t h e y t o o k a l e a v e t o h e l p t h e
Task Force.]
The L a w s u i t ( i f i t i s b r o u g h t u p ) :
•
The l a w s u i t i s c u r r e n t l y under appeal, b u t we a r e n o t here
t o t a l k about t h e l a w s u i t . We a r e here t o t a l k about how t o
make t h e h e a l t h - c a r e system work.
PHOTOCOPY
PRESERVATION
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Administrative Material on Constituency Groups and Ethics Working Groups – Folder 3
Creator
An entity primarily responsible for making the resource
Task Force on National Health Care
White House Health Care Task Force
Charlotte Hayes
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 2
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 15
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2006/2006-0885-F-2.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12093114" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
2/6/2015
Source
A related resource from which the described resource is derived
42-t-12093114-20060885F-Seg2-015-003-2015
12093114
-
https://clinton.presidentiallibraries.us/files/original/db76015b13480a450b7fb1a2b9a14ce2.pdf
254f46b77a582f3d77fa67abff981f27
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Hayes
Subseries:
OA/ID Number:
3015
FolderlD:
Folder Title:
Admin. Material on Constituency Groups & Ethics Working Groups-Folder 2
Stack:
Row:
Section:
Shelf:
Position:
S
56
3
5
1
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
SUBJECT/TITLE
DATE
RESTRICTION
001. biography
re: American Medical Association - Raymond Scalettar (partial) (1
page)
03/26/1993
P6/b(6)
002. biography
re: Richard Oliver Butcher (partial) (1 page)
03/26/1993
P6/b(6)
003. biography
re: Health Insurance Association of America - Bill Gradison (partial)
(1 page)
03/24/1993
P6/b(6)
004. biography
re: Blue Cross Blue Shield Representative - Senior Vice President Mary Nell Lehnhard (partial) (1 page)
n.d.
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Charlotte Hayes
OA/Box Number: 3015
FOLDER TITLE:
Admin. Material on Constituencey Groups & Ethics Working Groups - Folder 2
2006-0885-F
ip2697
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)]
Freedom of Information Act - [5 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information |(bXl) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions [(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells [(b)(9) of the KOI A]
National Security Classified Information [(a)(1) of the PRAj
Relating to the appointment to Federal office 1(a)(2) of the PRA)
Release would violate a Federal statute |(aX3) of the PRA]
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA]
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�American Chiropractic Association
Representative
Reeve Askew, D.C.
Executive Director
Reeve Askew, D.C. i s a member of the Board of Governors of
the American C h i r o p r a c t i c Association and a doctor of
c h i r o p r a c t i c i n Easton, Maryland, where he has p r a c t i c e d f o r the
l a s t twenty-three years. Dr. Askew has served i n numerous
e l e c t e d and appointed p o s i t i o n s both w i t h the ACA and the
Maryland C h i r o p r a c t i c Association. Dr. Askew has t e s t i f i e d
before the U.S. House of Representatives Committee on Ways and
Means and before the Maryland General Assembly on various h e a l t h
and safety issues. He received h i s degree as Doctor of
C h i r o p r a c t i c from New York College of C h i r o p r a c t i c and h i s
Bachelor of A r t s Degree i n Biology from F r a n k l i n & Marshall
College. A d d i t i o n a l l y , he has completed post graduate work i n
roentgenology and orthopaedics at National College of
C h i r o p r a c t i c i n Lombard, I l l i n o i s .
�NATIONAL ASSOCIATION OF SOCIAL WORKERS
MEMBERS:
145,000 p r o f e s s i o n a l s o c i a l workers.
REPRESENTS:
55 c h a p t e r s i n t h e U.S. 80,000 c l i n i c a l s o c i a l
workers p r o v i d e over h a l f o f the mental h e a l t h
c o u n s e l i n g i n t h e U.S.
TODAY'S SPEAKERS:
Sheldon G o l d s t e i n , E x e c u t i v e D i r e c t o r
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Strong g r a s s r o o t s , m o b i l i z e q u i c k l y , p r o t e c t
consumers, i n a l l s t a t e s .
S i n g l e payer
Strong s i n g l e payer t o m i d d l e range ( a n y t h i n g e l s e
w i l l l e a d t o two t i e r system and poor people w i l l
lose o u t ) .
Provide f l e x i b i l i t y t o s t a t e s .
Health care financed through dedicated f e d e r a l tax
on p e r s o n a l income and an e m p l o y e r - p a i d p a y r o l l t a x .
S i n g l e comprehensive s e t o f h e a l t h c a r e b e n e f i t s .
Mental h e a l t h b e n e f i t s must be i n c l u d e d i n p l a n .
POSITION ON
PLAN:
Open, s t r o n g , no o p p o s i t i o n .
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
Public Liaison, t r a n s i t i o n .
PET
Non
ISSUES:
HOT BUTTON ISSUES:
physician provider's health
care.
Comprehensive; p a r i t y f o r m e n t a l h e a l t h b e n e f i t s
w i t h p h y s i c a l h e a l t h i s s u e s . Don't b e l i e v e co-pay
should be d i f f e r e n t f o r m e n t a l h e a l t h .
�National Association of Social Workers
Representative
Sheldon R. Goldstein
National Executive Director
Sheldon R. Goldstein serves as the Chief Executive O f f i c e r
of t h e N a t i o n a l Association o f the 145,OOO-member p r o f e s s i o n a l
a s s o c i a t i o n o f s o c i a l workers (NASW), which i s the l a r g e s t
o r g a n i z a t i o n o f s o c i a l workers i n the world. Responsible f o r
oversight o f a l l governance and programs o f the association
i n c l u d i n g t h e NASW Press, a major publisher o f s o c i a l work books
and j o u r n a l s ; services t o the s t a t e chapters of the association;
government r e l a t i o n s ; c r e d e n t i a l i n g ; conferences and continuing
education; news and media; p o l i t i c a l a c t i o n ; insurance programs;
and N a t i o n a l Center f o r Social Policy and Practice. Responsible
f o r t h e prudent management o f a $15 m i l l i o n annual budget, and a
n a t i o n a l s t a f f of 150 people.
P r i o r t o becoming National Executive d i r e c t o r , Mr. Goldstein
served as Executive D i r e c t o r f o r the I l l i n o i s Chapter o f t h e
National Association o f Social Workers. He also served as the
D i r e c t o r o f Organizational Services f o r NASW from 1979-88, and
Executive D i r e c t o r of NASW, F l o r i d a Chapter from 1975-79. Mr.
Goldstein has also held c l i n i c a l s o c i a l work p o s i t i o n s i n both
the United States and England.
Sheldon Goldstein received a Bachelors o f Business
A d m i n i s t r a t i o n from the U n i v e r s i t y o f Miami, Coral Gables,
F l o r i d a , and a Masters o f Social work from t h e Jane Addams
Graduate School o f Social Work a t the U n i v e r s i t y o f I l l i n o i s a t
Chicago.
�R C V
B Y :
: 3-25-93 ; 1:05PM
2023368327^
SOCIAL OFFICER 2
On behalf of the 145,000 members of tfae National Assodaticm of Social Woiiers (NASW), I wish to
thank youforthe opportunitytopresent NASWs views on containing costs within a health care reform
initiative. Jt is indeed an honortoappear before this task force.
Professional social workers, as you may be aware, practice throughout the health and mental haairh care
delivery systems. They are employed in health planning, policy, and administration, as well as public
health, health promotirm and health education. Professional social workers also serve as primary health
and mental health care providers in a wide range of private and public settings-Additionally, many social
workeis face the increasingly difficolt job of trying to piece togetherfinancingfarneeded care that is
either not covered or madequately covered by insurance.
The social wori: profession has an historical perspective in viewing social systems as avennes for change.
It is from this outlook that NASW developed a health carereformproposal that we believe to be the ideal.
It addresses cost containment among health care providers; it also addresses the cost containment systemwide. It is a single-payer national health care program that would be administered by the states under
federal guidelines and would ofer comprehensive health, mental health, and long-term care services to
all Americans,
In brief, the cost containmentfeaturesthat NASW recommrads through its single payment plan are:
• The single-payer system itself, in which the government would collect and disburse thefinancesfor
health care. (Estimates on the savings of a single payer system rangefrom$72 billionto$150 billion pet
year in administrative costs,)
• The use of global budgeting, through the states, to cover aU covered health expenditures.
• Stateregulationof thefendsforcapital expansion and the purchase of highly-specialized equipment
�RCV BY:
: 3-25-93 ; i:C5PM !
2023368327-
SOCIAL OFFICE'.* 3
Other lecxmunendatioasforcost containm«t that are most directly rdated to health care providers include;
• The use of negotiatedfeeschedulesforphysicians and other health care practitioners, mcludrng social
workers, that arereimbursedon afee-fat-servicsbasis.
• The use of care coardmatiauforindividaals with chronic and/or costly health care conditions.
• The use of utilization review to screenforand evaluate the appropriateness of care.
• A benefit design that includes a Ml continunm of appropriate care, so that individuals may receive
more cost efficient care in outpatient community-based settings or partial hospitalization, as opposed to
more costly care in inpatient settings.
Additionally, there arefeaturesin the NASW plan,relatedto service delivery, that we believe wiU
ultimately lead to greater cost savings.
• Coverageforpreventive care, including immunizationsforall children.
• Coverageforcomprehensive mental health care, which we believe willresultin fewer visits for
unnecessary medical care. Currently, individuals who do not have mental health coverage may
inappropriately seek helpfiroma health care provider when their problem stemsfroman emotioual or
behavioral base.
• Recognition of the ability of duly regulated non-physician providers to provide quality, cost effective
care.
NASWs interest isforthe Clinton Administrationtodevelop a good, comprehensive plan that we may
wholeheartedly endorse andforwinch we may organize support- We offer our single-payer proposal as
our visicm of die blueprint by winch quality, comprehensive care may best be providedtoall Americans
in an equitable and affordable fashion. We recognize that the President has already endorsed the use of
�RCV BY:
3-25-93 : i:06PM !
' 2023368327-
SOCIAL OFFICER 4
"global budgetmg," a concept thai is intrinsictosingle-payer proposals and one, which we believe is
essentialtocontrolling health care costs. We encourage youtoalso utilize other cost control and cost
savingsfeaturesof the angle-payer system as the means to provide universal coverage for comprehensive
health, mental health, and long-term care.
Thank you.
�AMERICAN PSYCHOLOGICAL ASSOCIATION
MEMBERS:
APA represents more than 74,000 members n a t i o n a l l y
and around the world; 40,000 students, f o r e i g n , and
high school teacher a f f i l i a t e s ; d i v i s i o n s i n nearly
50 areas o f psychology; and a f f i l i a t i o n s w i t h s t a t e
and Canadian psychological associations.
TODAY'S SPEAKERS:
Bryant Welch, Executive D i r e c t o r f o r Professional
Practice
SCOPE OF
INFLUENCE:
Grassroots network.
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
HOT BUTTON ISSUES:
Focused on mental h e a l t h .
Assurance o f c l i n i c a l management f o r severe mental
disorders w i t h some increased co-payment f o r
psychotherapy.
The p r i o r i t i e s o f the APA include mental h e a l t h
b e n e f i t s , universal coverage, cost containment,
r e h a b i l i t a t i o n services. Q u a l i t y assurance
provisions necessary f o r persons w i t h d i s a b i l i t i e s .
Want t o be t r e a t e d as f u n c t i o n a l equivalents t o
psychiatrists.
Wait and see, dependent on b e n e f i t package; be
treated f a i r l y
T r a n s i t i o n , Public Liaison, Mental Health Subgroup
Uncontrolled coverage o f p s y c h i a t r i c services, drug
prices
�TEL: 202-336-5797
M r
Q7 17:A9
Mar 24,^-5 it
No.017 P .02
•• •
flpfl
Bryant L. Welch. J.D., Ph.D.
Bryant L. Welch is currently serving ae the Senior Advisor for National
Health Care Reform for the American Psychological Association. Dr.
Welch's diverse baclcground and experience has allowed him to emerge as
a leading advocate for the public's right to access quality mental
health services. Dr. Welch is a licensed attorney and a clinical
psychologist. He is a graduate of Harvard Law School and received his
Ph.D. from the University of North Carolina. Engaged in the practice
of clinical psychology for nearly 20 years, he has served a variety of
populations, including adolescents, and provided services ranging from
crisis intervention to intensive treatment for the seriously mentally
i l l . Most recently. Dr. Welch served as the Executive Director for
Professional Practice for the American Psychological Association, where
he was dedicated to legal and legislative advocacy on behalf of
professional psychology and those citizens in need of mental health
care.
The American Psychological Association is the world's largest
association of psychologists with membership including more than
114.000 researchers, educators, clinicians, consultants and students.
APA works to advance psychology as a science, a profession and as a
means of promoting human welfare.
•
�APq
TEL: 202-336-5797
-
Mar 25.93 13:38 No.Oil P.02
AMERICAN
PSYCHOLOGICAL
ASSOCIATION
STATEMENT
OF
THE AMERICAN PSYCHOLOGICAL ASSOCIATION
PRESENTED BY
BRYANT L. WELCH, J.D., PH.D.
TO THE
HHITB BOOSE TASK FORCE ON HEALTH CARE REFORM
750 First Street, NE
Washington, DC 20002-4242
(202)336-5500
�TEL: 202-336-5797
Mar 25,93 13 = 38 No.Oil P.03
Madam Chair. Distinguished Members of the Task Force, I am Bryant
Welch, J.D., Ph.D. representing the 114,000 members of the Aiterican
Psychological Association. I am a licensed' attorney and a clinical
psychologist. I will focus my comments on the mental health field in
which I have practiced for the last 20 years and the cost problems
affecting both mental health and the health delivery system.
There are two long-standing structural anomalies wasting millions of
badly needed dollars in the mental health system. First, we are
needlessly using very expensive hospital-based treatment for
significant patient populations who research shows could be better
treated in outpatient settings. AH evidence documents that recent
increases in mental health care costs have occurred only in inpatlent
alcohol and drug treatment and in inpatient adolescent care treatment.
At the same time, research now concludes that nearly 50% of these
patients could be treated as effectively or more effectively in
outpatient settings.
Why aren't these individuals treated in outpatient settings? The
reason i s based on current economic and insurance incentives. First,
in 1984 when the Medicare PPS/DRG system was established i t was not
applied to psychiatric units or psychiatric hospitals. As a result,
entrepreneurial hospital dollars were directed into psychiatric
facilities, producing a doubling of the number of such facilities
between 1984 and 1988. This, of course, led to much greater "provider
demand" for patients. Second, hospital-based treatment i s covered
often at 100% reimbursement with little or no expense to the
beneficiary while outpatient benefits are extremely limited and require
significant cost sharing. What this poses to a family i s a decision of
whether to keep a disturbed family member at home with outpatient
treatment or. instead, to put the patient in a hospital — giving
themselves respite, and eliminating their financial burden as well. I t
is this dual dynamic which has created the cost problem in mental
�RPR
TEL: 202-336-5797
Mar 25,93 13:38
No.Oil
-2-
health care. If we are to allocate resources to those most in need, we
must fund patients rather than facilities and give them incentives to
use appropriate, less expensive care.
The second anomaly in the mental health system i s in the outpatient
sector where increasingly, we are providing a level of coverage that
treats the healthiest patients and excludes the sickest from any care
at a l l . How did this come about? Managed care companies and, more
recently, other third-party payers have redefined traditional
outpatient care to make i t so brief i t is evidently inappropriate for
those in greatest need. Twenty-session treatments for healthy adults
going through difficult life transitions such as divorce or death of a
family member can be justified and i s good mental hygiene. But we
cannot treat a learning-disabled child or an abused child in 20
sessions of crisis intervention. Further complicating the problem i s
the fact that the managed care companies use burdensome utilization
review procedures appropriate for inpatient care. But these
utilization procedures are not cost effective for outpatient treatments
whose utilization can be effectively and more economically controlled
by adjusting copayments.
In summary, we believe that by controlling inappropriate inpatient
utilization we can free up resources for patient-appropriate, costeffective outpatient care. We believe that psychologists, as a
provider group in such a system, would not only accept a fee schedule
and certain reasonable price controls, but that we would agree to see a
certain percentage of lower-fee patients whose economic circumstances
do not permit them to meet their co-pay obligations.
Turning to the larger health care system, we believe that the best way
to control costs inside the health care bureaucracy i s through the
implementation of a progressive consumption tax in which each person
pays a portion of their health care expenditure based on their ability
P.04
�APR
TEL: 202-336-S797
Mar 25,93 13 = 38 No.Oil P..05
-3-
to pay. This has the benefit of raising badly needed resources to fund
the program in an equitable manner and also give each consumer a stake
which they do not now have in making cost-effective, rational decisions
about their health care consumption. We can see no compelling reason
why, given the health care economic crisis, individuals making
substantial incomes should not have to pay a reasonable portion of what
they consume so they, too, have an incentive to save badly needed
resources.
As some one who has practiced in the mental health field for 20 years,
I recognize the allure which the managed competition model has for
policy makers with its promise to make the treatment f i t the patient
and thereby elljninate waste. In reality, i t does not work that way —
instead, the operative dynamic working in the managed care system has
been that the largest profits are made by denying care to subsets of
those most in need. Current proposals to eliminate malpractice
liability just as we transition to these new systems are chilling and
can exacerbate problems we are presently experiencing.
In closing, we recognize that health care reform i s extremely complex
and that reasonable people can differ on the appropriate solutions to
i t . We in particular, as mental health providers, call your attention
to the structural anomalies in the mental health field believing that
i f corrected, could result in the elimination of very costly waste
while improving access. We again wish to reiterate our very deep
appreciation for the sensitivity and compassion to those most affected
by our ailing health system and your sincere efforts to find solutions
to our current health care crisis. The psychology community stands
ready to assist you in your task and to support your ultimate
recommendations.
�12:20-
PANEL FOUR-GENERAL HEALTH CARE PROVIDERS- TESTIMONY
ENDS
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
3_
�12:35--
PANEL FIVE-PHYSICIANS- TESTIMONY BEGINS
Now we will hear from some health care providers. The question we posed to them
was: "What can we do to ensure the immediate control of costs while ensuring quality care
and physician choice?"
Ourfirstwitness is Dr. Raymond Scaletter [SKA-LETTER] from
the American Medical Association.
�PANEL FIVE: PHYSICIANS
Question Posed:
What can we do to ensure the immediate control of costs while ensuring quality care and
physician choice?
Groups:
American Medical Association
American Association of Physicians and Surgeons
National Medical Association
American Academy of Family Physicians
American Academy of Pediatrics
American Psychiatric Association
Major issue concerns:
They will all probably be opposed to most of the short term cost controls that have been
talked about in the press. There will be a range of opinions about global budgets,
capitated payments, and managed care. The AMA and AAPS will be most conservative,
the NMA most liberal (they support single payer (see Message Sheet for Panel Eleven:
Consumers). The APA will obviously talk about mental health. Everyone is in favor of
tort reform.
,
Talking points:
1.
Everyone who has been making lots of money off of health care in the last 10
years will need to sacrifice to make the system work.
2.
We will help doctors by reducing paperwork and administrative costs, and by
doing something to curb malpractice suits.
3.
We need to encourage general practitioners instead of specialists.
4.
Single Payer: We support the goals of single-payer legislation -- cost containment,
simplification, reduced paperwork, high quality health care, a guaranteed benefit
package ~ which will be a central part of our May proposal. However, we are
committed to maintaining a uniquely American system ~ one that is rooted in the
private sector, builds on our employer-based system, maintains the highest quality
of medical care in the world, and preserves the right of Americans to choose their
doctors.
�AMERICAN MEDICAL ASSOCIATION (AMA)
MEMBERS:
Approximately 300,000 p h y s i c i a n
REPRESENTS:
F e d e r a t i o n o f 50 s t a t e medical a s s o c i a t i o n s
and t h e D i s t r i c t o f Columbia, c o u n t y ,
m e t r o p o l i t a n s o c i e t i e s and over 80 n a t i o n a l
medical s p e c i a l t y s o c i e t i e s
TODAY'S SPEAKER:
Dr. Raymond S c a l e t t a r
biography)
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
members
(See a t t a c h e d
I n f l u e n t i a l w i t h Congress; l a r g e campaign
c o n t r i b u t o r s ; able t o generate s i g n i f i c a n t
press coverage; major g r a s s r o o t s network
Universal
reforms
employer mandate w i t h M e d i c a i d
U n i v e r s a l access t o c a r e t h r o u g h an employer
mandate and Medicaid r e f o r m , i n s u r a n c e market
r e f o r m s , p a r t i c u l a r l y community r a t i n g , and
elimination of preexisting condition
restrictions.
Want t h e r i g h t f o r o r g a n i z e d m e d i c i n e t o
n e g o t i a t e w i t h f e d e r a l agencies and
r e g u l a t o r y programs and a t t h e l o c a l l e v e l
w i t h managed c o m p e t i t i o n e n t i t i e s .
Want p r o f e s s i o n a l l i a b i l i t y r e f o r m ; freedom
o f p a t i e n t s t o choose t h e i r p h y s i c i a n and
system o f h e a l t h c a r e d e l i v e r y ; q u a l i t y
assurance t h r o u g h p r a c t i c e parameters and
outcomes r e s e a r c h ; a d m i n i s t r a t i v e c o s t
reduction; establishment a t t h e f e d e r a l l e v e l
o f a minimum b e n e f i t s package ( w i t h r e p e a l o f
s t a t e mandates); and decreased r e g u l a t i o n .
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
PET
ISSUES:
Considering
T r a n s i t i o n , S e c r e t a r y S h a l a l a , I r a Magaziner,
OPL, Work Group members. V i c e P r e s i d e n t Gore
and Sec. S h a l a l a addressed Annual M e e t i n g .
Malpractice reform,
simplification
administrative
HOT BUTTONS ISSUES: Cost and P r i c e c o n t r o l s . R e s t r i c t e d p h y s i c i a n
c h o i c e . Loss o f p r o f e s s i o n a l autonomy
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. biography
SUBJECT/TITLE
DATE
re: American Medical Association - Raymond Scalettar (partial) (1
page)
03/26/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Charlotte Hayes
OA/Box Number:
3015
FOLDER TITLE:
Admin. Material on Constituencey Groups & Ethics Working Groups - Folder 2
2006-0885-F
ip2697
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)]
Freedom of Information Act -15 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA)
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information |(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions ((b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA]
National Security Classified Information 1(a)(1) of the PRA)
Relating to the appointment to Federal office 1(a)(2) of the PRA|
Release would violate a Federal statute 1(a)(3) of the PRA|
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA]
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(S) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�MRR 26
'93
18102
eee
RMP UIASH DC
P. 92
American Medical Association
Phyticltnj cMlottod to tha hailth of Anwrict
R^mond Scalettar, MD,ftpnetictng internist and rheunutologlstfromWashington, DC,
and a founding partner of the Waihln^ton Internal Medldne Group, DC, wureelectedtn
June 1991 to the American Medical Auodaliom (AMA) Board ofTmsteea and elected
aecretuy-treasurer of the AMA. In June 1992 he was elected chair of the AMA Board of
Xrusteefi. He had serwd as chalrof the AMA eonunlaBloneiB to the Joint Commbslon on
the Accreditation of Healthcare Organizations (JCAHO)fromJanuazy 1991 to June 1892.
Untfl hia election to the Board In 1985, Dr. Scalettar wu chair of the AMA's Committee
on Professional Liability and served on the AMA's CounoQ on Medical Servicefrom1981.
He was an alternate delegatefromthe Medical Society of the District of Columbia to the
AMA House of Delegatesfrom1969 to 1976 and became a delegate tn 1978.
Dr. Scalettar is put president and past chair of the board of the Medical Society of the
Raymond Scalettar, MD District of Columbia, and is vice chair of National Captttd Underwrtten, Inc., the
Chair, Board of TnutoM
manager for the society's profeaBtonal liability insurance oompany. His longstanding
Americui Medical Asaociaion interest in profeaaional liability prompted himtobeoomea
Society's Legal Reeouroes Fund and chair of the National Capttol Brokerage, Ltd., a
itibdMslon of the Sodetfa professional liability bamuioe oompany.
' • P6/(b)(6) _lDr,ScalettArwM graduated from Colu^
^UnJvraityaf New Ydft Downstate Medical Center. He completedrealdencyand postresidency training at Walter Reed General Hospi^
assigned as chief of one of the hospital's general medical serrioes and chief of
rheumatology. Dr. Scalettar is board cartifledtn internal medidne as well as
rheumatoloir. He has been dtaical profceaor of medldne at the George Washington
IMveratty Medical Center since 1981. In December 1986, Dr. Scalettar became the first
president of the medical staff at the National Rehabilitation Hospital in Washington.
Dr. Scalettar was the recipient of the Medical Soctty of DCs Meritorious Service
Award in recognition of his service to the medical prcfeeslon andtothedtlrenaof
Washington, DC. He has beenafttlowtf the American fonegerfPhys^^
1962, andtoa member of the Alpha Omega Alpha honor medical society.
A member of the Long Range Planning Committee of the American Rheumatlsra
Aaaodatlon, Dr. Scalettar has also beenamemberof the Board of Director! of the Lupus
Foundation, the Washington Metropolitan Qupter, and the Arthritis and Rheumatism
Association of DC. Hehassen^aspreskientctfboththelUieuinatismSodBtyafDCand
the DC Society of Internal Medicine. Dr. Scalettar wu fbnnerty editor difttical
Annali qfthe District qfCotumbia, a member of the Soctaty of Medical Consultants to
the Armed Forces and many other professional OEguibattona.
Dr. Scalettar and his wife, Nada, reside tn North Betheeda, MarylanA They are the
parents of a daughter, Lydia, and & son, Mark.
1992-1998
�^MflR
26
'91
16109
000
BMP URSH
DC
P.02
Oral Statement
of the
American Medical Association
to the
White House Task Force
on Health Care Reform
Presented by
Raymond Scalettar, MD
March 29, 1993
The American Medical Association appreciates this opportunity to
state once again, it's commitment to reform of this nation's health care
>
system. As we have said publicly the last several years and privately in
the constructive opportunities we have had to discuss our views with
representatives of the Administration and this Task Force over the last
few months, America's physicians know that change is necessary.
Far too many of our patients have no health insurance coverage.
The hassles of providing care under the burden of paperwork and
bureaucratic second-guessing frustrates physicians as well as our patients.
And the costs of health care are rising too quickly - for our patients and
the good of the nation. We do not defend the status quo.
You have asked us what can be done to insure immediate control
of health care costs while insuring quality care and physician choice.
There are direct, workable solutions that can be implemented
immediately; an employer mandate to provide a federally established
�MflR 26
'93
16:10
006
flnfi
UlflSH OC
P.03
essential benefit package with community rating.
Before I speak of them
and our written statement expands on
them -- I respectfully ask the Task Force to do one thing -- look at
experience. Contrary to perceptions, this nation does have experience in
both health system reform and controlling costs.
One lessen to be gained from experience is that true, effective cost
control has never been achieved in this or any other economy through
arbitrary caps on spending, or price controls. They did not work in the
1970s, only delaying natural price increases and impeding supply of
necessary goods and services.
They also will not work in health care. Price controls, or global
budgets, mean arbitrary decisions that will, without basis, limit our ability
to deliver needed medical care to our patients. With as much as we
know about medical care, its cost, and where it is needed, we cannot rely
on arbitrary decisions. We have suggested a better way
a partnership
between government, physicians, employers, and others. By working
together to isolate the costly failures in the health care system, tme
predictability can be brought to this nation's health care costs without
limiting patients' access to medical care.
Another equally important lesson is that health system reform has
already been demonstrated to work in the United States. We are puzzled
that more attention is not given to the successes in Hawaii and Rochester
NY have had in providing virtually universal access to health care
strongly based in primary care - at costs well below the rest of the
�k
MfiR is '93 ifeiu
eae Ana URSH
DC
p.a4
nation and most other countries. Hawaii insures its population at an
annual cost of 8.1 percent of its gross state product, well below that of
Canada and Germany, widely touted as systems that some argue should
be copied here.
How has this been accomplished? By doing two basic things a
long time ago
require all employers to provide health insurance to their
employees and require insurance premiums to be based on community
rating.
These two simple steps -- which most involved in health system
reform agrees with
cannot only control costs but go a long way
towards ensuring universal access.
Of course, much else must be included in comprehensive reform.
We are pleased that the Administration has identified liability reform and
a lessening of the administrative burdens physicians bear as essential to
reform. A strong commitment to public programs for the needy is also
needed.
We are most encouraged that the Administration has spoken of the
need for patient choice and competition. We hope that health system
reform will create a level playing field filled with clearly available
information to enable patients to make necessary health care choices.
To accompUsh that level playing field, choice must be guaranteed.
Choice between different types of insurance, not only managed care.
Choice of physician, guaranteed by anti-trust relief that will allow
physicians to bargain together against large insurers and allow physicians
�W
riRR 26 '93
16111
eee
RMPI UIBSH DC
p.es
to police their own profession.
It is only through these measures that empower patients and allow
physicians to make decisions in the best interest of their patients that
quality of medical care can be guaranteed while costs are controUed.
�AMERICAN ASSOCIATION OF PHYSICIANS AND SURGEONS
MEMBERS:
3,500 members
REPRESENTS:
The Association i s a n a t i o n a l , n o t - f o r - p r o f i t
physician and osteopath membership
corporation.
TODAY'S SPEAKER:
Dr. Jane M. Orient
SCOPE OF
INFLUENCE:
Not i n f l u e n t i a l .
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Preserve p r i v a t e medicine,
accounts.
Medical savings
Proposals include e s t a b l i s h i n g medical
savings accounts, insurance reforms, reducing
regulations and mandated b e n e f i t s , and
development o f p r i v a t e a l t e r n a t i v e s t o
Medicare. Believe h e a l t h care cost
escalation due t o : tax-subsidized prepaid
insurance; r e g u l a t i o n s ; and l e g a l overhead.
POSITION ON
PLAN:
Opposed t o process.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
None
PET ISSUES:
"Preserve American medicine".
HOT BUTTON ISSUES:
Managing system w i l l lead t o r a t i o n i n g .
�03/25-'1953
P. 02
10:;
1601 N. Tucson Blvd. Suite 9
Tucson, AZ 85716
(600) 636-1196
(602) 327-4885 In AZ
Association of American Physicians and Surgeons, Inc.
March 23, 1993
Prtirlrjeni
Norwolk. OH
Chonci W. Mr D©wf». Jp. M 0.
Alphnroflo. GA
LVnolri cjyirikm. MO.
To: Health Care To»k Force
R«: Prfteentation by the Aaaociation of American
Physicians and Surgsons, Pan»l 5, at March 29th
Public Hearing
Becaus* •arnings of phyaicians are »om*times
targeted ac the primary source of savinge, we would bring
NenniioU, ii
^ lOwvliCampooll, M.B.
your attention to the following facts:
JfM:".M. Soytot.jt.M.D.
income of physicians averages between $31 and $94, with
The hourly net
family phyaicians and other primary care physician© at
Clijurt A Uoyu. Ji„ WC>.
the lower end of the scale (tIAM 266:3453-3458 and
267:1822-1825). Physiciane' feea account for
Cyrtlj W. Culnw Sf.. M U .
Sjtktan, MS
. U I I J. Coi5«iOr>tJ. M R.
ItlllM^w. N.I
Jomw P Coy. M.D
L>»lonri. I (.
Jo*n j . l l w w , M.fi.
C^'COtfo, ll
V l f-wiir/.Mr).
health-care expenditures could be reduced by only 9% by
^ul I. dntHjCI,. S „ M o
Sar Anionic. IX
cutting physicians' net income to zero.
wftrmioi jotwn M. D
Atlonly,
/M'JiwwF.Moncw.M.O.
Ookiana. MO
l>0"W.ftlnl;.f/.t>
lUL'kW, (JA
Juwoi S e ^ w r . MD
SocilttdOta, A7
MichOBl Schll«. M.0.
KCf'iton, WA
tXtCUTlVT DWECTOI?
approximately 19* of health-care expenditures.
Roughly
half of the physician's fee covers overhead. Thus,
This
intervention would have obvious implications for the
availability and quality of services.
From a budgetary point of view, a reduction in
federal expenditures has a large, immediate impact. To
assure that reductions in federal expenditures have a
minimal effect on quality of care and physician choice,
^bNERAI COUNSCL
Kei.i M m l f W * ftown
the federal government must refrain from prohibiting
patients from using alternate sources of funding in order
to obtain services of their choice.
The federal government impacts copt^g. as opposed to
501li AMIXJOI Mooting. Oclvber 6 9.19*3
Uan Antorio, T«U6
P DAM
r n v
�03/25/1993
p
10=25
-
0 3
Assoc. of American Physicians and Surgeons, p. 2
expenditures/ in a number of ways. One i s by subsidizing
econofliieally unsound ("first-dollar") insurance through the tax
code. A second is by regulations that impose high compliance
coats without yielding measurable improvements in quality.
Another is by mandating coverage (or permitting states to mandate
coverage) of costs that patients would not choose to incur. I f
these laws were repealed, market forces would operate to cause an
imniediate, substantial reduction in prices.
The key to cost control with the preservation of quality and
choice i s to restore patients to their role as primary purchasers
of medical services-a role that has been largely usurped by third
parties-and to permit pflUsntS to benefit from their own prudent
cost-saving decisions.
The mechanism to achieve this i s to
permit tax subsidies only for those insurance plans that provide
catastrophic coverage with a high deductible. The savings in
premiums, in most cases, would be sufficient to cover the
deductible, i f the savings received the same tax treatment that
is now enjoyed by employer-provided first-dollar insurance
coverage.
Medical savings accounts should be permitted for a l l
Americans.
The high administrative costs of our present insurance can
only be relieved by removing the middleman from routine medical
transactions.
Restoring direct payment by the recipient of the
services would also eliminate incentives to "game" the system.
"Managed competition," on the other hand, would simply impose
another layer of bureaucracy without reducing costs (as observed
F O A
r» <*kK*
�^3/25,-1993
P
10:26
-
04
Assoct of Amarican Physicians and surgsons, p- 3
by ths GAO).
Sons have propossd that eliminating private medicine would
result in cost savings.
Private medicine, including solo
practice, i s the most efficient and economical delivery
mechanism.
I t i s the anl* mechanism that exists in large
portions of the country. To eliminate i t would drive up costs.
Furthermore, private medicine i s the gold standard of quality.
Any solution must allow private practice and patient choice
to continue,
withhold care.
in addition, i t must prohibit incentives to
�NATIONAL MEDICAL ASSOCIATION
MEMBERS:
More than 16,000 physicians
REPRESENTS:
Physicians i n a l l 50 states, Puerto Rico and
V i r g i n Islands, most of whom are m i n o r i t y and
of those most are A f r i c a n American.
TODAY'S SPEAKER:
Dr. Richard Butcher, President
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
May be i n f l u e n t i a l w i t h Congressional Black
Congress.
Single payer but f l e x i b l e .
Universal access, i n c l u d i n g s u b s i d i z a t i o n o f
coverage f o r the low-income. Comprehensive
package w i t h emphasis on prevention; freedom
of choice between provider and p a t i e n t ;
government assurance o f q u a l i t y medical care
w i t h representative m i n o r i t y p a r t i c i p a t i o n ;
and compliance w i t h T i t l e V I o f C i v i l Rights
Act. Address shortage o f m i n o r i t y
physicians.
B u i l d incentives f o r m i n o r i t i e s
t o enter medical profession.
Should support universal access. Concerned
about exclusion from managed care
contracting.
T r a n s i t i o n , OPL, I r a Magaziner (3/31)
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002. biography
DATE
SUBJECT/TITLE
03/26/1993.
re: Richard Oliver Butcher (partial) (1 page)
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Charlotte Hayes
OA/Box Number:
3015
FOLDER TITLE:
Admin. Material on Constituencey Groups & Ethics Working Groups - Folder 2
2006-0885-F
jp2697
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) of the PRA|
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA|
P3 Release would violate a Federal statute 1(a)(3) of the PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA|
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA)
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA]
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information |(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIAJ
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�S ^ i . ^ r
e
^ ....^Mflffife
SOCIAL OFF^^
Richard Oliver Butcher, M.D.
!:
r
IjC^ ^vl WrA»rf Olivtr BMcherX^< '- ^A: -P6/(b)(6) \>ii-.
.•;^,^| ru Mrs. Margaift Butcher and iht
tax Mr. Aljah Longsron Butchtr Sr. He is the setwdeldest offiw children. He aiiended incal schooh
and ^ Qeluatedji-om Glenville High Schoo!. Cleveland. Ohio in 19S6. He received the Baclieior of
Science degree from Allegheny CcllegeMeadville.Pennsylwtria in WW. Dr. Butcher decide thai
he wmito he aphyskfcn when he MW a young boygro^ng up in C/nvW, Okia. Two cfhls best
friends (Donald Lombrigh: and Lawence SclutPiake) hodfathers who physicians. His early
childhood latercctlons with these wo men shaped young Richard's life and gave him the asphxtllon
seek e career In medicine, h is this strong sense of community and role modeling that he witnessed,
a child, tlm fueled his spirit and supported his commitment to the betterment of African Americans.
Dr. Butcher received the Doctor ofMedicine degree in 1964 from Meharry Medical College, Nashvi
Tennessee. Upon completing medical school. Dr. Butcher did a rotating Internship at the US Now
Hospital, Great Lakes, Mmois fi-om 1964-1965 andfrom1967 - J9d9, a residency in General Practic
at Riverside General Hospital. He was certified by the Slate of CaHfomia Board cfMedical Quality
Assurance in 1967.
After his training. Dr. Butcher wrked with the following medical organizations; the Family Medira
Group ofSan Diego from7.970?1973 andfrom1986 to the present; the Western Medical Group from
1973-1986; and the Ford Medical Centerfrom1969-1970. He senvd as team physician for San Diego
State yniwrsityfcom 1977-1985. Currently, he is team physician fw Gram'ie Hills High School a
position to which he was appv'mtedin 1969.
His professional and ot teaching appointments include: the American Academy qf Family Practice
1979 - present; the Unlvetsity of California of San Diego Medical School WCSD] 1973 - present; and
the UCSD Nurse Practitioner Program • 1980»1987, He K'OJ Assistant Clinical Instructor at UCS
Medical Schoolfrom1969 -1971.
Dr. Butcher holds or has held membership in many professional societies, which include; the Americ
Academy qf Family Practice, the American Medical Association, the San Diego Chapter of the Natio
Medical Association, where he serird as Presidemfrom1978 • 1986, the Golden State Medical
Association, where he served e$ Councillorfrom1971 '1986 and as its President; the San Diego Count
Medical Society, where he sentd as President during 1988; the California Medical Association; and
the National Medical Association, where he sened as Trusteefrom1984-1988, Secretary 1929, Second
Vice President 1990 and First Vice President 1991.
His many awards and honors include: Outstanding Service Award. SNMA1975; Service Award, San
Diego Council on Smoking and Health Education, 1975; Distinguished Service Award, Golden Stat
Medical Association, 1978; Ontstandltu Achievement in Medicine. Action Inlerprisc Development
(AJ.D.) 1979; SA .S. Participant, Minority Medical Student Assoc'wtioa, 1984; and Certificate of
Appreciation, NMA 1986.
_
During the past several years, Dr. Butcher serxed on the following Boards: Board of Trustees.
Musewp ofMan 1990 'present; Board of Trustees, Allegheny College 1990 • present; Blue Cross cf
California Advisory Board 1985 - present; Gowning Board, Physician and Surgeons Hospital, 1982
7989; Board afComprehen^e Health Can 1979 -1988 and its Chairman in 1979; Board of Medical
Quality Assurance, 1979 -1982, and Its Chairman in 1978; Board cfDirectors. Pacific Coast Bank.
1980 -1981; Board <>f Trustees, Foundation For Medical Care, 1973 • 1981 and its Chairman from
1979 -1981; and Board cf Directors John Denis Family YMCA. 1976 -1976.
Dr. Butcher is married to the former Vickie Knight. They haveftve children, Rkhard II. April, Keliey
Longston and Crystal.
�RCV BYUhe White House
y
'.
; 3-26-93 ; 4:34PM
:
5
j.J-M:*!.iiiiiWi*
SOCIAL OFFICE-*
0CIAL
.^UMIMSK
8
B m t m t
n
*fm<* *
B
B
':i^
STATEMENT
by the
NATIONAL MEDICAL ASSOCIATION TO TIIE CLINTON HEALTH CARE TASK FORCE
THE NATIONAL MEDICAL ASSOCIATION (NMA) IS CONCERNED ABOUT HEALTH CARE IN THE UNTIED STATES,
ESPECIALLY IN THE MINORITY COMMUNITY. OVER THE YEARS NMA HAS BEEN INVOLVED IN HEALTH
POLICY ISSUES AND HAS STUDIED HEALTH CARE REFORM AT ALL LEVELS. NMA WELCOMES THIS
OPPORTUNITY TO COMMUNICATE WITH THE CLINTON ADMINISTRATION AS THE NATION MOVES TOWARD
THE REFORM OF OUR VITAL HEALTH CARE DELIVERY SYSTEM.
THE NATIONAL MEDICAL ASSOCIATION BELIEVES THAT IT IS TIME FOR THE UNITED STATES TO AFFIRM
TIIE FACT THAT HEALTH CARE IS A HUMAN RIGHT. THE NATIONAL MEDICAL ASSOCIATION BELIEVES
TIIAT THE UNITED STATES AS ONE OF THE WEALTHIEST COUNTRIES IN THE WORLD HAS THE RESOURCES
TO MAKE SURE THAT EVERYONE WHO NEEDS ISfEDTCAt, CARE SHOULD RECEIVE TT.
Thu public has become mow vocil rejarding the problonu with ihe current health care lyitem. Aa u result the United States
Congnro, Admioistratioa and other concerned orjjanizatior.K httve put forward proposals for the development of hoalth cure reforms,
THE NATIONAL MEDICAL ASSOCIATION SUPPORTS HEALTH CARE REFORM WHICH PROVIDES FOR
UNIVERSAL ACCESS AND COVERAGE, A SINGLE PAYOR SYSTEM, HEALTH PROMOTION AND DISEASE
^ R E VENTION AND QUALITY CARE.
'premium is placed on cost containment. Thus, the NMA uuppons universal aoceet to eoverage for hanlc core through a financing
^Ppr.
Nyatem that include* both public and private payors; provuler taxo*forwipport of Medicaid; decreaned cost of medicaHon; decrease
in tax wrilr off*; tort reforta; quality considerations such as practice guideline* and total quality macHgemeat (TQM); health Insurance
lw«ed on community hmtl ratin^ft; And, Allow* forftdecree in fidir,m|Jitr«t;ve coot*,
The Naiional Medlul Awralatinn talte^ that universal uccaki in hMlib tftr* oovutge ciu be provided by:
•
Requiring enqjbyers (e.g., over 25 enqjloyees) to oflfer each employee a basic package of health innurance bariifilii.
•
Providing Kpeciai assistance to imaU employers (e.g., less tbas 25 employees)tomake the coot of offering health insurance
mon affordable;
o
o
0
allowing for an appropriate phaae-ln of the requirement;
dwignatjng regional inHuren and entahlishriskpooli, and
provldifcf 6 federal iubsidiary for certain amall buiineaNH.
•
Requiring a tax for employen whofellto provide health coverage for their employees who are uninsured through employer
based health insurance or public programs that would be no lean than what it would have cost if they had frovlded Insurance,
•
Converting Medicaid from a welfare program to a source of funding for all iadividuala, r^gardleas of income, who an unable
to obtain employer based health insurance;
o
o
mandating national uniform eligibility standards; and
mandating a defined M of basic benefits.
�RCV BY:The White House
ficv>i
; 3-26-93 ; 4:33PM ;
.....J..l-2e:?l.ii2i§?P« »
SOCIAL OFFICE-*
mmmt
i#15
SOCIAL offiCEii
a
Encourtging the availability of private long-tern ea» produots ai now exiatforaoeithmtal death and dlamambernurt
inaunmoe and heal* insurance:
o
offering tax credit!forthe purchase of long-term care coverage; and
p r S g • sliding subridiaiy to enable lowincomebeoeficiaries (e g., tho« with income up to twicefeepoverty
level) to purchase private long-term care ineunmce.
ThcNationdMedicalA^Hrtonsuppo^
X r the Fede«l Reserve Board, w£se Job primarily would be to manage the plan and manage the country's health e««w*m.
Z Z i wSd be appointed ^ both t i PiSdent lad the Congress but would otherwise have independenc* bk. members of the
Federal Resorve Board, which set monetary policy. The duties of the Board woutd include;
•
Establishing a defined set of benefits to which all insurers would have to adhere;
•
EatabUshing a haellfa budget and fee schedules through negotiations with physicians, hospimb and insurers;
•
Planning proapectively, long term health care reforms and heallh planning; and
Devising and implementing a single payor ayaiea meohMiIsm. The benefits of theringlepayor system would Include:
improving efficiency Ln the administration of medicul buneilts reducing administrative costs; and dtwignmg a uniform policy
mechwiisra with a universal claim form.
The National Msdical Associstion support* expanding health promotion and disiwae prevention program* (i e. the proposed NMA
•uality Assurance Bill). The edumlion of the public wm be done by:
Restructuring medical education and health education intthoolsto emphasize promoting healdi through behivioral and
lifwiyle changes.
•
Focusing attwition at the primftry care level to educate health consumers on poor choice* (e.g., smoldng, unhealthy diet and
sedentary habits) which have an impaot on health status and life expectancy.
•
Sustaining a level of govemment and private support for innovative education efforts to inform the African American
community about the problems of behavior and lifestyle that contribute lo some of the leading health problemsfeeingour
nation, including infwit mortality, heart disease, AIDS, cancer, homicide and diabeten.
The plsn would provide for and asouxe patient* and health pmvid«re access to th» boaltb plan and remove barriers to appropriate
patient care. The atandard of can* would be improved through quality assurance In medical aerviwe and in the medical profoasion
with the cooperation of government and other paywu.
A high priority should be placed on studying (he outcomes of different medical interventions, developing practice guidelines to modif
physician behavior and providing a basis for setting payment criteria. Continuous attention must be given to quality improvemonls
to further facilitate the integration of care ami rofumtl of patients within health care settings.
The National Medical Associstion also supports the NAACP Health Policy recommendation to establish •CttntorsforImproving the
Hatllh of African America as" under the auspices of the U.S, Public Health Service.
The increaae in Health Maintenance Organizations (HMOs) and HMO eorollment rates indicate the historical transition from solo
prsctitloaers to professionals employed by institutional managoment care systems. With that to mind, the National Medical
Mociation is committed to working with the public and private sector to design a sygicm that is fair and equitable for all.^ The
Sticmnl Medical Asuociation and its House of Delegates has adopted the concept of 'Managed Care' with cost coniainmnt provisions
lading global budgeting.
m
�RCV BYiThe White House
(-:...*'ji'L. ....
; 3-26-93 ; 4:32PM ;
L.i-fZZW..VflZfr* •
SOCIAL OFFICE*
mmiilil
SUUIAL
t
:»H
urriUfcii z
MANAGED COMFETTTION
"MANAGED COMPETITION" INTRODUCES ADDITIONAL ISSUES ABOUT WHICH THE NATIONAL MEDICAL
ASSOCIATION HAS RESERVATIONS. ABOVE ALL, SUCH A SYSTEM SHOULD BE FAIR AND EQUITABLE TO
PROVIDERS AND CONSUMERS AND DELIVER QUALITY, AFFORDABLE CARE. Oor wacttiu about such a >y»t»m an>
as Mows:
•
Physician Concern*: Phyiicixn selection and recruitment axe miyor concerns when designing 'managod competition' plans.
African American physicians have boon excluded from participation in certiun managed care plans. While wo recognize that
not all physicisns will be Included, African American physicians may be selected to participate on the basis of hospiul length
of stay, morUtlity and morb'ulityrets*which are determined without oonsideration for the suvority of illness. Africa.']
American physicians may be excluded from closed panels despite the number of African American phyriciwu who provide
efficient, high quality care.
The NVicr.a! Medical Association supports an open application period with fair credentialing, fair utilization and peer review,
and a fair appeals process. The Nationsl Medical Association also supports the concept of African American organizations
serving as sponsors,
•
Patient Concerns: A ba$i? benefit package may be inadequate particularly for children, pregnant fumalos, severely ill
patient*, anj patients with multiple diseases. Also, it may be tiitfkult for a patient to obtain services on weekends or at
ni£ht. The ps'.icnt loses freedora of choice in selecting & physician and this can be detrimental to the important
patienl/physicion relntionsMp, if a patient is dissatisfied with the type of care received, the change to another physician may
btf diflkult. Also the possibility that patient* may not underhand the system is a major concern.
Taa NaucuKl MediCed Association rapport* conKumer education seuions prior 10 instituting the system; an adequate grievance
nuvhanism; and a basic benefit package which includes primary care and preventive services.
•
Qunlity Conwnu: Sponsors of managed care plans may make decisiors based solely on oo«tralhurthan quality. Managed
care plans targeted at the Medicaid population may end upreducinghealth services to low income children and pregnant
female*. Tn addition, moving massive resourcos over to these plans threatens the viability of some of our best providers,
suth as school based health services and clinics, community health centura and public health programs. The general
perception ii that there is a tfndency for usder-utilization, A needs assessment should be performed prior to the
iiripleaientalion of such a system.
The National Medical AsKwiatinn supports the use of practice guidelines and total quality management in the delivery of
medical care as an effort to assure quality care.
•
Punding Concerns: Co«t containment must not limit nor reduce aorviccs and must not cause exclusion of patients or
restriction cf benefits. Above all, efforts at containment should be fair and equitable to the underserved, uninsured, and
thow without the ability to psy.
The National Medic*! Association supportsfinancinghy a shift in tho D&fuosc budget, tort reform, decreased administrative
uwts (single payor system), sin taxes, decreased coats of medication, provider taxes, and limited tax deductionsforhospital
insurance.
IN THIS STATEMENT, THE NATIONAL MEDICAL ASSOCIATION HAS OUTLINED ITS CONCERNS ABOUT TIIE
HEALTH STATUS OF THIS NATION. ESPECIALLY THAT OF THE MINORITY COMMUNITY. NMA WILU
CONTINUE TO WORK WITH THE CLINTON ADMINISTRATION AS HEALTH CARE REFORM ISSUES ARE
^j^UATED AND WOULD WELCOME TIIE OPPORTUNITY TO CONDUCT ANY ADDITIONAL REVIEWS OR
^•VIMENT UPON ANY PROPOSED LEGISLATION, RULES OR REGULATIONS WHEN FURTHER DETAILS BECOME
^PFATLABLE.
�AMERICAN ACADEMY OF FAMILY PHYSICIANS (AAFP)
MEMBERS:
More t h a n 74,000 members
REPRESENTS:
National association o f family doctors w i t h
c h a p t e r s i n a l l 50 s t a t e s .
TODAY'S SPEAKER:
Dr. John Tudor (See biography on n e x t page)
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
Do n o t have a PAC. B u i l d i n g a g r a s s r o o t s
network. S o p h i s t i c a t e d press o f f i c e . Good
r e p u t a t i o n i n Congress.
U n i v e r s a l coverage t h r o u g h employer-based
system w i t h i n a g l o b a l budget.
The Academy i s one o f t h e two l a r g e m e d i c a l
s p e c i a l t y o r g a n i z a t i o n s t o come f o r w a r d w i t h
a r e f o r m p l a n t h a t endorses a g l o b a l budget
as p a r t o f c o s t containment.
Support
u n i v e r s a l access t h r o u g h an employer-based
system w i t h a p u b l i c s e c t o r component. Cost
containment t h r o u g h t h e use o f a g l o b a l
budget determined by a n a t i o n a l h e a l t h board.
S p e c i f i c s t r a t e g i e s t o move toward a
g e n e r a l i s t - o r i e n t e d h e a l t h c a r e system,
i n c l u d i n g reforming medical school admission
c r i t e r i a and c u r r i c u l u m , changing Medicare
s u p p o r t o f graduate m e d i c a l e d u c a t i o n , and
r e f o r m i n g p h y s i c i a n f e e schedules. W o r r i e d
about mismatch between i n f r a s t r u c t u r e and
expanded coverage. Concerned t h a t w i l l be
d i s p r o p o r t i o n a t e l y a f f e c t e d under a wage
f r e e z e because o f c u r r e n t d i s p a r i t i e s between
g e n e r a l i s t s and s p e c i a l i s t s . Concerned t h a t
s h o r t term c o s t containment w i l l d i m i n i s h
immediate i n v e s t m e n t i n p r i m a r y c a r e
training.
The AAFP does n o t s p e c i f i c a l l y endorse
managed c o m p e t i t i o n , b u t would a l l o w f o r i t
and encourage managed c a r e . Working on i d e a s
f o r "managed c o o p e r a t i o n " i n r u r a l a r e a s .
T r a n s i t i o n , S e c r e t a r y S h a l a l a , I r a Magaziner,
Judy Feder, OPL.
�American Academy of Family Physicians
Representative
John M. Tudor, Jr., M.D.
President
John M. Tudor, Jr., M.D. c u r r e n t l y serves as president o f t h e
American Academy o f Family Physicians, a 74,000 member
organization representing p r a c t i c i n g family physicians, f a m i l y
p r a c t i c e residents, medical students, and others. He maintains a
p r i v a t e solo family p r a c t i c e i n Salt Lake C i t y , Utah. He earned
h i s medical degree from Harvard U n i v e r s i t y i n 1964, and has a
master's degree from Michigan State U n i v e r s i t y i n higher
education and administration. I n a d d i t i o n , he previously held
a s s i s t a n t and associate professorships i n the Department o f
Family and Community Medicine a t the U n i v e r s i t y o f Arkansas, an
associate professorship o f the Department o f Family and Community
Medicine a t the U n i v e r s i t y o f Utah, and served as D i r e c t o r o f the
Family Practice Residency Program, also a t the U n i v e r s i t y o f
Utah.
�llftR 25 '93
P. 2 / 4
l i : 0 1 f l ^ AftFP-WASHINGTON. DC
s
WEMENT
of the
American Academy
of Family Physicians
Before The
WHITE HOUSE INTERAGENCY TASK FORCE ON HEALTH REFORM
Presented By
John M. Tudor, Jr., M.D.
President
AAFP Headquarter*
S880 Ward Parkway
Kansas City. Missouri 64114-271)7
(SI6) 333-9700
[Si
AAFP Washington Office
2021 Massachusetts Avenue, N.W.
Washingior, DC 20036
(202) 23:-9033 (202) 232-9044 (FAX)
�MAR 25 '93 11:01PM PPFP-WPSHINGTON> DC
P. 3/4
Good afternoon. My name is John M. Tudor, Jr., M.D., andftis my privilege to serve as
president of the American Academy of Family Physicians. I appreciate the opportunity to
briefly address the challenge of controlling health care costs in the short run while ensuring
quality care and physician choice.
Traditional efforts to control health care costs have generally involved tighter eligibility
standards, reductions in covered benefits, increased out-of-pocket costs, or price controls
(fee reductions).
All four mechanisms constitute blunt instruments that attempt to
indiscriminantly reduce the volume of services. None of these mechanisms have had
significant or lasting impact on health care costs and, in many instances, have resulted in
unintended and perverse consequences. For example, tighter eligibility standards, reduced
benefits, and higher out-of-pocket costs often result in unnecessary illness due to the failure
to obtain needed care in a timely fashion, and all four mechanisms tend to shift costs onto
more generous payers.
We believe the fundamental problem to be the failure to properly manage the receipt of
personal health care services. Our present health care system results in fragmented,
uncoordinated, and overly expensive care of inconsistent quality. The solution for both the
short and long run will be to create an environment where efficient systems for managing
personal health care can readily function. The basis of these systems is the interaction
between the patient and his or her personal physician, which has proven to be the most
effective element in cost reduction because of its contribution to preventive care, ongoing
health maintenance, and a reduction in the inappropriate utilization of services and
�MAR 25 '93 11:02AM AAFP-WASHINGTON, DC
P
-
4 / 4
procedures.
We understand that the Administration will propose incentives for the formation of large,
efficient managed care systems that are intended to compete on the basis of cost and
quality. However, even under the most optimistic scenarios it will take at leastfiveyears
for these incentives to yield measurable cost and quality improvements. In the short run,
substantial improvements can be achieved by requiring every individual to select a personal
physician who would be responsible for providing primary care services and, when necessary,
coordinating the receipt of secondary and tcrtiaiy services. Such a system should be
enforced by imposing higher cost sharing requirements for seeking and obtaining nonemergency secondary and tertiary services without a referral from the personal physician.
It is important to recognize that the success of the personal physician requirement hinges
on the availability of physicians who possess the broad range of primary care competencies.
For the most part, this includes physicians trained in the generalist specialties of family
practice, general internal medicine, and general pediatrics. The shortage of generalists
physicians significantly constrains the most important health care choice that patients can
make and, by default, abandons patients to make ill-informed decisions regarding the
management of their own care. No other developed country and no organized system of
care requires patients to make such decisions.
Once again, I appreciate the opportunity to participate in today's hearing. Please know that
the Academy stands ready to assist the Task Force in any way possible.
�AMERICAN ACADEMY OF PEDIATRICS
MEMBERS:
45,000 members
REPRESENTS:
P e d i a t r i c i a n s nationwide whose goal i s
advocacy f o r c h i l d r e n and youth. I n 1930 the
Academy became the f i r s t n a t i o n a l medical
organization t o recommend the use o f p u b l i c
funds t o provide maternal and c h i l d w e l f a r e
a i d t o those groups unable t o pay f o r medical
services.
TODAY'S SPEAKER:
Dr. Howard Pearson (See attached biography)
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Not strong lobbying force, but because o f
"white hat" p u b l i c r e p u t a t i o n o p i n i o n
important. Active c o a l i t i o n p a r t i c i p a n t .
I n l a s t Congress, endorsed Matsui b i l l (pay
or play f o r women and k i d s ) t h a t included
all-payer rates f o r p e d i a t r i c and o b s t e t r i c
services.
Their p r i o r i t y i s u n i v e r s a l access f o r
c h i l d r e n ; any coverage phase-in should begin
w i t h c h i l d r e n and pregnant women.
Benefits package should be c h i l d s e n s i t i v e ,
recognizing the p a r t i c u l a r needs o f a l l
children including children with special
h e a l t h care needs.
Must be o n e - t i e r system—"Medicaid doesn't
work".
Should address f u t u r e demand f o r
primary care physicians through: f l e x i b l e
loan p o l i c i e s , expansion o f the NHSC;
incentives t o increase number o f m i n o r i t y
primary care physicians; and development o f
p e d i a t r i c RBRVS t o guarantee adequate
reimbursement.
Cost-containment proposals must i n c l u d e
emphasis on preventive care and incomeadjusted cost-sharing.
POSITION ON
PLAN:
Nervous about g l o b a l budgets (concerned t h a t ,
absent guarantees, c h i l d r e n ' s access w i l l be
diminished f i r s t ) .
�INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
Transition, OPL, Work Group members
�RCV BY:
I 3-23-93 : 4:03PM ;
CMICrtch
DESIGN
202 662 7471-
SOCIAL OFFICE!* 3
HETWOWK
!
Americ an
^ \^lemy of j
Vdiatrics
HOWARD A. PEARSON, M.D.
AAP PRESIDENT
!
i
Howard A Pearson. M D . New Haven. Connecticut, is tne 1992-93 pfesktertt of ihe American Academy
ot Pediatrics (AAP)
Dr Pearson is professor of pediatrics i t Yale untversrty School of Medicine ahd aJi attending phy sictan at'
Yak; New Haven Hospital (YNHH) HfJalso serves as medical director of actor Paul Newman's Hole Ir the
Wall Gang Camp Tor cnlidren with cariicer and btood diseases.
|
Dr. Pearsgn joined the Academy in 1966, serving two terms on the AAP CommHtee on Nutrltlor and
Conimittee on Education. He was res^ons»Dle for wrhirkg a nutrttion comniittee siaitenient on iron in 969
Tho recommendations in the statemem lead to the near eradication of severe Iton dteficiency in f his coi ntry.
in 1968, Dr. Pearson became protesspr and head ot pediatric hematglugy/oncolbgy at YNHH. H< was
chair and chief of the Department of Pediatrics at YNHH for 13 years. He contirtues to care for ch Wren
witn blood diseases, especially those vlth thalassemia and sickle cell diseases.
Dr. Pearson received his medical degttee m 1954 from Harvard Medical School, ^e served his reskjency
at Belhesda Naval Hospital and completed a hematology fellowship at Boston Children's Hospital.
i Nonhwe^ Point Rlvd
FO Box 92"
Elk Crov* Vil|< gc, IL 60009-0927
�03/25/93
14:11
002
AMERICAN ACADEMY OF PEDIACTRICS
HEALTH CARE TASK FORCE - PUBLIC HE^RIHG
HOWARD A. PEARSON, M.D.
PRESIDENT, AMERICAN ACADEMY OF PEDIATRICS
MARCH 29, 1993
ORAL REMARKS
I
I
I AM HOWARD PEARSON, M.D., PRESIDENT OF THE AMERICAN ACADEMY
OF PEDIATRICS. I AM PARTICULARLY PLEASED THAT^ THE TASK FORCfe
HAS CHOSEN TO GIVE CHILDREN'S NEEDS A HIGH PRIORITY AS YOU
DEVELOP NATIONAL HEALTH CARE REFORM.
i
SPEAKING FOR CHILDREN'S HEALTH CARE NEEDS, THli ANSWER TO YOuJ*
QUERIES IS RELATIVELY SIMPLE
CHILDREN F I R S T J
SOCIETY IS j
FINALLY LEARNING THE PAINFUL LESSON TKAfr THE POUND OF CURE Ig
FAR MORE COSTLY THAN +HE OUNCE OF PREVENTION, j THE COSTS AND'
CONSEQUENCES OF MALNUTRITION, ANEMIA, LACK OF IMMUNIZATIONS, ;
TEEN PREGNANCY AND LEAD POISONING MAY NOT BE RECOGNIZED AS
HEALTH COSTS, BUT THE? SURELY APPEAR ON THE LEDGERS OF THE
SOCIAL SERVICES, EDUCATION OR CORRECTION SYSTEMS.
WHil,K 1 RECOGNIZE THAf THE PURPOSE OF TODAY'S iHEARING I S
KUCUbEU UN COST CONTROL, WHEN I T COMES TO OUR CHILDREN, WE
MUST THINK IN TERMS Of AN INVESTMENT
A STIM^LUi TO OUR
FUTURE ECONOMIC STABILITY. THE RECORD DOESN'T SUPPORT THE
CLAIM THAT I F SOCIETY TAKES CARE OF EVERYBODY, CHILDREN WILL
ViF. CARED FOR AS WELL. OUR CHILDREN HAVE BEEN :SHORT-CHANGED
FUK KAK TOO LONG. THE COST OF NEGLECT I S STAGGERING, BOTH 1^
TERMS OF LOST OF HUMAN POTENTIAL AND IN REVENUES.
THERE I S NO NEED TO C^TE THE GLOOMY STAtTISTICS THAT YOU ARE
WELL AWARE OF CONCERNING THE STATE OF OUR CHILDREN. BUT YOU
MAY NOT BE AWAKE THAT'FOR A MERE 10% INCREASE IN CURRENT
CHILD AND ADOLESCENT ijlEALTH CARE EXPENDITURES,; LHSS THAN 2%
OF TOTAL HEALTH EXPENDITURES, WE COULD CLOSE BOTH THEIR
UNINSURANCE AND UNDERINSURANCE GAP.
I
WITH RESPECT TO CHILDREN, SPECIFIC COST-CONTAINMllNT MEASURES
SHOULD INCLUDE THE FOLLOWING:
j
*
AN EMPHASIS Oljl PREVENTIVE CARE WITH SHOR** TERM GAINS
AS EXEMPLIFIED BY COST BENEFITSi OF IMMUNIZATIONS, AS
WELL AS LONG "fERM GAINS IN EARLV IDENTIFICATION
AND AMELIORATION OF CHRONIC DISABILITIES;
*
TARGETED, INCOME-ADJUSTED COST-$HARING;
*
DELIVERY OF HEALTH CARE SERVICER IN APPROPRIATE
SITES, SUCH AS SUBSTITUTING COStLY EMERGENCY ROOM
SERVICES WITH [PRIMARY CARE IN AN OFFICE laETTING AND
PROMOTING THE ' MEDICAL HOME CONCEPT OF tOI^T I NU I TY
OF CARE; AND !
j
1
*
i
!
1
I
]
1
;
COORDINATION OF CARE FOR CHILDREN WITH SPECIAL HEALTH
CARE NEEDS.
I
!
j
\
�14:12
03/25/93
AMERICAN ACADEMY OF PEDIACTRICS
003
I SUBMIT THAT THESE COST-CONTAINING MEASURES WOULD REAP
;
IMMEDIATE BENEFITS. ACCORDING TO THE CONGRESSIONAL RESEARCH
SERVICE, UNINSURED CHILDREN USED NEARLY ONE A^JD ONE-HALF
!
TIMES AS MANY HOSPITAL DAYS AS INSURED CHILDREN. THEY WERE ,
THE ONLY AGE GROUP IN WHICH THIS PHENOMENON OCCURRED.
INPATIENT CARE, WHICH I S ALMOST ONE-HALF OF ALL CHILDREN'S
MEDICAL EXPENSES. SHOULD ACTUALLY BE REDUCED ^F CHILDREN ARE}
INSURED. A RECENT REPORT BY THE PHYSICIAN PAYMENT REVIEW j
COMMISSION (PPPC) NOTED THAT CHILDREN COVERED BY MEDICAID
USE EMERGENCY ROOM FACILITIES EXCESSIVELY WHE^I LOWER-COST
CARP COULD BE PROVIDED THROUGH A MEDICAL HOME.
i
I WOULD LIKE TO EXPAN^D UPON THE MEDICAL HOME ioNfcEPT BECAUSE
IT GETS TO THE VERY HJEART OF THE ISSUE OF QUAhlTV. A MEDICAL
HOME IS SIMPLY A REGULAR AND ONGOING CQMPREHEJISIVE SOURCE OF
HEALTH CARE, AVAILABLfe AROUND THE CLOCK, EVERif DAY. I T
PROVIDES PREVENTIVE CARE, EARLY DETECTION AND'TREATMENT OF
ACUTE DISEASES AND THfc COORDINATION OF CARE FOR THOSE WITH !
CHRONIC OR HANDICAPPING CONDITIONS. OBVIOUSLY, t BELIEVE ]
THAT FOR CHILDREN ANDj ADOLESCENTS, THIS MEDICAL jlOME I S BESlj
PROVIDED BY A PEDIATRICIAN. I AM AWARE THAT OUR CURRENT
PEDIATRIC MANPOWER NEpDS TO BE SUPPLEMENTED
COMMUNITY
HEALTH CENTERS AND OTHER CLINICS, ALONG WITH A VARIETY OF
OTHER PROVIDERS.
|
•
!
i
-
SPECIFIC COST-CONTAINMENT MEASURES WITH RESPECT tO THE
PROVIDERS DELIVERING THIS CARE INCLUDE:
*
THE DEVELOPMENT OF A PEDIATRIC-iBASED IjlEL^TIVE VALUE
SCALE;
j
I
*
MEDICAL LIABILITY REFORMJ AND
*
ADMINISTRATIvt REFORM MEASURES.
THE ISSUE OF CHOICE MAY BE DIFFICULT TO ADDRESS UNDER A
MANAGED COMPETITION MpDEL SINCE PHYSICIANS WOULD BE
RESTRICTED TO A SINGLE PLAN. CHOICE I S IMPORtANf TO BOTH
PHYSTCTANS AND PATIENjTS. CONTINUITY OF CARE i s THE
CORNERSTONE OF PEDIATRICS. THEREFORE, WB WOULD URGE THAT
PHYSICIANS BE ALLOWED| TO PARTICIPATE IN MORE THAU ONE PLAN
GIVE PATIENTS (AND PHYSICIANS) SOME FLEXIBILITY.
3Y EXPANDING ACCESS T^) HEALTH CARE FOR OUR CH^LDliEN AND
j
IMPROVING THEIR HEALTH, WE WILL NOT ONLY DO WHAT I S RIGHT BYi
OUR CHILDREN, BUT WE WILL CONTAIN COSTS, HELP!INJURE QUALITY!
AND STRENGTHEN OUR ECONOMY. I T CAN BE DONE. I T MUST BE
DONE .
�AMERICAN PSYCHIATRIC ASSOCIATION
MEMBERS:
38,000 members
REPRESENTS:
N a t i o n a l medical s p e c i a l t y s o c i e t y
s p e c i a l i z i n g i n t h e d i a g n o s i s and t r e a t m e n t
o f mental i l l n e s s ( i n c l u d i n g substance
abuse). Comprise over 70 p e r c e n t o f t h e
nation's p s y c h i a t r i s t s .
TODAY'S SPEAKERS:
M e l v i n Sabshin, M.D. (See a t t a c h e d
SCOPE OF
INFLUENCE:
A c t i v e PAC.
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
biography)
Focused on mental h e a l t h
issues.
Signed on t o "Mental H e a l t h C o a l i t i o n "
Recommendation Document.
Support n o n d i s c r i m i n a t i o n between m e n t a l
h e a l t h and o t h e r h e a l t h b e n e f i t s f o r
p a t i e n t s . Focused on e l i m i n a t i n g what t h e y
f e e l a r e a r t i f i c i a l l i m i t s ( e . g . 20 v i s i t s ,
e t c . ) on s e r v i c e s .
Guaranteed b e n e f i t s package must i n c l u d e
a p p r o p r i a t e mental h e a l t h b e n e f i t s ( i n p a t i e n t
care, o u t p a t i e n t t r e a t m e n t , and p a r t i a l
h o s p i t a l i z a t i o n and ambulatory c a r e ) . A l s o
s u p p o r t coverage o f p s y c h o p h a r m a c o l o g i c a l
t r e a t m e n t s under drug b e n e f i t .
Want t o ensure t h a t i n n o v a t i v e s t a t e e f f o r t s
t o expand mental h e a l t h coverage c a n
continue.
Concerned about consumer
p r o t e c t i o n s , reimbursement o f p r o v i d e r s , and
oppressive u t i l i z a t i o n review.
Nervous about
s t a t e and f e d e r a l e f f o r t s t o r e i m b u r s e nonp h y s i c i a n mental h e a l t h p r o v i d e r s .
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
PET
ISSUES:
Encouraged by Mrs. Gore's i n v o l v e m e n t .
B e n e f i t package w i l l be s i g n i f i c a n t f a c t o r i n
determining t h e i r support.
T r a n s i t i o n , Work Group members, HHS
officials.
Coverage o f p s y c h i a t r i c s e r v i c e s .
�03/23/93
H i : 23
© 2 0 2 682 6287
[21004
APA GOV T RLTNS
lilvin S&bshln, R.D.
Melvin sabshin, M.D., is Medical Director of ths 4,00fr>w*tr A«-ican
1
ffS *^**^?^
00,
i t sc h i o f
^
^tive, he
2?
reidtxcns. and service programs v.-hich seek to improve the i & i t y w d
amiability of psychiatric care, itia American Psychiatric
^
Aeisociation, founded in 1844, is the oldest medical srwcialty aocietv
in the united States and is headquartered inlashingtSn? oTg
^
Or. Sabshin was appointed APA Medical Director in September 1974, after
a broad career in psychiatric practice, «edical eduction? and
?;?! " S ; ,
. ^f
S* " the university of Illinois
Co..iege of Medicine in Chicago from July 1973 until his APA
ajajointment. He had served since 1961 is Professor and Head of the
DWtMnt of Psychiatry at the school, in 1967, helSok I ySar'T
sabfcetical as a rellcw with the Center for Advanced StuS i n ^ l
B«rt!avioral Sciences in Palo Alto, California.
!
C
S
e
r
s e r V e d
C
i
a a
t l n 9
d
,S
degr
1
o £
,, f r o m
lSM fi^?. ! ! T
? ' *
^ university of riorida in
1 * £ ^ e i ^ i ^ r f ' S « » * v . r i i t y School of Medicine in
is><:8. He interned at Chanty Hospital of New Orleana. servM »
piq-chiatric residency at Tulane f?c«nl949 until 195? 'aS^!?A\ A M I
M t h Service r e l l ^ h i p in PsychStJlc ^ a r c i l ^ S ^ l *
f
n
^ I K ! i ^ ^ " " t i o n a l affairs, Dr, Sabshin is a Distinguished Fellow
of: the Egyptian, Hong Kong, and Royal Australian and New^SSSnd
Paychiatric Associations and an S r a ^ S l ^ o f U ^ S b ? ! ? ^
3 ; ^ ^
of
Dr. sabshin is Chairperson of the American Psychiatric Press inr
th*
and th. AMticim Association of PiyrtliSS 3 £ l t t 2 £ £ . *
t
y
i > t t y
studi.s ot norral bahaviSr, cUniral oh^SSL™ S l ?
;
MKM,. and scienc, v ^ i
S ^ . ? ^
" "
e
April, 1992
e
P
i
o
ln<:1
n
«iin9
"
a
�03/25/83
12:10
American
Psychiatric
'Association
© 2 0 2 682 6287
APA GOVT RLTNS
Inn
1400 K SLTCI. N.W.
Wastiingtor.. DC. JGOCS
'
Telephone: 1.202) 682-OO.W
Statement of the American Psychiatric Association
On:
Coverage of Treatment for Mental Illness
in Health Care Systems Reform
Presented to the White House Task Force
On Health Care Reform
Hillary Rodham Clinton, Chair
Presented by Melvin Sabshin, M.D.
Medical Director
Smith Center
George Washington University
March 29, 1993
Panel 5: Physicians
21003
�03/25/93
12:10
© 2 0 2 682 6287
©004
APA GOVT RLTNS
Madam Chair, I am Melvin Sabshin, M.D., a p s y c h i a t r i s t and t h e
Medical D i r e c t o r of the American P s y c h i a t r i c Association (APA), t h e
medical s p e c i a l t y society representing more than 38,000 p s y c h i a t r i c
physicians i n the United States.
The APA welcomes your leadership i n reforming t h e nation's health
care system.
We share your conmitment t o a health care system which
provides a l l Americans w i t h access t o an equitable package of health
insurance b e n e f i t s a t a f a i r p r i c e .
Mrs. Clinton, our message on behalf of our patients and ourselves
i s simply t h i s : I f mental i l l n e s s affected something other than the
minds of i t s victims, the United States would have long ago declared a
pandemic and attacked these i l l n e s s e s with the resources required to
meet the needs of the public.
The APA's recommendation f o r h e a l t h care reform — set f o r t h i n our
attached Statement ox P r i n c i p l e s — can be stated q u i t e simply:
We urge your strong
support
for health
reforms
pervasive
pattern
of discrimination
against
JoentcLL illness
and those
who treat
them.
treatment
for mental
illness
should be included
health
benefit
which end the
persons
with
coverage
of
as a
uniform
in the Administration's health care
reform
proposal,
subject
to the same scope and duration
as applied
to
non-psychiatric
medical
illness,
persons
with mental illness
— and their
treating
physicians
— should be subject
to the
same protocols,
the same reviews,
and the same cost
controls
as are required
of patients
with
non-psychiatric medical
illnesses and the physicians who treat
them.
More than any other medical doctor, p s y c h i a t r i s t s know f i r s t hand
about t h e h e a l t h insurance c r i s i s a f f e c t i n g t h e United States. As the
"primary care" physician f o r persons w i t h mental i l l n e s s , we are
confronted every day by t h e f a c t t h a t many o f our p a t i e n t s e f f e c t i v e l y
have no h e a l t h insurance, p a r t i c u l a r l y i f they s u f f e r from "severe"
mental i l l n e s s .
Our insured p a t i e n t s face d i s c r i m i n a t i o n i n t h e form o f higher
coinsurance or d i f f e r e n t a r b i t r a r i l y established l i m i t s on i n p a t i e n t o r
o u t p a t i e n t coverage d u r a t i o n f o r t h e i r mental i l l n e s s than i s otherwise
applied t o other non-psychiatric medical i l l n e s s e s . Regrettably, many
of our p a t i e n t s because o f stigma refuse t o use t h e insurance coverage
they have purchased out of fear of being denied h e a l t h insurance i f they
ever change jobs.
Even t h e Federal Government i s g u i l t y o f " d i s c r i m i n a t i o n by
diagnosis." More than 30 years a f t e r t h e enactment o f t h e Medicare
program, our nation's senior c i t i z e n s
and d i s a b l e d
Medicare
b e n e f i c i a r i e s must s t i l l pay out of t h e i r own pockets 50 cents of every
d o l l a r f o r o u t p a t i e n t care by a p h y s i c i a n p s y c h i a t r i s t , c l i n i c a l
psychologist, or c l i n i c a l s o c i a l worker.
This i s d i r e c t and b l a t a n t
d i s c r i m i n a t i o n by t h e Federal Government against persons w i t h mental
illness.
�03 25/93
12:11
©202 682 6287
APA GOV'T RLTNS
®
0 0 5
Discriminatory insurance coverage, and the concomitant lack of
access to needed treatment, stem from a series of myths — rooted i n
ignorance and fear — about mental i l l n e s s . The three most pervasive
myths about mental i l l n e s s and i t s treatment are as follows:
•
Myth Number One:
Illness."
"Diagnostic C r i t e r i a are Too Broad for Mental
The fact is that mental
as "physical"
disorders.
disorders
are at least
as clearly
definable
According to recent data from the National I n s t i t u t e of Mental
Health (NIMH), the f u l l spectrum of a l l mental disorders a f f e c t s about
22 percent of the adult population i n a given year; 7 percent of the
population have symptoms which l a s t for a year or longer, and; only 9%
of the population report some d i s a b i l i t y associated with mental
disorders.
Using similar c r i t e r i a , 50 percent of the adult population suffer
from respiratory disorders, and 20 percent suffer from cardiovascular
diseases.
Mental i l l n e s s e s are thus c l e a r l y and objectively diagnosable, and
do not occur i n "disproportionate" numbers r e l a t i v e to the incidence of
other non-psychiatric medical disease i n the population as a whole.
•
Myth Number Two: "Mental I l l n e s s e s Cannot Be E f f e c t i v e l y Treated."
The fact
is exactly
the
opposite.
The NIMH data shows that treatment of severe mental i l l n e s s e s ,
including bipolar disorder, obsessive compulsive disorder, panic
disorder, major depression, and schizophrenia, have success rates of 60
to 80 percent.
In contrast, the success rate for two major forms of cardiovascular
treatment — atherectomy and angioplasty — have effectiveness ranges of
41 to 52 percent.
Let me repeat that: NIMH data shows that treatment
for
severe
mental illness
is up to 100% more effective
than a commonly
accepted
medical treatment
for cardiovascular disease.
Health planners should therefore be confident that coverage of
treatment for mental i l l n e s s i n health care reform i s not an "open
ended" proposition — treatments are defined and e f f e c t i v e .
•
Myth Number Three: "We Cannot Afford to cover Treatment of Mental
I l l n e s s as Part of Health Care Reform."
afford
Again,
the fact
is
to exclude such
precisely
treatment.
the
opposite:
The nation
cannot
In 1990, the nation's health care b i l l was approximately $670
b i l l i o n . Of that, the direct cost of treating a l l mental disorders was
10 percent, or $67 b i l l i o n .
�03/25/93
12:11
©202 682 6287
APA GOVT RLTNS
12006
Recent data from Rice, e t a l (attached t o t h i s statement) shows
t h a t t h e i n d i r e c t costs of mental i l l n e s s ( i . e . , t h e cost of not
p r o v i d i n g treatment i n terms of l o s t p r o d u c t i v i t y , etc.) was $75 b i l l i o n
i n 1990.
Thus, t h e t o t a l cost ( d i r e c t and i n d i r e c t ) of mental disorders i n
1990 was $148 b i l l i o n .
This compares t o the t o t a l costs o f
cardiovascular disease of $159 b i l l i o n i n 1990, according t o NIMH data.
Health planners do not advocate exclusion o f treatments f o r cardiovascular disease.
Why then, should treatment of mental i l l n e s s be
considered f o r exclusion due t o spurious concerns about t o t a l d i r e c t and
i n d i r e c t costs?
witnesses before your panel were asked today to address the
question: "what can we do to ensure the immediate control of costs
while ensuring quality care and physician choice?"
We make t h e f o l l o w i n g response:
The APA suggests that the best
way ot controlling
the
regl
costs of mental illness is to end discrimination
by
diagnosis
against
persons
with mental illness
and those who treat
them.
We know t h a t t i m e l y i n t e r v e n t i o n s , i n c l u d i n g t h e use of
psychotropic medications i n conjunction w i t h appropriate psychotherapy,
can make an enormous d i f f e r e n c e t o persons w i t h mental i l l n e s s , enabling
them t o resume a f u l l and productive l i f e .
We also know t h a t these
treatments are c l i n i c a l l y e f f e c t i v e and cost e f f e c t i v e . And we know
t h a t p r o v i d i n g coverage f o r treatment of mental i l l n e s s would save t h e
n a t i o n nearly $100 b i l l i o n i n annual i n d i r e c t costs i n c u r r e d from our
f a i l u r e t o provide access t o care today. We thus b e l i e v e t h a t coverage
of treatment f o r mental i l l n e s s should be included i n whatever h e a l t h
care reform model the A d m i n i s t r a t i o n u l t i m a t e l y puts forward.
Madam Chair, i n t h i s regard, the APA asks simply t h a t p s y c h i a t r i s t s
and t h e i r p a t i e n t s be t r e a t e d l i k e a l l other physicians and p a t i e n t s are
t r e a t e d under a reformed h e a l t h care system. We should be subject t o
the same cost c o n s t r a i n t s and t h e same i n t e r n a l reviews as are other
physicians and p a t i e n t s .
We should be subject t o t h e same outcomes
measurements as are imposed on other medical s p e c i a l t i e s and t h e i r
p a t i e n t s . These studies w i l l show what we have known a l l along: mental
i l l n e s s e s are r e a l , can be c l e a r l y diagnosed, and can be t r e a t e d
effectively.
As a r e s u l t , APA recommends t h a t we and our p a t i e n t s be e n t i t l e d t o
the same coverage of b e n e f i t s and the same scope and d u r a t i o n o f care as
other physicians and p a t i e n t s .
The time f o r d i f f e r e n t i a l treatment
based on p r e j u d i c e and ignorance rooted i n f e a r and ignorance i s past.
The APA was deeply heartened by r e p o r t s t h a t your Task Force would
recommend broad coverage of treatment f o r mental i l l n e s s i n h e a l t h care
reform. We commend your support — and most p a r t i c u l a r l y t h e t i r e l e s s
work of Mrs. Gore — f o r ending d i s c r i m i n a t i o n by diagnosis against t h e
m i l l i o n s of Americans who, through no f a u l t o f t h e i r own, happen t o be
s u f f e r i n g from a mental i l l n e s s .
Thank you.
I would be pleased t o answer any questions.
�1:35-
PANEL FIVE-PHYSICIANS-- TESTIMONY ENDS
[MEG DEPARTS ]
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
0
�1:40--
PANEL SIX-PHYSICIANS- TESTIMONY BEGINS
THE VICE PRESIDENT DEPARTS
[CAROL RASCO PRESIDES ]
�PANEL 6; 1;4Q - 2;40
Insurance
Bill Gradison
President
Health Insurance Association of America
Eric Gustafson
President
Independent Insurance Agents of America
Mary Nell Lehnhard
Senior Vice-President
Blue Cross Blue Shield Association
Jack Moynihan
Executive Vice President, Group Insurance, Metropolitan Life Corporation
on behalf of
Alliance for Managed Competition
James Doherty
President
Group Health Association of America
�PANEL SIX: INSURANCE
Question Posed:
Why do insurance companies use pre-existing conditions to determine who to cover?
Groups:
Health Insurance Association of America
Independent Insurance Agents of America
Blue Cross Blue Shield Association
Metropolitan Life Corporation on behalf of Alliance for Managed Competition
Group Health Association of America
Mqjor issue concerns:
The insurance industry is badly split on the subject of managed competition and health
care reform. The big five companies like managed competition overall because it
preserves a strong role for them, but it will probably drive large numbers of medium
sized companies out of business. Insurance agents are very concerned about many of
them losing their jobs, particularly if we take away their ability to sell workers comp and
auto insurance under the twenty-four hour coverage option. None of them like
community rating.
Talking points:
1.
People not being able to get insurance because of pre-existing insurance is
fundamentally wrong.
2.
There are too many different insurance forms, there is too much micromanagement of health care providers.
3.
Our plan will ensure that all Americans will have comprehensive insurance
coverage regardless of employment status or pre-existing conditions.
�HEALTH INSURANCE ASSOCIATION OF AMERICA (HIAA)
MEMBERS:
270 Members
REPRESENTS:
Trade a s s o c i a t i o n f o r nation's commercial
health insurance companies.
TODAY'S SPEAKER:
B i l l Gradison, President
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
HOT BUTTON ISSUES:
Gradison i s w e l l respected on t h e H i l l , b u t
has l o s t the 5 b i g i n s u r e r s r e c e n t l y .
Support general managed competition framework
A f t e r r e g u l a r l y opposing any k i n d o f
comprehensive reform, now i n a n e g o t i a t i n g
p o s i t i o n . On access, would r e q u i r e employers
to o f f e r , but not pay f o r , a plan, and o f f e r
a p a y r o l l deduction so t h a t employees can
purchase the coverage. On cost containment,
would r e q u i r e uniform r a t e s e t t i n g f o r
providers, but managed care should be primary
vehicle f o r achieving sustained systemwide
cost savings. Insurance reform, i n c l u d i n g no
p r e - e x i s t i n g c o n d i t i o n l i m i t s . On HIPCs,
HIAA l i k e s e x i s t i n g a s s o c i a t i o n type schemes.
Believes HIPCs should be t r i e d but should
compete against other p o o l i n g arrangements.
Want f e d e r a l preemption o f s t a t e anti-managed
care laws. Support a t a x cap. Opposed t o
global budgets.
W i l l i n g t o work w i t h us, but have major
problems w i t h key elements o f our plan, and
may end up opposing us.
T r a n s i t i o n , I r a Magaziner, Work Group members
No monopoly power f o r HIPCs—allow employer
opt-out; Extent o f community r a t i n g mandated;
caps on premiums; allow supplemental
insurance
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
003. biography
SUBJECT/TITLE
DATE
re: Health Insurance Association of America - Bill Gradison (partial)
(1 page)
03/24/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Charlotte Hayes
OA/Box Number:
3015
FOLDER TITLE:
Admin. Material on Constituencey Groups & Ethics Working Groups - Folder 2
2006-0885-F
jp2697
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)j
Freedom of Information Act - |S U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) of the PRA|
P2 Relating to the appointment to Federal office 1(a)(2) of the PRAj
P3 Release would violate a Federal statute [(a)(3) of the PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA]
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors [a)(S) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(a)(6) of the PRA]
b(l) National security classified information [(bXl)of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency [(b)(2) of the FOIA|
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the KOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) of the FOIA|
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells [(bX9) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�HIAA
Health Insunncc Ajsoctalton of America
BILL GRADISON
Mr. Gradison i s President of the Health Insurance
Association of America (HIAA), the trade group representing the
nation's commercial health insurance companies.
Prior to assuming his current post in February 1993,
Gradison served in the House of Representatives for 18 years
where, most recently, he was ranking minority member of the House
Budget Coinmittee and the Health Subcommittee of the House Ways
and Means Committee. He also was Chairman of the House Wednesday
Group, a by-invitation organization of House Republicans that was
established in 1963.
Mr, Gradison i s Chairman of the Economic Roundtable of the
American Enterprise Institute, a Washington-based think tank and
served as Vice Chairman of the U.S. Bipartisan commission on
Comprehensive Health Care (a.k.a. The Pepper Commission).
An investment broker, he was Chairman of the Board of the
Federal Home Loan Bank of Cincinnati (1970-74). Prior to that,
he served for 13 years on the Cincinnati City council (1961-74),
including four years as Vice Mayor (1967-71). He was Mayor of
Cincinnati in 1971.
Mr. Gradison began his career in public service as Assistant
to the Under Secretary of the Treasury (1953-55). Before
returning to Cincinnati, he served as Assistant to the Secretary
of Health, Education and Welfare (1955-57).
P6/(b)(6) . '
; 'v .••.• • | he was educated in the city's
public schools. He received his B.A. from Yale University
(1948), his M.B.A. (with high distinction) from Harvard
University (1951) and doctorate from Harvard (1954).
1025 Connecticut Avenue, NW Washington, DC 20036-3998 202/223-7780 Telecopier 202/223-7896
ZOOia
WIH
6881 C2Z ZO'G
OC'-SO
CS/frZ/CO
�HIAA
HcaJth Insurance Association of America
STATEMENT OF HIAA
OH
COMPREHENSIVE HEALTH CARE REFORM
PRESENTED BY
BILL GRADISON
PRESIDENT
BEFORE THE
PRESIDENT*S HEALTH CARE TASK FORCE
MARCH 29, 1993
1025 Connecticut. Avenut, NW.
Washingion, D.C. 20036-3998
202-223-7780
-6ZStr 828 ZOZ
: wdss:9 : ee-sz-s :
�I am B i l l Gradison, President of the Health Insurance Association
of America. F i r s t , I want to say that we applaud the dedication of
the President's Health Care Task Force, a l l i t s members, and i t s
chair, H i l l a r y Rodham Clinton. At HIAA we too have been engaged
in reform, over the past few years we have promoted extensive
market reform i n the states; and, more recently, we have
conceptualized our v i s i o n of health care for the future. This
vision includes universal, cradle-to-grave coverage, mandates on
individuals to purchase coverage and on employers to provide
coverage, and guaranteed issue. Clearly, then, we understand that
our industry must change the way we do business—but we also think
we have much to contribute,
r
HIAA supports early federal action to support our mutual goals:
universal coverage, controlling health care costs, maintaining the
high standard of American health care, and, most important,
restoring to the American public that sense of security that comes
from knowing that they w i l l have health care when they need i t .
Achieving these goals w i l l require fundamental change from
everyone—insurers, providers, consumers, and government. I t w i l l
also require fairness i n how these goals are achieved. HIAA
believes that adherence to certain guiding p r i n c i p l e s w i l l
f a c i l i t a t e change and make success f a r more l i k e l y .
F i r s t , a l l players, including public and private payers, must play
by the same rules and pay the true cost of health care. There must
be universal cradle-to-grave coverage for a l l Americans, with an
e s s e n t i a l benefit package and with the government subsidizing those
who cannot afford to purchase coverage. Insurance market reforms
must be adopted. We must build on our employment-based system and
require employers to help pay for at least part of the cost of the
essential benefit package. Because of t h i s f i n a n c i a l concnitment,
employers must remain actively involved i n t h e i r employees' health
care coverage. Individuals and employers must also retain choice
and they should not be required to purchase insurance only through
group purchasing pools. The health care delivery system must be
changed, with an emphasis on the continued evolution of managed
care. There should be an equitable tax policy for health insurance
e #:30idrio ivioos
m IM
: wdse:3 : ee-sz-E !
:Ag AOH
�coverage. Individuals must themselves take responsibility for
their own health and adopt healthier l i f e s t y l e s .
What we hear most often from the public are concerns about
security: fear of losing coverage i f they become sick, fear of
being denied coverage i f they change jobs or their employers change
insurers, or fear of dramatic increases i n premiums that they
cannot afford.
HIAA was the f i r s t to develop reforms addressing these concerns.
At l e a s t 20 states have adopted a l l and 14 more states have adopted
some of these reforms. These include: 1) guaranteed issue - so
that no one would be denied coverage; 2) coverage of whole groups so that no individual may be excluded from the group's coverage; 3)
renewability - so that coverage w i l l not be cancelled because of
health status or claims experience; 4) p o r t a b i l i t y - so that once a
person has s a t i s f i e d an i n i t i a l plan's pre-existing condition
r e s t r i c t i o n , that person would not have to meet a pre-existing
condition limitation when changing jobs or when the employer
changes c a r r i e r s ; and 5) rating reforms - to assure that no one i s
charged a premium that d i f f e r s s i g n i f i c a n t l y from the insurance
company's average rate.
HIAA does not, however, support s t r i c t community rating, which
would r e s u l t in a considerable increase i n premiums for most groups
and ultimately add to the number of uninsured because lower-risk
groups would drop coverage as rates begin to s p i r a l . Even in a
mandatory market, some limited experience rating provides an
incentive to employers and individuals to promote healthy behavior.
Insurers have needed to use pre-existing condition r e s t r i c t i o n s to
protect t h e i r current policyholders from the f i n a n c i a l impact
caused by those who t r y to "game the system by waiting u n t i l they
are sick to buy insurance. I n essence, these individuals are
trying to insure burning houses. Without pre-existing condition
limitations, increases i n premiums for those who have bought
insurance would be dramatic and there would s t i l l be no guarantee
H
- 2 -
�that insurers would have adequate resources to pay policyholders'
claims.
HIAA does, however, support limiting the use of pre-existing
conditions even under today's system—in fact, 24 states have
adopted such l i m i t s . And under our reform proposal, pre-existing
condition l i m i t s w i l l eventually become obsolete (though not during
the t r a n s i t i o n or for those who violate a mandate to purchase
coverage).
In addition, there are many steps we can take now to slow healthcare cost i n f l a t i o n . We can apply outcomes research, expand
managed care, reform the malpractice system, provide more primary
care, emphasize prevention, c u r t a i l fraud and abuse, encourage
electronic data interchange, target subsidies to certain employers
and individuals, and l a s t , but certainly not l e a s t , eliminate costshifting by the government. (Cost-shiftinq i s i n effect a hidden
tax to employers and to privately insured patients.)
These p o s i t i v e changes w i l l go far in controlling costs. But one
thing that w i l l not reduce the escalation of health care costs i s
the imposition of r i g i d l i m i t s on insurance premiums. Note f i r s t
that premium l i m i t s would affect only one-third of private health
care coverage. And the premiums that insurers charge r e f l e c t ,
rather than cause, the escalating cost of health care. Limits on
premiums w i l l not slow health care inflation, but they would
e f f e c t i v e l y cut off the c a p i t a l needed for the continued
development of managed care and w i l l negate the positive
contribution of the health care industry toward an economic
recovery.
Working with the government, the commercial health insurance
industry can serve the national interest by providing universal
coverage and displaying a sound sense of s o c i a l r e s p o n s i b i l i t y .
HIAA looks forward to working with the President, the Congress and
the American public to achieve these goals.
- 3 -
9 rsoiddo ivioos
m zos
: wd9£:s : es-sz-s :
JAG AOH
�INDEPENDENT INSURANCE AGENTS OF AMERICA ( I I A A )
MEMBERS:
280,00 i n s u r a n c e agents and t h e i r employees
REPRESENTS:
Largest n a t i o n a l trade a s s o c i a t i o n o f
independent i n s u r a n c e agents, who a r e l o c a t e d
i n v i r t u a l l y e v e r y town and c i t y i n t h e
country.
TODAY'S SPEAKER:
E r i c G. Gustafson, P r e s i d e n t (See a t t a c h e d
biography)
SCOPE OF
INFLUENCE:
Large PAC campaign c o n t r i b u t i o n s , v e r y
i n f l u e n t i a l at thestate l e g i s l a t i v e level.
V i s i b l e i n l o c a l communities.
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Support c o s t containment measures i n c l u d i n g
a d m i n i s t r a t i v e s i m p l i f i c a t i o n , managed c a r e
and u t i l i z a t i o n r e v i e w . Tax i n c e n t i v e s f o r
self-employed i n d i v i d u a l s and s m a l l
businesses t o p r o v i d e h e a l t h c a r e coverage.
Insurance reform i n c l u d i n g e l i m i n a t i o n o f
r i s k e x c l u s i o n s , and guaranteed p o r t a b i l i t y .
Reinsurance mechanisms f o r i n s u r e r s .
Preemption o f s t a t e mandated h e a l t h b e n e f i t s .
Medical malpractice reform.
POSITION ON
PLAN:
Have n o t commented.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
I r a Magaziner addressed
HOT BUTTON ISSUES:
t h e i r group i n March.
Elimination o f t r a d i t i o n a l insurance
functions.
�MAR 23 '93
P. 3 / 3
11=14
Independent Insurance Agents of America
INCORPQKATEO
ERIC G. GUSTAFSON
PRESIDENT
INDEPENDENT INSURANCE AGENTS OF AMERICA
CAPITOL HHl OffICE
SUITE 300
412 FIRST STREET, S.L
WASHINGTON, D.C. 20003
202/863-7000
FAX 202/863-7015
IIAA President E r i c G. Gustafson i s an independent insurance
agent from Portsmouth, N.H.
Agency
i n Portsmouth.
He i s chairman c f Blake Insurance
Mr. Gustafson
was elected
t o IIAA's
Executive Coinmittee i n 1986 and was e l e c t e d president i n September
1992., As a small business owner, Mr. Gustafson has been a c t i v e i n
a number of community-related a c t i v i t i e s i n Portsmouth, i n c l u d i n g
serving as chairman o f the board of Portsmouth H o s p i t a l .
As a
r e s u l t of t h i s experience, Mr. Gustafson has viewed the h e a l t h care
d e l i v e r y system from three d i f f e r e n t perspectives--as a purchaser
and p r o v i d e r of h e a l t h coverages and as a d i r e c t o r o£ a h e a l t h care
facility.
�RCV BY:
I 3-25-93 ; i:07PM !
CCITT G3-
Independent Insurance Agents
of
America
Incorporated
TESTIMONY OF:
Mr. Eric Gustafson, CPCU, AIA
President, Independent Insurance Agents of America
Submitted to
The White House Task Force on Health Care
March 29,1993
IIAA Capitol Hill Office
Suite 300
412 First Street. S.E.
Washington, D.C 20003
1202) 863-7000
Fax (202) 863-7015
SOCIAL OFFICE!* 2
�RCV BY:
; 3-25-93 ; i:OBPM
CCITT Q3-»
SOCIAL OFFICE!* 3
1
Good afternoon Mrs. Clinton and members of the Task Force. My name is Rick
Gustafson and I am an independent insurance agent and Chairman of the Blake
Insurance Agency in Portsmouth, New Hampshire. For this year, I am President of the
Independent Insurance Agents of America.
The question you ask, "Why do insurance companies use pre-existing conditions
to determine who to cover?" speaks directly to my role as an insurance agent and small
business person. Asa producer of insurance products my job is to find the best coverage
at the lowest price for my clients - consumers. As the owner of a small business, I also
provide coverage for my own employees at prevailing prices and! am painfully aware that
the best price is often not good enough.
Let me begin by saying the Independent Insurance Agents of America supports the
elimination of pre-existing conditions as a determination of coverage. Unfortunately, due
i
to a segmented market and rising health care costs, the insurance industry in recent
years has been forced to move away from community rating toward a system of risk
selection as a method of determining a premium and assuring coverage.
i
Millions of Americans without health coverage still require health care and receive
it to some degree. Each time they receive care and do not pay the bill, the cost is
passed on to those who are covered. Many Americans are insured by Medicare,
Medicaid and other entities that pay different rates for health care and their costs are also
shifted to the rest of us who are privately insured.
Finally, big companies whose employee base is large enough to spread risk have
opted out of the general market and into self-insured plans. What remains are mostly
�RCV BY:
; 5-25-93 : rOSPM :
CCITT Q3-»
SOCIAL OFFICE!* 4
2
small businesses and individuals who are served primarily through the private insurance
industry. The people in this market help pay the bill for the rest of the country. This bill
continues to increase at almost double the rate of general inflation.
These rising costs and the limited universe of consumers in this market have
forced insurance companies in the small-group market to adjust their policies. The
economies of scale work both ways - a small group cannot create an actuarially sound
base to withstand the costs of payment for some treatments.
This returns us to my original point -- presently, without some risk selection based
on pre-existing conditions, companies would be unable to offer high coverage at a low
cost to their other policyholders. This is tragic and must be changed.
The elimination of pre-existing conditions as a determination of coverage, in
conjunction with community rating of health insurance, would work if the causes of the
current situation were addressed by: implementing cost savings, eliminating cost shifting
and expanding coverage to the uninsured. We must preempt costly state mandates,
provide incentives for employers to cover their workers and overhaul our nation's medical
malpractice system.
All these things can be accomplished within a system of managed competition.
But, while this concept has much to offer, it also poses a new set of potential problems.
In addition to health insurance, my agency also sells workers compensation, auto and
commercial liability. These lines of insurance also pay a portion of our nation's health
care costs. Any form of federal health reform must also take property/casualty insurance
concerns into consideration. However, incorporating the medical portion of these lines
�RCV 5Y:
; 3-25-93 ! i:09PM i
CCITT Q3-»
SOCIAL OFFICE;* 5
3
into all health coverage would pose a great risk to the financial stability of the new
program.
Another concern with managed competition is that of service. Under some
proposals, I understand that consumers, albeit to a lesser degree, will maintain some
choice of both their policy and by whom they will be treated. Unfortunately, the exclusive
Health Insurance Purchasing Cooperatives, under the guise of cost effectiveness, may
lack some valuable services. We believe that non-exclusive HIPCs and independent
agents should, and could, compete in an environment that would prove beneficial to
consumers. The personalized service agents provide wili continue to be a desirable and
affordable service to many Americans.
We appreciate the opportunities we have had in the past to provide information on
health care issues - our staff will be providing you with additional detailed information and
an independent economic study regarding these issues, dearly, you and the President
are trying to solve one of the greatest problems confronting this country. All of us,
including independent insurance agents, will benefit by an improved system where costs
are low, services are high and competition prevails.
As you also know, reform of any kind may have unforeseen results. President
Clinton has said many times, the economy cannot grow if the health care system is not
improved. I know you are well aware of the far-reaching implications of the task ahead
of you. I wish you the best and would be happy to answer any questions.
�BLUE CROSS AND BLUE SHIELD ASSOCIATION
MEMBERS:
71 Independent Blue Cross and Blue S h i e l d
Plans
REPRESENTS:
Coordinating o r g a n i z a t i o n f o r BC/BS Plans
throughout the n a t i o n . C o l l e c t i v e l y , t h e
Plans provide h e a l t h b e n e f i t s p r o t e c t i o n f o r
n e a r l y 70 m i l l i o n people, and serve an
a d d i t i o n a l 34 m i l l i o n people through t h e
Medicare program where Plans administer 70
percent o f a l l the program's claims.
TODAY'S SPEAKER:
Mary N e l l Lehnhard, Senior Vice President
(See attached biography)
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Viewed as moderate voice among i n s u r e r s ;
widely consulted.
More progressive p o s i t i o n than HIAA.
Do not believe HIPCs are necessary, j u s t
l a r g e r pools. Because of t h e i r h i s t o r y , they
b e l i e v e they w i l l be a t a competitive
disadvantage i n a managed competition system
and w i l l be looking f o r some assurance o f
r i s k adjustments and standardized b e n e f i t s .
Support insurance reform ( r a t i n g / p r e - e x i s t i n g
c o n d i t i o n bans), increased managed care, and
a d m i n i s t r a t i v e s i m p l i f i c a t i o n . Would move
the market t o community care networks w i t h
o b l i g a t i o n s t h a t t h e percentage o f people i n
AHPs increase each year. Would r e q u i r e
employers t o c o n t i n u a l l y increase percentage
of employees i n AHP each year i n order t o
keep t h e i r deduction.
POSITION ON
PLAN:
Wait and see
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n , I r a Magaziner, OPL
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
004. biography
DATE
SUBJECT/TITLE
re: Blue Cross Blue Shield Representative - Senior Vice President Mary Nell Lehnhard (partial) (1 page)
n.d.
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Charlotte Hayes
OA/Box Number: 3015
FOLDER TITLE:
Admin. Material on Constituencey Groups & Ethics Working Groups - Folder 2
2006-0885-F
ip2697
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - [5 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information |(bXl) of the FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency [(b)(2) of the FOIA]
b(3) Release would violate a Federal statute [(b)(3) of the FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information [(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIAj
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells [(b)(9) of the FOIA)
National Security Classified Information 1(a)(1) of the PRA|
Relating to the appointment to Federal office 1(a)(2) of the PRA|
Release would violate a Federal statute 1(a)(3) of the PRA|
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA|
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Blue Cross Blue Shield Association
Representative
Mary N e l l Lehnhard
Senior Vice President
Mary N e l l Lehnhard i s the Senior Vice President o f t h e BCBSA.
She heads t h e O f f i c e o f Government Relations and has worked f o r
the A s s o c i a t i o n f o r nearly t h i r t e e n years. P r i o r t o t h e
Association, Mary N e l l was a p r o f e s s i o n a l s t a f f member f o r t h e
House Ways and Means Health Subcommittee. She has a l s o worked
f o r t h e Congressional Research Service. Mary N e l l p P6/(6)(6)
P6/(b)(6) [and attended the U n i v e r s i t y o f Arkansas where she
received a bachelors o f science degree i n chemistry and
economics.
�RCV BY:
: 3-25-93 I 1:25PM !
1 202 626 4833*
SOCIAL OFFICE!* 1
ORAL STATEMENT
BEFORE THE
WHITE HOUSE TASK FORCE ON HEALTH CARE
Presented by:
Mary Nell Lehnhard
Senior Vice President
Blue Cross and Blue Shield Association
T
Post-lt " brand fax transmittal memo 7671
March 29, 1993
Co.
Dept.
* °'pages >•
2*
�RCV BY:
; 3-25-93 ; 1:26PM !
1 202 626 4333-
SOCIAL OFFICE!* 2
I am Mary Nell Lehnhard, senior vice president of the Blue Cross and Blue
Shield Association, the coordinating organization for 71 independent Blue
Cross and Blue Shield Plans.
I would like to thank you for this opportunity. I also commend President
Clinton and First Lady Hillary Rodham Clinton for putting comprehensive
health care reform in its rightful place at the top of the American agenda.
The Blue Cross and Blue Shield Association is ready to work with you. Our
goals are the same as yours: To stop the unconscionable cost increases
that are jeopardizing the nation's fiscal health and to make health
insurance a right for all.
Meeting the challenges of cost-control and access will require fundamental
changes in the health care financing and delivery system.
We believe the cost containment goal can best be met by a managed
competition approach. To implement managed competition, Congress must
first address the inequities that now exist in the insurance industry.
Blue Cross and Blue Shield Plans strongly support a top-to-bottom shake up
of the industry to eliminate competition based on risk selection. Instead,
insurers must compete on their ability to manage costs.
We envision a set of strict federal standards that apply to all insurers
and self-funded entities. Only those insurers or self-funded plans that
adhere to strict standards would be certified as Accountable Health Plans.
Indeed, we urge you to use insurance reform to lead the overall reform
effort and couple those reforms with changes in the tax code. These two
initiatives could be used to achieve four of the five key goals of managed
competition quite rapidly.
•
Limiting the tax treatment of employer-provided health benefits would
encourage and hasten the movement of consumers into more cost-effective
delivery systems.
-1-
�RCV BY:
; 3-25-93 ; 1:27PM :
1 202 626 4833-
SOCIAL OFFICE;# 3
• Requiring AHPs to offer standardized benefit packages and report on
quality measurements would allow price and quality comparisons between
different AHPs.
• Requiring all insurers to adopt an open enrollment standard would assure
that any group or individual could purchase coverage from any AHP
regardless of their health status.
• Requiring AHPs to community rate with limited demographic adjustments
would assure that high-cost groups do not have disproportionately higher
premiums.
The fifth goal -- providing for individual choice of an AHP -- would
require establishment of Health Insurance Purchasing Cooperatives (HIPCs)
or some other similar entity in every area.
But it would be difficult and time consuming to establish these entitles
everywhere. And, we don't need to delay the other necessary reforms -- and
the cost savings they could be yielding -- until HIPCs are in place. In
addition, this approach would eliminate the risk of making a reform
strategy entirely dependent on a HIPC everywhere.
The HIPC concept could then be put in place in a number of areas to gain
experience. States also could move ahead on their own to establish HIPCs.
In searching for ways to control health care cost in the short-term, some
reform proponents have proposed limits on the premiums insurers charge to
their subscribers. Among the limits being discussed are freezing premiums,
limiting the rate at which they can increase or actually setting a single
premium that all insurers in an area must charge.
None of these limits on premiums would work in either the short-run or the
long-run.
-2-
�RCV BY:
; 3-25-S3 ; 1:27PM I
•
1 202 526 4833-
SOCIAL OFFICE!* 4
If premium limits are implemented before comprehensive insurance reform
is in place, insurers could respond by being more selective in accepting
groups, canceling coverage of high-risk enrollees, or redesigning
benefits.
• Waiting for insurance reforms to become effective does not solve the
problem. Under a community rating requirement, insurers would have to
increase rates significantly for low-risk enrollees in order to reduce
rates for high-risk enrollees.
•
Premium limits raise an even more serious problem for many insurers:
Solvency. If, insurers are not able to raise rates sufficiently to
offset their actual experience with increased health care costs the
shortfall would have to be made up from their reserves. Once these
reserves were depleted, insurers would face insolvency.
•
Premium limits also would inhibit an insurer's ability to make the
capital investments needed for the sort of innovative programs that
would ensure the success of managed competition.
Finally, premium limits would affect only one-third of the private health
care coverage. The remaining two-thirds of the coverage is in self-funded.
Price controls or freezes on hospitals and physicians also are being
discussed as a short-term strategy. We believe that:
• They would freeze the ability of insurers and employers to establish
cost-effective provider networks. And, Medicare all-payer rates would
literally dismantle all the networks established to date.
•
Price controls on providers work directly against managed competition's
goal of restructuring the health care delivery system.
•
Price controls offer no incentives to encourage hospitals and doctors to
change their practice patterns and become more cost-effective.
-3-
�RCV BY:
; 3-25-93 ! 1:28PM ;
1 202 626 4833-
SOCIAL OFFICE;* 5
• Price controls would not address the volume of health care services.
In summary, we support aggressive movement to managed competition through
immediate insurance reforms and changes in the tax treatment of employerprovided benefits. We oppose limits on insurance premiums and providers as
counter-productive to changing marketplace incentives.
�ALLIANCE FOR MANAGED COMPETITION
MEMBERS:
Aetna, CIGNA, MetLife, The P r u d e n t i a l ,
Travelers
REPRESENTS:
C o l l e c t i v e l y provide h e a l t h care coverage t o
more than 60 m i l l i o n Americans
TODAY'S SPEAKER:
Larry English, President, Employees B e n e f i t
Group, Cigna Corporation
APPROACH TO
REFORM:
Managed competition
POSITION ON
PLAN:
Support managed competition
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n , I r a Magaziner, OPL
HOT BUTTON ISSUES:
Wage and p r i c e c o n t r o l s
�MRR-26-1993 14:29
FROM OLDAKER> RYAN & LEONARD
Human Eeaouroes
TO
4566241
P.02
.
HKPROPOLHSMI L I T E U^URAKCE COHPAKY
One Madison Avesue
Mew York, B . Y .
10010
Doeesiber 1990
ffOHM D* KOTWAWMfff
A*
John D. Keynaha*, J r . , XB an executive vice-prefiident ana a
»evt>er of the corporate masaqmat office of Metropolitan L i f e
Insurance CoopanyIn thin pocition, nr. Moynahan ha» responeitoillty for
Metropolitan* s group insurance department, which provides group
insurance and related aaployee benefit eervice* to Metropolitan'B
castosers throughout the Onited States.
» . Moynahan joined Metropolitan i n 1957 as a service supervisor
in the group department. He advance through positions of
increasing responsibility and, in 1971, was appointed a regional
vice-president.
I n 1980 He beoane a senior vice-president.
aBeuaed his present position i n 1986.
He received h i s B.A. degree i n English, cu» laude, from the
University of Fotre Dane i n 1957.
He
�' MPR-26-1993
14:29
FROM OLDftKER. RYAN & LEONARD
TO
4566241
* * E00-3Sfctd "IbiOi * *
- aMr. Moynahan is a M b c r of the board of directors of the
Metropolitan Property and Casualty Company, corporate Health
Strategies, Inc., and MetTife Healthcare Mfcnageaent corporation.
Mr* Hoynahan and his faaily reside in Darien, Cam.
- 30 -
P.03
�MPR 26 '93 11:07
FROM GPIRD 212 579 2926
PfiGE.002
Highlights of Comments by
Mr. John D. Moynahan, J r .
Metropolitan L i f e Insurance Company
to Mrs. H i l l a r y Rodham Clinton
on Monday, March 29, 1993, Mr. John D. Moynahan, J r . , Executive
Vice President of Metropolitan L i f e Insurance Company w i l l address
the Clinton Administration's Health Care Task Force.
Mr. Moynahan w i l l represent the views of Metropolitan and four of
Anerica's other largest managed care companies providing health
care coverage to 60 million Americans—Aetna, CIGNA, The
Prudential, and Travelers. These companies recently formed an ad
hoc lobbying c o a l i t i o n known as The Alliance for Managed
Competition (AMC.)
The AMC supports the Federal enactment of managed competition,
because i t i s a health care reform proposal designed to release
competitive market forces to achieve lower costs with consistent
quality, while preserving patient choice.
As a r e s u l t of the
enactment of managed competition:
— Access to and security of private health care coverage would
be s i g n i f i c a n t l y improved; limitations would be placed on pree x i s t i n g condition clauses; cancellation of coverage because of
i l l n e s s would be prohibited; renewal would be guaranteed; a l l
plans would have to accept a l l enrollees; and individuals could
continue standard health insurance coverage even when losing a job.
— The c o l l e c t i v e purchasing power of individuals and small
employers i n the marketplace would be assured by the creation of
Health Insurance Purchasing Cooperatives.
~ Reliable, accessible, and user-friendly consumer information
would be introduced into the marketplace concerning any health
plan's pricing, performance, patient satisfaction, and medical
outcomes.
Consumers would have the a b i l i t y to change plans during open
enrollment periods and would have a wide range of provider choices
both within plans and between plans.
Greater emphasis on preventive care, including c h i l d
immunization, would be provided through more e f f e c t i v e use of
managed care arrangements known as Accountable Health Partnerships.
In addition:
— AMC endorses the enactment of medical malpractice reform.
— AMC opposes provider and premium p r i c e controls, because they
imbed existing system i n e f f i c i e n c i e s and w i l l undermine the
country's movement to a reformed system based on managed
competition.
March 26, 1993
�GROUP HEALTH ASSOCIATION OF AMERICA (GHAA)
MEMBERS:
323 member HMOs, e n r o l l i n g more t h a n 27
m i l l i o n people.
REPRESENTS:
Largest trade a s s o c i a t i o n f o r organized
p r e p a i d h e a l t h c a r e systems.
TODAY'S SPEAKER:
James F. Doherty, P r e s i d e n t (See a t t a c h e d
biography)
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
PET ISSUES:
L e g i s l a t i v e r e p r e s e n t a t i o n a t t h e f e d e r a l and
s t a t e l e v e l , l e g a l counsel, education
programs, and r e s e a r c h , and wide d i s t r i b u t i o n
of p u b l i c a t i o n s .
Managed c o m p e t i t i o n
Basic b e n e f i t s package must be comprehensive,
w i t h reasonable c o s t s h a r i n g . "Managed c a r e "
s h o u l d be d e f i n e d i n s t a t u t e and s h o u l d
i n c l u d e an HMO component, s e l e c t i v e
c o n t r a c t i n g w i t h p r o v i d e r s , q u a l i t y assurance
and u t i l i z a t i o n r e v i e w programs, and
f i n a n c i a l i n c e n t i v e s f o r e n r o l l e e s t o use t h e
p l a n ' s p r o v i d e r s and procedures.
Exclusive
HIPCs f o r s m a l l employers.
Tie tax
d e d u c t i b i l i t y o f h e a l t h b e n e f i t s t o lowest
p r i c e d p l a n . Risk a d j u s t m e n t f o r premiums.
Concerned about c a p a c i t y o f p l a n s t o absorb
l a r g e new p o p u l a t i o n s .
S u p p o r t i v e , w i t h concerns about o v e r r e g u l a t i o n o f managed c a r e systems
Transition, Office o f Public Liaison, I r a
Magaziner i s scheduled t o meet w i t h them.
Long term care, p r e s c r i p t i o n drug b e n e f i t
�RCV 3Y:
! 3-23-93 ;i2:00PM !
QHAA-*
SOCIAL OFFICE;* 2
aOGRAPWCAL OVERVIEW
JAMES F. DOHERTY
President
Group Heelth Association of America, Inc.
1129'20th Street, N. W.
Washington, DC 20036
Mr. Doherty Is the chief administrative officer of the
country's largest and most Important national trade association
for organized prepaid health care systems, the Group Health
Association ot America, inc. (GHAA). He was elected executive
director by the full Board of Directors In December 1978,
assumed the position In July 1979, and was consequently named
president of GHAA In March, 198$. His selection as executive
director followed eight years as the organization's legislative
counsel, years during which he played a key role In the passage
of the federal 1973 HMO Act and, In subsequent years,
Amendments to that law. A highly respected health lawyer, Mr.
Doherty served as founding president of the National Health
Lawyers Association. He also chaired a committee responsible
for drafting the HMO solvency requirements adopted by the
National Association of Insurance Commissioners.
Mr. Doherty Joined the GHAA staff In 1970 following
several years as counsel to the Committee on Banking and
Currency of the U. & House of Representatives. Prior to the
Capitol Hill appointment, he worked for three years aa a
legislative representative for the AFL-CIO.
Mr. Doherty Is a graduate of the Georgetown University
Law Center and Is a member of the District of Columbia and
Pennsylvania Bars. He has served on the faculty of the George
Washington University Law School In Washington, D. C.
�SENT BY:
3-25-80 -.ll :29AM :
GHAA-NAT ECONOMIC COUNCIL;? 2/ 4
TESTIMONY
OF THE
GROUP HEALTH ASSOCIATION OF AMERICA. INC.
JAMES F. DOHERTY
PRESIDENT AND CHIEF EXECUTIVE OFFICER
BEFORE
THE
WHITE HOUSE HEALTH CARE TASK FORCE
March 26,1993
Washington, DC
�SENT BY:
3-25-93 ; 11:29AM :
GHAA-NAT ECONOMIC COL'NCIL;? 3/ 4
Thank you for the opportunity to appear here today.
We in the HMO and managed care industry are pleased that
the reported direction taken in your discussions favors
managed competition and an expanded role for our member
plans.
The main reasons for our extraordinary success
over the last two decades lies in the fact that our group
enrollments are not underwritten nor are our enrollees
excluded because of preexisting conditions. This principle
is an inherent characteristic of our programs including those
HMOs owned or operated by insurance companies. This
requirement is reflected in the Federal HMO Act and in
various federal programs and state statutes. We hope that
this Administration and the Congress will extend the same
privileges to all persons in all programs. This is necessary
so that all have access to affordable, quality health care and
because it will appropriately level the playing field.
�SENT BY:
3-25-93 :11:30AM ;
GHAA-NAT ECONOMIC COUNCIL:# 4/ 4
-2*
We are a bit concerned about being on this panel
and assigned this particular subject. We do hope that the
members of this task force realize the important
characteristics which distinguish the legislative and
regulatory policies toward HMOs and managed care and
those dealing with indemnity insurance. Direct responsibility
for provision of health care, prospective budgeting, defined
rating systems, quality assurance requirements and
solvency requirements are a few examples of these distinct
characteristics. Failure to consider these essential
differences in the past have often put us in a legal
quagmire, hampered our ability to operate in the private
market and takes valuable time and effort to correct.
We look forward to working with this Administration
and the Congress as work on health care reform proceeds.
HMOs and similar managed care systems are an
appropriate role model as they enhance quality, access and
value for all health care consumers.
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
�PANEL 7; 2;45 - 3;35
Pharmaceuticals
Robert F. Allnutt
Executive Vice President
Pharmaceutical Manufacturers Association
Dee Fensterer
President
Generic Pharmaceutical Industry Association
Dr. Charles West
Executive Vice President
National Association of Retail Druggists
G. Kirk Raab
Board of Directors, Chair on Health Care Reform
Industrial Biotechnology Association
Dr. John Gans
Executive Vice President
American Pharmaceutical Association
�PANEL SEVEN: PHARMACEUTICALS
Question Posed:
Why are prescription drugs so much more expensive in this country than in other
countries?
Groups:
Pharmaceutical Manufacturers Association
Generic Pharmaceutical Industry Association
National Association of Retail Druggists
Industrial Biotechnology Association
American Pharmaceutical Association
Mqjor issue concerns:
f
These groups will be all over the map. The Pharmaceutical Manufacturers Association
and the biotech group will probably be the closest to each other, with each saying you
can't impose price regulation on drugs without hurting research. The generics group will
attack the Pharmaceutical Manufacturers Association, while the two pharmacy groups
have a divided position with National Association of Retail Druggists being more
generally supportive of drug price regulation and American Pharmacists Association
being more concerned about "pharmacist empowerment".
Talking points:
1.
Drug prices are higher in the U.S. than in other countries.
2.
Drug companies' profits have been incredibly high over the past few years.
3.
Drug companies spend more on advertising than on research.
�PHARMACEUTICAL MANUFACTURERS ASSOCIATION
REPRESENTS:
More t h a n 100 f i r m s t h a t produce drugs i n t h e U.S.,
i n c l u d i n g Mercke, S e a r l e , B r i s t o l - M y e r s Squibb,
P f i z e r , I n c . I s a n o n p r o f i t s c i e n t i f i c and
professional organization.
TODAY'S SPEAKER:
Robert F. A l l n u t t , E x e c u t i v e V i c e P r e s i d e n t
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
A b i l i t y t o mobilize quickly, powerful l o b b y i s t ,
advocates f o r t h e drug m a n u f a c t u r i n g i n d u s t r y ,
e f f e c t i v e grass r o o t s , s i g n i f i c a n t f i n a n c i a l
resources and s u b s t a n t i a l c l o u t i n Congress.
Noncommittal, b u t a n t i - government i n v o l v e m e n t .
The PMA Board s u p p o r t s a managed c o m p e t i t i o n
approach t o comprehensive h e a l t h c a r e r e f o r m
including the following,
• i n c l u s i o n o f p r e s c r i p t i o n drugs
• p r e s c r i p t i o n drug b e n e f i t t o Medicare b e n e f i c i a r i e s
•Medicare p r e s c r i p t i o n d r u g coverage t o a t l e a s t
100% o f p o v e r t y l e v e l .
I n p r i n c i p l e , managed c o m p e t i t i o n i s bad f o r them
because o f t h e f o r m u l a s , b u t t h e y c o u l d g e t d r u g
benefits.
The i n d u s t r y has come around towards o u r p l a n .
Supports g l o b a l b u d g e t i n g , f e e f o r s e r v i c e o p t i o n ,
and a n t i t r u s t r e l i e f .
Opposes e v e r y t h i n g i n c o s t c o n t r o l package b o t h i n
t h e s h o r t and l o n g term. Wants v o l u n t a r y p r i c e
controls.
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
PET ISSUES:
Supports Managed-competition approach t o h e a l t h care
r e f o r m , n o t a f r a i d o f managed c o m p e t i t i o n , and w a i t
and see.
I r a Magaziner, T r a n s i t i o n , P u b l i c
C u t l e r o f t h e Task Group
Liaison,
David
P r e s c r i p t i o n drug b e n e f i t , s m a l l b u s i n e s s r e l i e f ,
managed c a r e , u t i l i z a t i o n r e v i e w , m e d i c a t i o n ,
v o l u n t a r y p r i c e c o n t r o l s and c o m p e t i t i o n .
HOT BUTTONS ISSUES: Drug p r i c e r e v i e w board, n a t i o n a l f o r m u l a , c o s t
control
�RCV BY:
; 3-23-93 ;iC:21AM ;
202 835 3595-
SOCIAL OFFICE!* 2
Robert P. Allnutt
Executive vice President
Pharmaceutical Manufacturers Association
Bob Allnutt joined PMA in 1985. He previously served as Vice
President for Government Relations at the Communications
Satellite Corporation, and as vice President and Legal Counsel
for the U.S. Committee for Energy Awareness, an association
sponsored by electric u t i l i t i e s .
He was with NASA through most of the 1960's and from 1978-83 was
the third ranking NASA o f f i c i a l . He also served as Assistant
Administrator of the Energy Research and Development Administration; Staff Director of the U.S. Senate committee on Aeronautical
and Space Sciences; and Associate General Counsel of the U.S.
Commission on Government Procurement.
Allnutt has an engineering degree from the Virginia Polytechnic
Institute and both a Juris Doctorate and a Masters of Law degrees
from George Washington University
*
He serves on the Board of the National Health Council; the
National Council on the Aging; the NASA Alumni League; the Legal
Aid Society of the District of Columbia; the National Space
Society; the Air and Space Heritage Council; and i s a member of
the Bars of Virginia, the District of Columbia and the U.S.
Supreme Court.
July 1992
�MAP 25 '93 14:30 PHA/HCS
P.2''4
ORAL STATEMENT OF ROBERT F. ALLNUTT
EXECUTIVE VICE PRESIDENT
PHARMACEUTICAL MANUFACTURERS ASSOCIATION
BEFORE THE PRESIDENT'S HEALTH CARE TASK FORCE
MARCH 29, 1993
o
PMA
s t r o n g l y supports your e f f o r t s to devise a
healthcare-reform
maintain
plan that w i l l c o n t r o l c o s t s , i n c r e a s e a c c e s s ,
q u a l i t y -- and,
continued
key to each of these goals, ensure the
discovery and development of new
cost-effective,
life-
saving medicines.
o
Every American should have p r e s c r i p t i o n - d r u g coverage.
More than 60 m i l l i o n Americans l a c k any such coverage.
Those 60
m i l l i o n d i s p r o p o r t i o n a t e l y include the e l d e r l y and the poor, and
that must change.
o
We b e l i e v e a l l FDA-approved drugs must be included i n the
standard-benefit package under managed competition.
There
should
be a p r e s c r i p t i o n - d r u g b e n e f i t under Medicare i n the managedcompetition
s e t t i n g , or otherwise.
I f Medicaid i s to remain
f r e e - s t a n d i n g , we support Medicaid p r e s c r i p t i o n - d r u g coverage up
to a t l e a s t 100 percent of the poverty l e v e l .
o
A managed-competition system w i l l c o n t a i n c o s t s
effectively.
We
recognize the need f o r h e a l t h c a r e c o s t
containment during the period of t r a n s i t i o n to managed
competition,
and we're w i l l i n g to do our p a r t .
have already slowed d r a m a t i c a l l y .
Price increases
�MfiR 25 '93 14:60 PMA/HCS
P.3/4
- 2 o
I n December/ the PMA. Board of D i r e c t o r s unanimously
d i r e c t e d the s t a f f , a c t i n g w i t h i n the c o n s t r a i n t s of the
a n t i t r u s t laws, to urge P r e s i d e n t - e l e c t C l i n t o n to seek
voluntary, independent pledges
from each company to hold p r i c e
i n c r e a s e s at or below the i n f l a t i o n r a t e .
not y e t seen f i t to take t h i s step.
The A d m i n i s t r a t i o n has
Our only other option to
achieve auditafcle and enforceable voluntary
industry-wide
r e s t r a i n t i s to request J u s t i c e Department c l e a r a n c e under the
a n t i t r u s t laws to agree among ourselves to do so.
requested t h a t c l e a r a n c e .
We have
We urge the Administration to
support
us on one of these two paths to cost containment i n the
t r a n s i t i o n period.
o
We must oppose Government p r i c e r e g u l a t i o n .
Price
c o n t r o l s on medicines would have immediate impacts on the amount
and the very nature of r e s e a r c h , b i a s i n g r e s e a r c h toward
r i s k , low-benefit new products.
And r e g u l a t i o n of new-product
p r i c e s would have a p a r t i c u l a r l y d e v a s t a t i n g impact on
entrants i n the biotechnology
our country's most promising
low-
new
i n d u s t r y -- which has been one
emerging growth i n d u s t r i e s .
of p r i c e c o n t r o l s have a l r e a d y profoundly
of
Fears
affected capital
markets.
International Price Variations
o
I n t e r n a t i o n a l p r i c e v a r i a t i o n s should be considered i n
two c o n t e x t s :
v a r i a t i o n s between the U.S.
and
other
i n d u s t r i a l i z e d n a t i o n s ; and v a r i a t i o n s between the U.S.
developing
nations.
and
�P
MfiR 25 '93 14=01 PMA/HC5
-
4 / 4
- 3With reaoect to industrialized nationai
o
I n the past, drug prices i n industrialized countries
tended to vary f a i r l y widely based on local market conditions.
However, a study we have submitted to Mr. Magaziner shows that
introductory prices i n recent years have been v i r t u a l l y i d e n t i c a l
in the U.S. and Europe.
Of the 20 most-prescribed drugs i n 1991,
15 are priced highest i n Europe, Canada or Japan.
According to
the OECD, U.S. per capita expenditures on pharmaceuticals are
about average for an industrialized country.
With regard to developing countries;
0
Many developing countries, including Mexico u n t i l quite
recently, allow patent pirates to freely manufacture and s e l l
patented drugs of U.S. and European companies.
u n r e a l i s t i c a l l y low prices.
This r e s u l t s i n
I n such countries, and i n any
country with an extremely low standard of l i v i n g , a company i s
faced with the choice of marketing i t s product at a concessionary
price, or denying patients i n that country the medical benefits
of the product.
These are complex issues.
My prepared statement has
considerably more d e t a i l on each of them, and on the high-tech,
internationally competitive, job-creating character of our
industry.
I urge the Task Force to read the f u l l statement.
1 s h a l l be pleased to answer your questions.
�GENERIC PHARMACEUTICAL INDUSTRY ASSOCIATION
REPRESENTS:
The Generic Pharmaceutical Industry A s s o c i a t i o n
(GPIA), composed o f the leading U.S. manufacturers
of generic p r e s c r i p t i o n drugs, was e s t a b l i s h e d i n
1981 t o f o s t e r knowledge o f the s a f e t y , e f f i c a c y ,
equivalency and q u a l i t y o f generic drugs and t o
promote t h e i r increased acceptance and use.
TODAY'S SPEAKER:
Dee Fensterer, President
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Influence a t both the n a t i o n a l and s t a t e l e v e l s , but
do not come close t o matching t h a t o f the name brand
manufacturers.
Open but
undecided.
The Association supports the f o l l o w i n g p r i n c i p l e s
f o r h e a l t h care reform, u n i v e r s a l access and
expansion o f Medicare t o include o u t p a t i e n t drug
benefits.
To c o n t r o l costs, t r u e competition should be
returned t o the pharmaceutical marketplace through
the establishment o f a s i n g l e reimbursement p r i c e
f o r multi-source drugs and establishment o f a
n a t i o n a l open formulary f o r multi-source products.
They argue t h a t they are not c o n t r i b u t i n g t o drug
p r i c e i n f l a t i o n . The generic i n d u s t r y i s already
cost-competitive and should not be burdened w i t h
rebates s i m i l a r t o those imposed on the high p r i c e d
innovator products. Their primary request i s t o
insure t h a t they be t r e a t e d d i f f e r e n t l y than t h e
name brand manufacturers.
T h e o r e t i c a l l y , they should support p r i c e c o n t r o l s ,
because they would not lose as s u b s t a n t i a l l y as the
commercial manufacturers, but they have y e t t o take
this position.
Reform Medicaid law t o e l i m i n a t e mandatory rebate
p r o v i s i o n , which they argue u n f a i r l y h i t s them
because they do not have p r o f i t margins.
POSITION ON
PLAN:
Wait and see
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n and Public L i a i s o n
PET ISSUES:
Drug p r i c i n g and p r e s c r i p t i o n b e n e f i t s
HOT BUTTON ISSUES:
Treating them the same as the name brand i n d u s t r y .
�Generic Pharmaceutical Industry Association
Representative
Dee Fensterer
President
Dee Fensterer j o i n e d t h i s association a t the time of i t s founding
and became president i n 1985. Her previous background includes
campaign p o l i t i c s , business management and government service.
I n the mid-1970s, f o r example she worked w i t h the New York State
Assembly committee t h a t produced the f i r s t formulary o f
interchangeable drugs, and then assisted other states i n enacting
drug product s e l e c t i o n laws.
�RCV BY:
; 3-25-S3 ;iQ:52AM \
9-
SUMMARY STATEMENT
OF
DEE FENSTERER, PRESIDENT
GENERIC PHARMACEUTICAL INDUSTRY ASSOCIATION
BEFORE THE
HEALTH CARE TASK FORCE
MARCH 29, 1993 PUBLIC HEARING
GEORGE WASHINGTON UNIVERSITY
SOCIAL OFFICE!* 2
�RCV BY:
; 3-25-93 ;10'.52AM :
9-
SOCIAL OFFICE:* 3
Generic pharmaceutical companies s e l l t h e i r products i n
a f i e r c e l y competitive marketplace, which i s e n t i r e l y d i f f e r e n t
from the market f o r brand-name drugs.
A soon-to-be-released
study
shows, f o r example, t h a t the 1988 wholesale p r i c e f o r 100 t a b l e t s
of I n d e r a l (80 mg) was $37.97, while the generic version cost $4.00.
By 1992, the p r i c e of the brand had increased 51 percent t o $57.36,
while the p r i c e of the generic had decreased 54 percent t o $1.84,
The dynamics of these p r i c e d i f f e r e n c e s i l l u s t r a t e t h a t
there are r e a l l y two pharmaceutical i n d u s t r i e s i n the United States.
Both make products c e r t i f i e d by the f e d e r a l goverment as safe,
e f f e c t i v e and medically equivalent t o one another.
But i t i s only
the generic i n d u s t r y t h a t has engaged i n t r u e competition.
To take advantage of generic competition, the United States
must do one simple t h i n g :
Stop reimbursing two pharmaceutical
i n d u s t r i e s f o r the same product a t two d i f f e r e n t p r i c e levels,.
Instead, any pharmaceutical b e n e f i t f o r Americans needs t o f o s t e r
competition by s e t t i n g a s i n g l e reimbursement p r i c e f o r each m u l t i p l e
source product.
Single-price reimbursement i s i n c r e a s i n g l y used i n p r i v a t e
sector programs.
I n c o n t r a s t , Medicaid's t w o - t i e r reimbursement
system has been c a l l e d the only p r e s c r i p t i o n drug coverage program
i n the country t h a t provides an i n c e n t i v e t o dispense higher cost,
brand multisource drugs.
reimburses pharmacists
Using the I n d e r a l example. Medicaid now
$67,36 f o r 100 t a b l e t s , but pays them only
$2.33 f o r the generic version, p r o p r a n o l o l .
�RCV 3Y:
I 3-25-93 ;10:53AM ;
9-»
When competition works, i t should be nurtured.
SOCIAL OFFICE\* 4
For example,
the establishment of a n a t i o n a l open formulary f o r multisource drugs
would increase competition w i t h i n therapeutic classes, reducing the
average cost of each therapy occasion.
I n addition, disincentives
and unnecessary p r i c e r e s t r a i n t s must be removed.
Mandatory rebates,
as an example, are having the most negative e f f e c t on the most
competitively-priced generic products, d r i v i n g them out of the
marketplace.
F i n a l l y , there must be some n a t i o n a l standards that pre-empt
ad hoc and c o n f l i c t i n g s t a t e a c t i o n s , which i n t e r f e r e w i t h e f f e c t i v e
marketplace forces and thereby reduce, rather than n u r t u r e , p r i c e
competition.
A n a t i o n a l p o l i c y which provides a s i n g l e competitive
environment f o r pharmaceuticals w i l l ensure p r e d i c t a b l e cost
containment.
I w i l l be happy t o respond t o any questions you may have.
�NATIONAL ASSOCIATION OF RETAIL DRUGGISTS
MEMBERS:
Represent t h e economic i n t e r e s t s o f d r u g s t o r e
owners ( e i t h e r i n d i v i d u a l owners o r c o r p o r a t e ) .
REPRESENTS:
40,000 independent r e t a i l pharmacies, i n c l u d i n g more
t h a n 60,000 pharmacies and employing more t h a n
112,000 community pharmacists who d i s p e n s e over two
b i l l i o n prescriptions annually.
TODAY'S SPEAKER:
Dr. Charles West, E x e c u t i v e V i c e P r e s i d e n t
SCOPE OF
INFLUENCE:
Strong grassroots, g e n e r a l l y e f f e c t i v e l o b b y i n g .
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
PET
ISSUES:
HOT BUTTON ISSUES:
S u p p o r t i v e as l o n g as t h e y can n e g o t i a t e volume
p r i c e d i s c o u n t e r i n same way as a l l o t h e r
purchasers.
Concepts fundamental t o any r e f o r m o f h e a l t h c a r e .
•Pharmacy S e r v i c e s and p r e s c r i p t i o n drugs must be
c o s t - e f f e c t i v e methods o f p r o v i d i n g q u a l i t y h e a l t h
c a r e and serves as a c o s t containment t o o l f o r
reducing o v e r a l l h e a l t h care expenditures,
• o u t p a t i e n t pharmacy s e r v i c e s b e n e f i t
•streamline administration i n t h i r d - p a r t y
p r e s c r i p t i o n drug programs
• f r e e access and c h o i c e i n pharmacy s e r v i c e s
•eliminate pharmaceutical manufacturers'
discriminatory pricing practices
•pharmaceutical p r o d u c t s i n c l u d e d i n c o r e b e n e f i t
package
•cost containment
•pharmacy s e r v i c e s b e n e f i t s
•health education benefits
Support managed c a r e w i t h open access and/or managed
competition
I r a Magaziner, OPL, and T r a n s i t i o n
Drug p r i c i n g and i n c l u s i o n o f drugs i n b e n e f i t s
package
D i s c r i m i n a t o r y p r i c i n g . Drug m a n u f a c t u r e r s
practices.
�FROM :NRRD
TO
t
2024567739
1993.03-25
01:19PM »797 P.02/04
President's Task Force on Health care Reform
I'ublic Hearing, March 29, 1993
2:45 p,m,, Panel Seven
George Washington University. Washington, D.C.
Remarks by Charles M. West, P.D.
"Why Are Prescription Drugs So Much More Expensive
in This Country Than in Other Coimtries?"
Wc do not need to look beyond our borders to ascertain why
presciption drug prices are so high for the vast majority of American
consumers. Nor do wc have to look beyond our borders to find
radically different costs for the same prescription drug products.
We would not have significantly higher prices for most American
consumers if we eliminated the unfair discriminatory pricing practices
of the nation's pharmaceutical manufacturers. These manufacturers
currently sell the same quantities of the same medications at price
differentials of 30, 50, 70, even 90 percent depending upon the type
of pharmacy that Is purchasing the products.
That the pharmacies purchasing these products at radically different
prices arc in direct competition with one another seems not to
matter. That the dramatically lower prices paid by, say, a mall order
pharmacy or an HMO are made up for in the highest prices being
charged to cominunity retail pharmacies where most Americans buy
their prescription medications - also appears to be of litUe
consequence.
We agree with House Judiciary Chairman Jack Brooks' characterization
of these multiUcr drug pricing practices as "bogus classes of trade,"
devised by the pharmaceutical manufacturers to conceal illegal price
discrimination in the pharmaceutical marketplace — price
discrimination that has its most profound adverse impact upon the
mnjority of Americans who purchase their medications in community
retail pharmacies.
As pharmaceutical prices have continued to escalate for more than a
decade, gross margins in the nation's community retail pharmacies
have continued to shrink, reaching an all-time low of 28 percent in
1992. Of the average $26.00 prescription price, only 50 cents, or 2
percent, is profit for the pharmacy - barely enough to stay in business.
The community retail pharmacist is clearly not responsible for rising
prescription drug prices. Manufacturers are, and it is their
discriminatory pricing practices that are driving up the prices paid by
community retail pharmacies and. in turn, by the majority of
Americans.
�FROM :NORD
TO
:
2024567739
1993,03-25
01:19PM »797 P.03/04
West remarks/2
Let's take a brief look at discriminatory pricing in action. Typical is a
September 1991 invoice for nearly 500 prescription medications paid
by Prucare. a buying group for hospital pharmacies in the Southeast.
On average, the prices paid by Prucare were 59 percent lower that the
wholesale prices paid for the same products by community retail
pharmacies. Selected popular products were priced at as much as 90
percent below the average community retail pharmacy wholesale
price.
Let mc emphasize again that the prices paid by these select
purchasers -- hospitals, mail order pharmacies, llMOs. nursing homes,
clinics, and others -- are noi based on volume or economies of scale.
Ijsi me also make clear that these lower prices are nol being passed
on to the consumers, or the payors, in these settings.
What is the net impact of these discriminatory pricing practices? The
lower the price offered to these retail pharmacy competitors, the
higher the manufacturer's increase In price will be to the community
retail pharmacy. That is not only seriously hurting ihe pockctbooks of
American consumers, it is causing alarming numbers of seniors and
others to go without much needed prescription medication, simply
because they cannot afford it.
To add insult to Injury and further assure that community retail
pharmacy customers pay the highest prices, brand-name
manufacturers steadfastly refuse to extend even economies of scale to
community retail pharmacy buying groups. At every turn, our buying
groups have been turned down by manufacturers when trying to
purchase brand-name prescription drug products.
So, again, we needn't look to Canada, to the European Community, or
to Mexico to sec unjustifiable, radical differences in the costs of
prescription drugs. These multitier prices are the principal cause of
higher prices to community retail pharmacies and to most American
consumers.
If fair pricing practices were established — for example, by adopting
the current average manufacturer's price as ths. price for the product,
subject only to legitimate economies of scale, i.e., volume purchases —
the bulk of American consumers would realize significant savings in
the cost of their community retail pharmacy services.
Turther, by requiring manufacturers to give community retail
pharmacy buying groups access to economics of scale in their
prescription drug purchases, competition would be enhanced and
consumers would benefit.
�FROM :NRRD
TO
:
202456773'9
1993,03-25
01:20PM 8797 P. 04/04
West remarks/S
Given tiie present condition of our marketplace, it is certainly
understandable why the Community Retail Pharmacy Health Care
Reform Coalition, which represents all pharmacies and pharmacists
practicing In outpatient settings, has included as one of its four
principles essential to health care reform the elimination of
discriminatory pricing practices by pharmaceutical manufacturers.
Discriminatory pricing practices are driving community retail
pharmacists out of business. They are promoting the proliferation of
remote, inaccessible, monopolistic systems that do nothing more than
distribute products, depriving consumers of the pcrsonallised,
professional, cost-effective care they have come to expect from their
neighborhood pharmacist.
But health care is personal. If it is to remain so, we must ensure that
consumers continue to have access to their community retail
pharmacist the most accessible member of the health care team in
every neighborhood in this country. To ensure that access and to
contain the rising price of prescription drugs, the discriminatory
tricing practices of the nation's pharmaceutical manufacturers must
je eliminated.
Thank you.
�INDUSTRIAL BIOTECHNOLOGY ASSOCIATION
MEMBERS:
Three o u t o f f o u r b i o t e c h companies have fewer than
50 employees, and 990 o u t o f 100 have fewer t h a n 300
employees. Most f i r m s are l e s s t h a n t e n y e a r s o l d .
REPRESENTS:
More than 150 companies ( s m a l l and e n t r e p r e n e u r i a l
f i r m s ) t h a t are r e s p o n s i b l e f o r more t h a n 85 percent
o f t h e s a l e s , revenues and r e s e a r c h and development
expenditures i n the biotechnology i n d u s t r y .
TODAY'S SPEAKER:
G. K i r k Raab, Board o f D i r e c t o r s
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
The 1 o f 2 a s s o c i a t i o n s f o r t h e b i o t e c h community.
T h e i r i n f l u e n c e i s growing, b u t s t i l l young. Plans
are t o merge w i t h t h e A s s o c i a t i o n f o r B i o t e c h n o l o g y
Companies t h i s summer w i l l add even more. Not much
on advocacy, b u t c o u l d r a l l y w i t h t h e r i g h t i s s u e .
S u p p o r t i v e as l o n g as new d r u g p r o d u c t s are n o t
s u b j e c t e d t o government p r i c e r e v i e w r e g u l a t i o n .
The p r i m a r y c r i t e r i a f o r t h e IBA i s s t r o n g d r u g
b e n e f i t package ( i n c l u d i n g m e d i c a t i o n , p r e v e n t i o n ,
i m m u n i z a t i o n ) , o u t p a t i e n t drugs, c o s t c o n t a i n m e n t
f o r o v e r a l l h e a l t h c a r e c o s t s , and HIPCS.
IBA says r e g u l a t i n g drug p r i c e s won't be enough.
Any r e g u l a t i o n w i l l n o t o n l y c o n s t r i c t b u t may
eliminate biotech industry.
Under a managed c o m p e t i t i o n system c o u l d succeed a t
keeping t h e p r i c e o f drugs f a i r l y low, e x c e p t f o r
new drugs o r c u r r e n t drugs f o r w h i c h t h e r e i s no
t h e r a p e u t i c a l t e r n a t i v e s , and t h e n t h e IBA would be
hurt i n this e f f o r t .
W i l l i n g t o negotiate plan, t o l i m i t f u t u r e p r i c e
i n c r e a s e s i n exchange f o r t h e r i g h t t o c o n t i n u e t o
set i n t r o d u c t o r y prices.
POSITION ON
PLAN:
Wait and see. J u s t nervous.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n and OPL
PET
Drug development
ISSUES:
HOT BUTTON ISSUES:
P r i c e c o n t r o l s on new drugs, e x p a n s i o n o f t h e
c u r r e n t medicaid r e b a t e program, t h e r a p e u t i c
s u b s t i t u t i o n , and g l o b a l b u d g e t i n g .
�I n d u s t r i a l Biotechnology Association
Representative
G. K i r k Raab
P r e s i d e n t and Chief E x e c u t i v e O f f i c e r
Genentech, I n c .
K i r k Raab j o i n e d Genentech i n February 1985 as p r e s i d e n t ,
c h i e f o p e r a t i n g o f f i c e r and a d i r e c t o r . He became p r e s i d e n t and
c h i e f e x e c u t i v e o f f i c e r i n February 1990. P r i o r t o j o i n i n g
Genentech, Mr. Raab worked f o r Abbott L a b o r a t o r i e s f o r 10 y e a r s ,
most r e c e n t l y as p r e s i d e n t , c h i e f o p e r a t i n g o f f i c e r , and a
d i r e c t o r . P r i o r t o t h a t appointment i n J u l y 1981, he was
c o r p o r a t e e x e c u t i v e v i c e p r e s i d e n t , f o l l o w i n g p o s i t i o n s as v i c e
p r e s i d e n t , i n t e r n a t i o n a l o p e r a t i o n s and v i c e p r e s i d e n t , L a t i n
America. I n a d d i t i o n , Mr. Raab l i v e d i n L a t i n America f o r 11
y e a r s and h e l d p r e v i o u s management and m a r k e t i n g p o s i t i o n s a t
P f i z e r , A.H. Robbins, and Beecham.
He serves on t h e Board o f Overseers f o r t h e U n i v e r s i t y o f
C a l i f o r n i a a t San F r a n c i s c o , and i s a t r u s t e e o f t h e San
F r a n c i s c o B a l l e t . He i s a l s o a member o f t h e Board o f D i r e c t o r s
o f t h e I n d u s t r i a l B i o t e c h n o l o g y A s s o c i a t i o n , Cholestec, I n c . and
Oclassen P h a r m a c e u t i c a l s , I n c . Mr. Raab has a b a c h e l o r ' s degree
from C o l g a t e U n i v e r s i t y , i n Hamilton, New York, where he i s a
member o f t h e Board o f T r u s t e e s .
�MAR-25-1993 12:03 FROM
IBP
TQ
4566241
P.02
ORAL STATEMENT OF G . KIRK RAAB, C E O OF GENENTECH INC.,
ON BEHALF OF THE INDUSTRIAL BIOTECHNOLOGY ASSOCIATION AND THE
ASSOCIATION OF BIOTECHNOLOGY COMPANIES
BEFORE THE PRESIDENT'S HEALTH CARE TASK FORCE
The U.S. biotechnology industry is one of the strengths of our present health care
system. The products developed by our industry have brought relief for previously untreatable
diseases, have proven cost-effective, and have improved the quality of life for millions of
Americans. We are proud of these achievements and excited about future opportunities for
even more dramatic advances.
! want to make three points today. The first concerns pricing. Madame Chairperson,
progress in the biotechnology industry has not come to American consumers at prices which
are demonstrably higher than prices to consumers in other countries. The answer to your
question ~ "Why are prescription drugs so much more expensive in this country than in other
countries?" -- is that biotech drugs are not more expensive in this country than in other
countries. Most biopharmaceuticals are priced for sate in the United States at or below the
government-set price in most other industrialized nations around the world.
In Japan,
biotechnology products are priced up to three times higher than they are in this country.
Let me cite some examples. G-CSF is an Amgen product used to stimulate white blood
cell production in chemotherapy and bone marrow transplant patients.
Three hundred
milligrams of G-CSF sells for $112 in the U.S. and $101 in Canada. The average European
price is $1 n , with a high of $143 in France and a low of $88 in Italy. In Japan, G-CSF sells
for $378.
Another product, EPO, used to treat anemia associated with severe kidney disease,
sells for $40 per 4.000 unit vial in the U.S. In Canada, the drug sells for $43. In Europe, it
sells for an average of $57, with a high of $61 in Belguim and a low of $50 in Italy. In Japan,
a vial of EPO sells for $99.
Derek Hodel of the AIDS Action Council here in Washington D.C. testified recently
about international pricing of primary AIDS drugs like AZT and ddl. At Senator Pryor's
February 24th hearing this year on the federal government's support of new drug research.
�fttR-25-i993
12 •••09
FROM
IBfl
TO
4566241
P. 03
Mr. Hodel volunteered. In response to a question posed to another panel of witnesses, that
these AIDS products are priced consistently in the U.S. and in other countries.
My second point concerns price restraint. The biotechnology industry is committed
to achieving profitability through innovation, and not through inflation of existing drug prices.
Virtually all of the twenty-two biopharmaceuticals on the market are selling for the same price
today as they were on the day of FDA approval, which, in one case, was as long as a decade
ago. Our industry is committed to continuing voluntary price restraints in the future.
Our industry is prepared to support federal action which creates strong incentives to
limit future price increases in exchange for the right to continue to set introductory prices in
accordance with the need to provide equity investment in our industry.
My third and final point is critical to the future of the U.S. biotechnology industry. We
believe that government-imposed controls on introductory drug prices would strangle
investment in our companies. The fear that price controls may be imposed has already
reduced our industry's market capitalization by 4 0 % since November.
While established pharmaceutical companies have access to working capital from
profits on existing product lines, the vast majority of biotech firms do not have a stream of
product revenues from which to finance their research. Instead, biotech companies rely on
equity financing to obtain the capital needed for R&D. If introductory prices are controlled by
the government, investors will continue to redirect their money into other sectors of the
economy with more promising rewards. Without their support, the biotechnology industry will
become financially incapable of fulfilling its potential to help millions of critically ill patients.
I want to conclude with a few words on the strength of the U.S. biotechnology
industry. Biotech companies do not develop slightly improved versions of existing products
and we do not make "me too" drugs. We attempt, through our research and development
programs, to redefine the treatment and prognosis for critically ill patients with severe
diseases for which there are no cures. Continuing investment is critical for our industry to
maintain this commitment to research and development, which accounts for 3 8 % of all costs
incurred by biotechnology companies.
�MAR-25-i993
12:09 FROM
T
IBP
0
4566241
P.04
These figures are unmatched by any other industry in the world, and we believe that
they are a perquisite to making meaningful therapeutic progress against intractable and
debilitating diseases. But progress comes at a cost; the industry lost $3.4 billion last year,
and at least $9 billion since its inception.
investing in a biotech company is risky. Substantial scientific, manufacturing, and
regulatory hurdles must be overcome before a new product can be marketed. Experimental
therapies fall by the wayside, sometimes accompanied by their corporate sponsors. Very few
firms have achieved profitability, and a substantial number have folded, merged, or been taken
over. In light of this already risky investment environment, the continuing capital needs of
biotechnology companies can only be met if investors can foresee a return commensurate
with the risks involved in biopharmaceutical development.
Madame Chairperson, thank you for the opportunity to testify here.
The U.S.
biotechnology industry looks forward to working with this Administration to secure better
health care for all Americans.
# ##
Industrial BiotechnoloQv Association/Association of Biotechnology Companies
The Industrial Biotechnology Association (IBA) represents 150 companies that are responsible
for more than 85 percent of the sales, revenues, and research and development expenditures in the
U.S. biotechnology industry. The Association of Biotechnology Companies (ABC) represents 350
members from 27 countries, including biotechnology companies, state and academic biotechnology
research centers, non-profit and government affiliated entities, and other organizations interested in
biotechnology.
ISA and ABC have announced an agreement in principle to merge this year on July 1 of this
year. Our combined association will be called the Biotechnology Industry Organization (BIO) and will
represent over 90% of U.S. investment in biotechnology.
G. Kirk Raab, President and Chiqf Executive O K ^ r . Genantech Inc. (S. San Francisco. CA)
Kirk Raab joined Genentech in February 1985 as president, chief operating officer and a
director. He became president and chief executive officer in February 1990. Prior to joining
Genentech Mr. Raab worked for Abbott Laboratories for 10 years, most recently as president, chief
marketing positions at Pfizer, A.H. Robbins, and Beecham.
S
ve
o n
t h e
l* !i l t
Boa^ of Overseers for the University of California at San Francisco, and is
BiS^o^A«^2 )S rh 1 !- ^
, ^?
industrial
S S S ^ S L i f 9 ? ?
' . c . and Oclassen Pharmaceuticals, Inc. Mr. Raab has a
Sf TmstMs
University, m Hamilton, New York, where he is a member of the Board
a
!
S C
B
h
9
e
9
, t e
t
e
, S a l S o
c
I n
a
m b e r
o f t h e
o f
D i r e c t o r s
o f t h e
�AMERICAN PHARMACEUTICAL ASSOCIATION
MEMBERS:
APhA r e p r e s e n t s more t h a n 195,000 pharmacy
p r a c t i t i o n e r s , s c i e n t i s t s , and pharmacy s t u d e n t s .
REPRESENTS:
The i n t e r e s t s o f p r o f e s s i o n a l p h a r m a c i s t s i n
academic s e t t i n g s , i n pharmacies, and i n
i n s t i t u t i o n a l s e t t i n g s such as h o s p i t a l s and n u r s i n g
homes.
TODAY'S SPEAKER:
John A. Gans, Pharm.D.
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
The t h i r d o f t h e t h r e e most i n f l u e n t i a l pharmacy
groups on C a p i t o l H i l l — ( t h e N a t i o n a l A s s o c i a t i o n
o f R e t a i l D r u g g i s t s and t h e N a t i o n a l A s s o c i a t i o n o f
Chain Drug Stores a r e t h e o t h e r t w o ) .
Has n o t t a k e n a p o s i t i o n on n a t i o n a l r e f o r m ; focuses
p r i m a r i l y on p h a r m a c e u t i c a l and pharmacy i s s u e s .
Strong s u p p o r t e r t h a t p r e s c r i p t i o n d r u g coverage be
i n c l u d e d i n t h e b a s i c h e a l t h c a r e package.
S i m i l a r l y s u p p o r t i v e o f a Medicare Rx d r u g b e n e f i t .
Wants Rx drug coverage t o pay f o r t h e p r o f e s s i o n a l
p a t i e n t c o u n s e l i n g done by p h a r m a c i s t s .
Believe
t h a t such u t i l i z a t i o n r e v i e w s e r v i c e s a r e e x t r e m e l y
cost e f f e c t i v e .
POSITION ON
PLAN:
W i l l l i k e l y support t h e p l a n u n l e s s t h e above
mentioned h i g h p r i o r i t i e s a r e l e f t unaddressed.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n and P u b l i c L i a i s o n
PET
Pharmacy c o u n s e l i n g and drug u t i l i z a t i o n
ISSUES:
review.
�American Pharmaceutical Association
Representative
John A. Gans, Pharm.D.
Executive Vice-President and Chief Executive Officer
John A. Gans was selected as t h e Executive Vice-President
and Chief Executive O f f i c e r o f the American Pharmaceutical
Association i n May 1989. since 1969, he has been p r o f e s s i o n a l l y
a f f i l i a t e d w i t h t h e P h i l a d e l p h i a College o f Pharmacy and Science
where he earned h i s pharmacy degree i n 1966 and h i s doctorate i n
pharmacy i n 1969. From 1988 u n t i l h i s appointment t o APhA, Dr.
Gans served as t h e Dean o f t h e School o f Pharmacy. Dr. Gans
began h i s career as a community pharmacist i n Broomall, PA and
from 1974 t o 1985, was t h e Managing D i r e c t o r o f Pharmaservices, a
consultant f i r m t o nursing homes. During 1967-68, Dr. Gans
served a residency a t t h e Hospital o f the U n i v e r s i t y o f
Pennsylvania.
Dr. Gans served as t h e Chairman o f the Delaware V a l l e y
Regional Poison Control Program. I n 1980-81, he served as
President o f t h e Pennsylvania Society o f Hospital Pharmacists
and, i n 1986-87, as President o f the American Society o f Hospital
Pharmacists.
�MAR-25-93 THU 19:38
AM PHARtl ASSOC
FAX NO. 202 783 2351
P. 03
DRAFT
Testimony of Dr, John Gans, Executive Vice President
American Pharmaceutical Association
before the
Health Care Task Force
March 29, 1993
I am Dr John Gans, Executive Vice President of the American Pharmaceutical Association the
national professional society representing pharmacists in all practice settings. I am pleased to
address the question posed to this panel regarding the expense of prescnpbon drugs in the United
States. We recognize that the problem of escalating drug prices is a senous problem for the
American public.
As the Task Force members are acutely aware, there are a number of factors which must be
considered when contrasting the economics of health care in the U.S. and other countries.
Government control of prices, and specifically pharmaceutical prices, is the norm outside of this
country While I am not an expert on the pricing practices of multinational companies or
foreign governments, I do recognize that there is a complex relationship between industry pricing
strategies, government regulation, corporate profitability and the investment of the industry in
research and innovation.
The pharmacist, when properly utilized, can provide solutions to the nation's problems of cost,
access and quality of care. I speak to the issue of the pharmacist's responsibility for patient
health outcomes through education and drug therapy management. To become more effective,
pharmacists must be allowed to move away from their traditional role which saw them primanly
as dispensers of drug products and into their rightful position as a full-fledged partner with
patients and prescribers in the provision of primary health care services. This will require
access to patient information and changes in pricing and payment models for pharmaceuticals
and pharmacists' services.
It is important to emphasize the fact that pharmaceuticals and the services provided by
pharmacists are among the most cost effective components of health care available. There is
evidence, however, that the public is not realizing the full potential, benefit from these resources.
Prescription medicines successfully treat major acute and chronic diseases and prevent
unnecessary physicians' visits, hospitalizations, surgeries and long-term care. When properly
used, they save far more than the 7% of health care costs and 1/2% of the GNP that they cost.
Although medication use has assumed a primary role in health care, its provision is often
uncoordinated and highly fragmented. One result is that medication-related problems impact a
portion of the 1.6 billion prescriptions that are written and filled each year, It has been estimated
that $36 billion could be saved annually by improving patient compliance, reducing inappropriate
drug use and medication-induced illnesses and hospitalizations, and decreasing preventable
adverse effects and interactions. This represents about 4% of America's health care bill that
�M-25-93 THU 19:39
AN PHARH ASSOC
FAX NO. 202 783 2351
P. 04
could be saved through pharmaceutical care.
Health Care Task Force
March 29, 1993
page 2
The federal government recognized this fact in the passage of the Omnibus Budget Reconciliation
Act of 1990, relevant provisions of which became effective on January 1st of this year. This
legislation mandated pharmacists' counseling services and prospective drug utilization review for
patients covered by the Medicaid program.
Many pharmacists have adopted counseling and drug use review as their standard of practice for
all patients even prior to the implementation of OBRA '90. Others have moved even further by
providing primary care services which seek to insure the most cost-effective, high quality health
care for patients. This level of service is called "pharmaceutical care.
H
There are obstacles in the current health care system that prevent pharmacists from delivering
this level of care to all patients who could benefitfromit. One obstacle is access to the
relevant, patient-specific information that is needed to provide the quality assurance activities
so integral to pharmaceutical care.
The ether obstacle relates directly to the costs of pharmaceuticals. Many citizens do not have
insurance coverage for outpatient drug therapy and often face a difficult financial burden in
assuring that their medication needs are met. This is further complicated by the pricing practices
of pharmaceutical manufacturers and the payment methodologies currently used by most insurers
and third-party programs.
Pricing practices and payment systems of manufacturers, insurers and other payors currently do
not reward equally quality providers, efficient purchasers and economies of scale. Instead, anticompetitive marketing practices arbitrarily shift costs from one market segment to another.
Hence, those without coverage often pay significantly more for their medications than they
would if more equitable systems of pricing and payment were marketplace norms.
Time does not allow me to provide additional details, however we are prepared to share specific
concepts of pharmacy benefit design which correct certain problems in the existing marketplace.
I will leave you again with a commitment that the nation's 195,000 pharmacists are prepared to
provide solutions to those health care problems of cost, access and quality your task force has
been asked to address. The American Pharmaceutical Association looks forward to working
with you.
�HAR-25-93 THU 19:37
AM PHARM ASSOC
FAX NO. 202 783 2351
P, 02
American Pharmaceutical Association
The American Pharmaceutical Association (APhA) is the national professional society of
pharmacists in the United States. APhA represents the third largest health profession, composed
of more than 195,000 pharmacy practitioners, scientists and pharmacy students. Since its
founding in 1852, APhA has been a leader in the professional and scientific advancement of
pharmacy, and in safeguarding the well-being of the individual patient.
APhA seeks to advance its members' abilities to provide primary health care semces to the
public through education and advocacy. Further, it seeks to enhance the public's recognition
that optimal drug use can only be achieved through the appropriate application of the
pharmacists' sophisticated knowledge of drug therapy and skills as a pharmaceutical care
provider.
The American Pharmaceutical Association is located at 2215 Constitution Avenue, NW,
Washington, DC 20037. Contact WilUam Hermelin, Director of Government Affairs or Lucinda
Maine, Senior Director for Pharmacy Affairs for additional information by calling (202) 4297514.
Biographical Summary
John A. Gans, Pharm.D.
John A. Gans was selected as the Executive Vice-President and Chief Executive Officer of the
American Pharmaceutical Association in May 1989. Since 1969, he has been professionally
affiliated with the Philadelphia College of Pharmacy and Science, where he earned his pharmacy
degree in 1966 and his doctorate in pharmacy in 1969. From 1988 until his appointment to
APhA, Dr. Gans served as the Dean of the School of Pharmacy. Dr. Gans began his career as
a community pharmacist in Broomall, PA, and from 1974 to 1985, was the Managing Director
of Pharmaservices, a consultant firm to nursing homes. During 1967-68, Dr. Gans served a
residency at the Hospital of the University of Pennsylvania.
Dr. Gans served as the Chairman of the Delaware Valley Regional Poison Control Program.
In 1980-81, he served as President of the Pennsylvania Society of Hospital Pharmacists and, in
1986-87, as President of the American Society of Hospital Pharmacists.
�NATIONAL ASSOCIATION FOR HOME CARE
5,000 home care providers and the individuals
they s e r v i f j ^ j ^ ;
MEMBERS:
REPRESENTS t
The NAHC represents home health agencies,
home care a i d organization^ and hospics i n
-t^aH 50 states. They are committed to
assuring the a v a i l a b i l i t y of human, costeffective, high-quality home c a r e .
TODAY'S SPEAKERSt
SCOPE OF
INFLUENCEX
Sophisticated lobbying e f f o r t s a t the Federal
and state levels on home health care.
APPROACH TO
REFORM:
Advocates of a national plan <
SUMMARY OF
POSITION:
The NAHC supports a comprehensive federal
health care program that guarantees universal
access and coverage of long-term care as an
integral part of the package.
NAHC i s supportive of home care and hospice
as the best way to reduce costs and increase
health care i n both acute and long term care
settings; access i s based on need and not
age; provider participation; safeguards for
quality assurance^Cost containment; and,
financing must be progressive and broadly based.
[
POSITION ON
PLAN:
wait and see
INTERACTION W/
TASK FORCE AND
WORKING GROUPS t
Transition and Public Liaison
PET ISSUES:
Long term care and acute care basic benefit
package
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
\ X
�^
^
3:40--
THE VICE PRESIDENT RETURNS AND PRESIDES
[SECRETARY SHALALA PRESIDES AS THE VICE PRESIDENT
RETURNS.]
PANEL EIGHT—HOSPITALS—TESTIMONY BEGINS
We are going to hear from some of the hospital concerns, who will be talking to us
about: "Why do some hospitals charge $5 for an aspirin and $35 for a towel and what can we
do about this problem?" Ourfirstwitaess is David Davidson, President of the American
Hospital Association.
�PANEL 8: 3:40 - 4:40
Hospitals
Dick Davidson
President
American Hospital Association
Michael Bromberg
Executive Director
Federation of American Health Systems
Jerry Dykman
C 9 (^£
- MArt
Executive Vice President
American Protestant Health Association
Sister Bemice Coreil
Senior Vice President
Catholic Health Association
Lawrence A. McAndrews
President
National Association of Children's Hospitals
�AMERICAN HOSPITAL ASSOCIATION
MEMBERS:
5,300 h o s p i t a l s
REPRESENTS:
Umbrella organization f o r h o s p i t a l s o f a l l sizes and
ownership types nationwide.
I t i s the largest
h o s p i t a l trade association i n the country.
TODAY'S SPEAKER:
Dick Davidson, President
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
I n d i v i d u a l h o s p i t a l s are major employers and
therefore have s u b s t a n t i a l i n f l u e n c e i n d i s t r i c t s .
Support the development o f h e a l t h care networks
based around h o s p i t a l s .
Coverage through a core b e n e f i t package i n a pay-orplay system. Delivery reform through community care
networks s i m i l a r t o managed care. Concerned t h a t
managed competition w i l l d r i v e h o s p i t a l s t o be the
lowest p r i c e vendor and t h r e a t e n t h e i r mission
o r i e n t a t i o n . Do not support a g l o b a l budget b u t
might support a "bottom up" budget through
c a p i t a t i o n o f payments. Advocate a n t i t r u s t reforms
t o permit easier c o o r d i n a t i o n / c o l l a b o r a t i o n between
hospitals.
Their plan i s s i m i l a r i n many ways t o A d m i n i s t r a t i o n
plan. Very nervous, wait and
see.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n , OPL, I r a Magaziner
PET ISSUE:
Universal access
HOT BUTTON ISSUES:
Cost c o n t r o l s which s h i f t costs
�1
; 3-23-93 ;1:44AM
RCV BY:
202 625 2345-
SOCIAL OFFICE'.* 3
Cipitcl Ptacc.Building*3
50 F Sreei. N.W
SuitcllOO
Washington.DC. 20001
Tekphone 202 638-1! 00
FAX NO. 202 626-2345
RICHARD J« DAVID8QN
RicharcL J. Davidson, 56, i s president o f the American Hospital
Association.
He assumed the AHA presidency i n 1991 a f t e r
serving f o r 22 years as president of the Maryland H o s p i t a l
Association, L u t h e r v i l l e .
Davidson i s a c t i v e l y involved w i t h many l o c a l , s t a t e , and
n a t i o n a l h e a l t h care p o l i c y committees, and he has served as a
consultant t o the Robert Wood Johnson Foundation and the Pew
Memorial Trust. A popular speaker and w r i t e r , he serves on the
e d i t o r i a l boards of numerous journals and p e r i o d i c a l s and has
appeared on many AHA programs,
Davidson also has served on numerous AHA special committees,
advisory panels, and commissions, i n c l u d i n g t h e Special
Committee on A l t e r n a t i v e s t o DRG-Based Prospective P r i c i n g
(1986-87), the New D i r e c t i o n s and I n i t i a t i v e s committee on
Membership and S t r u c t u r e (1986-87), and the Center f o r Nursing
Advisory Board (1989-90).
Before j o i n i n g t h e Maryland Hospital Association i n 1969,
Davidson was d i r e c t o r of education f o r the Maryland-D.C.Delaware H o s p i t a l A s s o c i a t i o n and was a secondary school teacher
and p r i n c i p a l .
Ke holds a bachelor's degree i n secondary education from West
Chester (PA) State College; a master's degree i n education from
Temple U n i v e r s i t y , P h i l a d e l p h i a ; and a doctorate i n education
from George Washington U n i v e r s i t y , Washington, DC.
10/92
�MAR 25 '93
01:21PM AMERICRN HOSP. ASSOC
P. 1/4
Anwrto*" Hotptttl AModMton
m
Capitol Place, Building 03
SO F Street, N.W.
Suite 1100
Wariiington, D.C. 20001
Telephone 202.638-1100
FAX NO. 202.626-2345
Statement
of the
American Hospital Association
before the
President's TasX Force on National Health Care Reform
March 29, 1993
Madam Chairman, I am Dick Davidson, President of the American
Hospital Association representing 5,300 health care i n s t i t u t i o n s
across America.
I have four thoughts I want you t o leave t h i s room
with today.
F i r s t , hospitals strongly support and are working f o r radical
change i n the status quo i n health care i n t h i s country. The
problems are too big to be solved by simple tinkering.
That's why
we want r e a l , community-based restructuring of the health delivery
and financing non-system we have today.
Second, the radical change hospitals support i s the development of
3
Community Care Networks ".
Community care networks have three
d i s t i n c t characteristics: collaboration, capitation, and community
focus on health.
�MAR 25 '93 01:22PM AMERICAN HOSP. ASSOC
P.2/4
-2Our idea for community care networks is' consistent with the local
health networks the President talked about in the campaign.
As we see them, community care networks are consortia of hospitals,
physicians,
other
providers
and
community groups,
and
others
l o c a l l y organized and managed.
These community care networks would provide a package of essential
health services for a set annual payment per person and be publicly
accountable for community health needs. The goals: coordinate care
throughout
a
community,
keep
people
well,
and
get
r i d of
unnecessary care or duplicate s e r v i c e s .
Third, community care networks are the solution to the problems in
the
health
care
system
that
highlighting around the country
you
have
been
so
effectively
over the past few weeks: high
costs, concern about quality, and consumer s a t i s f a c t i o n .
I f we are concerned about putting patients f i r s t , about having a
t r u l y patient centered health care delivery system, our approach
does that.
As enrollees i n community care networks, patients enter a seamless
system of care.
They w i l l no
longer have to wander unguided
through a fragmented system, but w i l l have a single entry point for
a l l needed services.
�MRR 25 '93 01:22PM AMERICAN HOSP. ASSOC
P.3/4
-3-
Everybody i s concerned about cost.
Our vision attacks rising
health care costs by encouraging collaboration among providerrs.
A set annual payment w i l l drive collaboration by aligning the
incentives of health care providers.
When providers are paid as a group, they w i l l act as a group to
monitor the use of health care resources and avoid unnecessary
care.
Over time, excess capacity and duplication of services and
technology w i l l be eliminated.
Precious resources now spent on excessive paperwork, unnecessary
competition, and the administrative demands of multiple payers can
be harnessed to improve patient care.
The job of this important task force in our view i s to include in
your reform plan incentives to speed up the kind of behavior
changes we are talking about to bring providers and communities
together with one aim: keeping people as healthy as possible and
improving the entire community's health status.
I want to emphasize one final point.
Communities and community
care networks can't alone solve the problem of the five-dollar
aspirin.
The insured patient who pays for a five-dollar aspirin
is buying aspirin for the uninsured patient who later walks in the
�mR 25 '53 01:22PM AMERICAN H05P. ASSOC
P.4/4
-4hospital door seeking care.
That i s the wrong way to provide
universal health care.
We must have a national commitment to providing
health care
coverage for a l l Americans. Anything short of that w i l l force our
health care givers to continue to levy the hidden tax that enables
them to care for those without resources.
For the record, I am submitting a f u l l explanation of AHA's vision
for reform that details how we can bring a more rational set of
incentives to our current delivery system.
Thank you for this
opportunity.
CCN.
all
I n c . *nd S4n C4.90 Cooroinity H u l t h c m
right*.
A l H . n c . urn* t h a n*m, Cgmminlty C«r« N t t « O r i t t
Xhm'r i a r v 1 c « mark and
r„.rv.
�FEDERATION OF AMERICAN HEALTH SYSTEMS
REPRESENTS:
1400 I n v e s t o r owned h o s p i t a l s and s e v e r a l
c a r e companies
TODAY'S SPEAKER:
M i c h a e l Bromberg, E x e c u t i v e D i r e c t o r
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Major campaign c o n t r i b u t o r s ,
lobbying organization.
Managed
managed
Very e f f e c t i v e
competition
Proposal would p r o v i d e u n i v e r s a l access t o coverage
t h r o u g h i n c o m e - r e l a t e d s u b s i d i e s ; cap t a x - f r e e
p o r t i o n o f employers and employees h e a l t h premiums;
c r e a t e Accountable H e a l t h Plans w h i c h cannot e x c l u d e
based on p r e - e x i s t i n g c o n d i t i o n and must community
r a t e ; and e s t a b l i s h N a t i o n a l H e a l t h Board t o s e t
s t a n d a r d b e n e f i t s package and f a c i l i t a t e h e a l t h
outcomes d a t a .
POSITION ON
PLAN:
Very wary o f c o s t and budget c o n t r o l s .
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n , I r a Magaziner, OPL
PET ISSUES:
Managed c a r e i s most p r o m i s i n g o p t i o n t o c o n t a i n
costs
HOT BUTTON ISSUES:
Budgets and p r i c e c o n t r o l s
�Federation of American Health Systems
Representative
Michael D. Bromberg, ESQ.
Executive D i r e c t o r
M i c h a e l D. Bromberg has been t h e e x e c u t i v e d i r e c t o r o f t h e
F e d e r a t i o n o f American H e a l t h Systems ( f o r m e r l y , t h e F e d e r a t i o n
o f American H o s p i t a l s ) s i n c e 1969. Echoing Mr. Bromberg's
r e p u t a t i o n as an a r t i c u l a t e and i n f l u e n t i a l h e a l t h p o l i c y
i n s i d e r . M e d i c i n e and H e a l t h ' s P e r s p e c t i v e s , a F a u l k n e r and Gray
p u b l i c a t i o n , s a i d o f him, "Among h e a l t h l o b b y i s t s , Bromberg r a t e s
highest."
C u r r e n t l y , he i s a member o f t h e N a t i o n a l H e a l t h Lawyers
A s s o c i a t i o n and a past p r e s i d e n t o f t h e group. He i s t h e a u t h o r
o f numerous a r t i c l e s about n a t i o n a l h e a l t h c a r e p o l i c y and t h e
h o s p i t a l i n d u s t r y , and has appeared on many n a t i o n a l l y b r o a d c a s t
TV programs, i n c l u d i n g t h e M a c N e i l l Lehrer Hour, The Today Show,
CBS Morning News, The C h a r l i e Rose Show, and C r o s s f i r e .
I n 1985-86, Mr. Bromberg served as a member o f t h e n a t i o n a l
A d v i s o r y Commission on C a t a s t r o p h i c I l l n e s s .
T h i s commission's
r e p o r t was t h e f o u n d a t i o n f o r l e g i s l a t i o n t o p r o t e c t e l d e r l y
p a t i e n t s a g a i n s t f i n a n c i a l r u i n from c a t a s t r o p h i c i l l n e s s e s .
P r i o r t o j o i n i n g t h e F e d e r a t i o n , Mr. Bromberg was campaign
manager and s u b s e q u e n t l y l e g i s l a t i v e and a d m i n i s t r a t i v e a s s i s t a n t
t o former U.S. R e p r e s e n t a t i v e H e r b e r t Tenzer (D-NY) from 1966 t o
1970.
An a t t o r n e y , Mr. Bromberg p r a c t i c e d as New York and
Washington Counsel f o r t h e New York law f i r m o f Tenzer,
G r e e n b l a t t , F a l l o n and Kaplan from 1962-1970.
Mr. Bromberg graduated from Columbia C o l l e g e i n 1959 and
r e c e i v e d h i s LLB from New York U n i v e r s i t y Law School i n 1962. He
i s a member o f t h e Bars o f t h e S t a t e o f New York, t h e D i s t r i c t o f
Columbia and t h e U.S. Supreme Court.
�RCV SY:
; 3-25-93 ;10:4BAM ;
202 797 4840^
SOCIAL OFFICE!* 2
Statement o f Michael D. Bromberg
Executive D i r e c t o r
Federation o f American Health systems
to the President's Task Force on National Health Care Reform
March 29, 1993
Madam Chair and members of the Task Force, I appreciate t h i s
opportunity t o appear before you and t o pledge our cooperation i n
the search f o r a health reform p o l i c y which assures access t o
affordable q u a l i t y health care f o r a l l
The
question
you asked
me
Americans.
t o address
i s "Why
do some
h o s p i t a l s charge $5 f o r an a s p i r i n and $35 f o r a towel, and what
can we do about t h i s probleiTi?"
First,
i t i s obvious t h a t an
a s p i r i n does not cost $5 nor does a towel cost $35. I t i s also a
f a c t t h a t t h e meat i n a $5 hamburger served i n a restaurant does
not cost $5 i n a supermarket.
There are several reasons such
charges appear as " l i s t p r i c e s " i n many h o s p i t a l s .
First,
aspirin
i s not the product.
Hospitals are labor
intensive i n s t i t u t i o n s which also have high c a p i t a l costs.
Those
overhead costs must be paid f o r and a reasonable operating margin
achieved t o assure t h a t
patients.
the
cost
technology
quality
services
are rendered t o our
I f a nurse d e l i v e r e d a s p i r i n t o your bedside a t home,
of t h a t
equipment
aspirin
would
and services
quickly
multiply.
and nursing
I f high
care were kept
around the clock i n your hemes, t h a t cost would m u l t i p l y again.
�RCV BY'.
; 3-25-93 ;iC:48AM ;
202 797 AS40^
SOCIAL OFFICE!* 3
2
Second, posted charges are misleading because approximately
30 percent of p a t i e n t s or t h e i r insurers do not pay l i s t p r i c e s ,
but r a t h e r pay negotiated, discounted
Medicare and Medicaid,
those
charges.
I n the case of
disccunts are u n i l a t e r a l l y set by
government, and payments are s u b s t a n t i a l l y below cost.
c h a r i t y or non-paying p a t i e n t s pay nothing.
Finally,
The r e s u l t i n g cross
subsidies d r i v e up the l i s t p r i c e of t h a t a s p i r i n even f u r t h e r .
Third, h o s p i t a l operating margins frorr. a l l p a t i e n t revenues
are less than one-half percent and t o t a l margins are about f i v e
percent.
20
That average includes negative average margins of 10 t o
percent
percent
evidence
from
Medicare
and Medicaid
underpayments
negative
margins
from
care.
that
there
i s no
charity
rip-cff
when
and 100
That
i s clear
the t o t a l
bill is
reviewed.
Fourth, h o s p i t a l s could reduce charges f o r s i n g l e items l i k e
a s p i r i n or towels, but t o maintain margins they would have t o
r a i s e charges f o r room and board, p e n a l i s i n g p a t i e n t s who stay
longer than the average time i n i n s t i t u t i o n s .
Government irdcromanagement
of charges w i l l
do nothing t o
c o n t r o l costs.
We must move t o a system which contains strong
incentives
reduce
to
unnecessary
treatments,
encourages
preventive care, and f o s t e r s i n t e g r a t e d d e l i v e r y and financing
systems which compete on both q u a l i t y and a s i n g l e per capita
�RCV BY:
; 3-25-93 ;10:49AM :
202 797 4640-»
SOCIAL OFFICE!* 4
3
premiuir. f o r t o t a l
care.
Price
c o n t r o l s freeze
i n place the
current u n i t p r i c i n g system which encourages increased volume and
set a r t i f i c i a l
limits
that w i l l
certainly
lover q u a l i t y and i n
e f f e c t r a t i o n services as has happened i n many other c o u n t r i e s .
The
Federation urges you t o support the managed competition
reforms which use the t a x code t s reverse current i n c e n t i v e s f o r
increased volume.
by
h e a l t h plans
Those reforms would f o s t e r competitive bidding
t o large purchasing
cooperatives
and increase
a f f o r d a b l e choices f o r a l l Americans.
The
$5 a s p i r i n makes good t h e a t e r and e f f e c t i v e
rhetoric,
but i t would
be a mistake
t c conclude t h a t
c o n t r o l s would address t h e underlying problem.
merely
increase
ether
costs
q u a l i t y o f other services.
political
and are l i k e l y
price
Price c o n t r o l s
t o d r i v e down the
Restructuring our system and r e v i s i n g
incentives w i l l make h e a l t h care more a f f o r d a b l e and a v a i l a b l e t o
a l l Americans.
We look forward t o working
enact meaningful
w i t h you because i t i s time t o
reform and t h a t can only happen i f we cooperate.
�RCV BY:
; 3-25-S3 MOUSAM !
202 797 4e40-*
SOCIAL OFFICE'.* 5
MICHAEL D. BROMBERG, ESQ.
Executive D i r e c t o r
F e d e r a t i o n o f American H e a l t h Systems
1111 19th S t r e e t , N.W.,
S u i t e 402
Washington, D.C. 20036
(202) 833-3090
Michael D. Bromberg has been t h e e x e c u t i v e d i r e c t o r o f t h e
F e d e r a t i o n of American H e a l t h Systems ( f o r m e r l y , t h e F e d e r a t i o n
o f American H o s p i t a l s ) s i n c e 1969.
Echoing Mr.
Bromberg's
refutation
as
an
articulate
and
influential
health
policy
i n s i d e r , Medicine and Health's P e r s p e c t i v e s , a F a u l k n e r and Gray
p u b l i c a t i o n , s a i d c f him, "Among h e a l t h l o b b y i s t s , Bromberg r a t e s
highest."
C u r r e n t l y , he i s a member o f t h e N a t i o n a l H e a l t h Lawyers
A s s o c i a t i o n and a p a s t p r e s i d e n t o f t h e group.
Ke i s t h e a u t h o r
o f numerous a r t i c l e s about n a t i o n a l h e a l t h c a r e p o l i c y and t h e
h o s p i t a l i n d u s t r y , and has appeared on many n a t i o n a l l y broadcast
TV programs, i n c l u d i n g the MacNe.il Lehrer Hour, t h e Today Show,
CBS Morning News, The C h a r l i e Rose Show and C r o s s f i r e .
I n 1985-86, Mr. Bromberg served as a member of t h e n a t i o n a l
A d v i s o r y Commission on C a t a s t r o p h i c i l l n e s s .
T h i s commission's
r e p o r t was t h e f o u n d a t i o n f o r l e g i s l a t i o n t o p r o t e c t e l d e r l y
p a t i e n t s a g a i n s t f i n a n c i a l r u i n from c a t a s t r o p h i c i l l n e s s e s .
P r i o r t o j o i n i n g t h e F e d e r a t o i n , Mr. Sromberg was campaign
manager and s u b s e q u e n t l y l e g i s l a t i v e and a d m i n i s r r a t i v e a s s i s t a n t
t o former U.S. R e p r e s e n t a t i v e H e r b e r t Tenzer (D-NV) from 1966 t o
1970.
An
attorney,
Mr.
Bromberg p r a c t i s e d as New
York
and
Washington Counsel
f o r t h e New
York law
firm
of Tenzer,
G r e e n b l a t t , F a l l e n and Kaplan from 1962 t o 1970.
Mr. Bromberg graduated from Columbia C o l l e g e i n 1959 and
r e c e i v e d h i s LLB from New York U n i v e r s i t y Law School i n 1962.
He
i s a member of t h e Ears of t h e S t a t e of New York, t h e D i s t r i c t o f
Columbia and t h e U.S. Supreme Court.
X X X X
X
The F e d e r a t i o n o f American H e a l t h systems i s a n a t i o n a l t r a d e
association
r e p r e s e n t i n g the
n e a r l y 1,400
investor-owned
h o s p i t a l s and h e a l t h systems t h a t o f f e r t r a d i t i o n a l acute care,
ambulatory c a r e , p s y c h i a t r i c and r e h a b i l i t a t i v e c a r e ; and a l l i e d
companies i n v o l v e d i n h e a l t h i n s u r a n c e and h e a l t h care systems.
Our members a l s o manage more than 300 n o t - f o r - p r o f i t h o s p i t a l s .
�AMERICAN PROTESTANT HEALTH ASSOCIATION
MEMBERS:
200 P r o t e s t a n t c h u r c h - r e l a t e d h e a l t h c a r e
institutions.
REPRESENTS:
H o s p i t a l s o f P r o t e s t a n t Church h e r i t a g e and
affiliation.
TODAY'S SPEAKER:
J e r r y Dykman, E x e c u t i v e V i c e
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Community h o s p i t a l s can be i n f l u e n t i a l i n l o c a l
district.
Community c o l l a b o r a t i o n and commitment.
Seek fundamental r e f o r m o f h e a l t h c a r e system making
u n i v e r s a l coverage a t reasonable c o a t a r e a l i t y .
Develop i n c e n t i v e s , b u i l t upon c a p i t a t e d payments
f o r p o p u l a t i o n groups, t o change c o r p o r a t e and
i n d i v i d u a l behavior.
Move from d i s e a s e t r e a t m e n t t o
h e a l t h improvement. Community based s e r v a n t
l e a d e r s h i p i s key t o u n i v e r s a l and a f f o r d a b l e
coverage.
POSITION ON
PLAN:
Seek fundamental r e f o r m .
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
Transition.
PET
Mission-driven
ISSUE:
President
providers
�American Protestant Health Association
Representative
Jerry Dykman
Executive Vice President
J e r r y Dykman i s Executive Vice President o f APHA. He served
as a board member o f APHA from 1985-90. His a c t i v i t i e s include
government and church r e l a t i o n s f o r APHA and I n t e r H e a l t h . These
two o r g a n i z a t i o n s represent n e a r l y 200 Protestant church-related
h e a l t h care organizations throughout the U.S.
�03/25/93
NO. 188
14:02
P002/006
8765W.HiggiBtRd., Suite 410 Chicago. IL 60631-4101
TESTIMONY BEFORE
i
THE WHITE HOUSE TASK FORCE ON HEALTH CARE
MARCH
29,1993
BY
JERRY LDYKMAfr
EXECUTIVE VICE HIESIDENT
�03/25/93
NO.188
14:03
F003/006
Mircb29, 1993
Mtdtm Chair •
j
and diitirguidwi Tuk Fore* maBtocn..,
For gver 70 years th* American Proteitwt HMlth A wodatlfln hu ttftueM Adventiit,
Baptist, Lutiwran, Method st and Presbyterian health caite inititutlons throughout the United
j
States.
|
Motivated by a compusiooate ministry for healing and wholeness, theffi^jorportion of
oui nation's hospitals,fflitftaghomes and clinics have provided health treatment and human
services to individuals and jbmilies across our land. While the focus of your work is to comet
problems that are threatening the worlds most advanced riedicai can, we also give thanks for
the immeasunble good tbas has been accoropMed.
Inherenttoour membenhip health miailofi is the bslief that all human life ii sacred and
central in this world. A distinct Protestant ethic is also that of individual responslbfflty and a
loving concent for our neighbor. To the extent that chutch-rdated institutions became slaves
I
j
to or vicdmB of the reimbtpemcnt, competitive, ootpomte mind of the TO's and SO'i, we must
seek our communities and constituents forgiveness and seek fundamental change. Our changed
behavior must be rewarded and supported by the very {national and local reforms you will
propose. With these reform incentives, built upon capitated payments foe population groups,
those exorbitant, embarrassing, unexplainable line item chiirges will go away. These aspirin and
towel examples are indicative of the results of a micro regulated, controlled, cost shifting
reimbursement system. Charges bear little resemblance »i costs, since most patients do not pay
costs or charges but a negotiated payment based on a pa diem, capitation rate, DRG-type flat
fee per admission, or they may not pay at all., .the consequence of which ii that hospital chargea
�03/25/93
14:03
NO.188
P004/006
axe largely mythical aod paid by a coctinually decreasing p arcentage of payers which of coune
pushes up the charge structure to reflect the "discounts' tm n charges negotiated by most payers.
(Deacolness Health System in St.LouU chargea $1.86 for an aspirin and the six-towel pack ia
i
»
free, but if the patientrequestsa second one, the charge ii $2.50)
As surely as our corporate behavior must change so must that of the individuals; the "me
0
Ar it desires of our citizens. Appropriate incentives and! disincentives must permeate reform
in order to reduce costs and achieve universal coverage, j When 1 of 4 dollars - 25% * $200
billion plus is spent on the treatment of disease resulting pom behavior/misbehavior - our life
style habits - eating, exerdis, addictions, living, loving and even in dying...significant strategy
must be developed to change negative behaviors.
Our community cafe and independent delivery networks must include our places of
worship, church, parish, synagogues, schools, day care and senior centers. The institutional and
program incentives that prevent disease and promote healthy life styles must share in the
capitated fee keeping a pojmladon healthy. We axe sure that if 25ft of the health care dollar
could be "medicated" or "deviced" massive research would begin. It's harder than that! Its
personal. It's behavior. It's life.
The membership of the American Protestant Hdalth Association developed 7 Basic
pi^mj^tti or Belief Statements Toll Gates if you will, vthich are essential to Health System
Reform. They're attached and explained aa part of our \mtten testimony. One statement we
believe central to your task:
COMMUNITY-BASED SERVANT JLEADERSEUP IS ESSENTIAL TO MAKE
HEALTH CARE SERVICES BOTH UNIVERSAL AND AFFORDABLE.
�03/25/93
14:04
NO.18G
P005/006
tho competitive, ooipoxaie, profit model bu not produced program! toward broader
coverage or lower costs. Concerned community oollabortfion and compassion might Both
corpontt and personal tun around must be accomplished. To that extent national policy and
financial incentives must tx established in order to enhande the change.
Church-related organizations do have several models that are worth studying, Including
cost-effective alternatives, i.e., congregational health/nurse partnerships. Frankly - no
alternative should include the concept FREEZE.. .That will only injure the continuance of those
unexplainable line items. Church-related, values driven organizations in covenant with their
communities can be challenged to control, reduce or even eliminate those items even during a
i
transition period. Setting new boundaries, establishing policy andftamework,within a capitated
i
negotiated fee. Then let the providers work! Those lino items become their problem not the
i
payors, We urge the Task Force to continue its Health Focus and not become the Medical
System Cost Cutting or Controlling Commission. Devise a system that will eliminate the need
for billingforevery aspirin, and instead establish a globsl reimbursement system based on a
capitation, DRG or other flat rate that will cover actual costs.
Unless forced out of business, due to financial restraints or beingforcedto practice
against their value beliefs, the church and its related instiUitions have been and will continue to
be heart and soul of not only the medical delivery system, but more importantly of health
delivery.
Our membership IK eager to be part of the solutions to improving the health of all
Americans. God Bleu!
�03/25/93
14:35
NO.188
P006/006
BASIC ELEMENTS OF ACONCEPTUAL
FRAMEWORK FOR HEALTHCARE POLICY
* L
HHALTBCAttlBreni MUSf BMBRACB
sTOrruALANO waraaHAL
WELL-BSNO Df OlDBllTO UAXXMBE TUB
BFFECnVENBM OF MEDICAL TSCATUBNT
BBALTBCAKBSfiPOaU
RBCONCfiPTUAUZAtlON OP
nSATMBNTTO 8BAL1H
AlAUC
FROUDBEAH
in.
HIPaOVBD HttALTHPOH ALL
B88T ACSIIBVED fiYMBtSDN
Pf COVINANT AND
wrratma
XBOPIBNT OSUENTBD QUALTIY ^lALTMCAKB
IERVICB8 KSQUag A OOMUNUUlflOTCAtS AND
TOBDOM OF CBOKJB
V.
COMMUNITY BABD 8EKV,ANTLEADSXIHIP
LTHSARESBftVICSS
V BMHNTIALTO MAKE HlAL'
BOTH UNIV8EIAL AND AWOIDABLB
VL
HfiALraCAOiBKVICBS ABB PXttlAtllLY A IVBIONAl
AND LOCAL mrONKBIUTY
vn.
COMWBHBNBVB SOLUTIONS AND I FUNDAMENTAL
HBALTHCAKB RBPOnc MUST BB uUOVSD FROM
NATIONAL POLITrCALmOCBSS
�CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES
MEMBERS:
1200 h e a l t h care
REPRESENTS:
Nation's largest organization representing n o t - f o r p r o f i t , single-sponsor, health care i n s t i t u t i o n s .
TODAY'S SPEAKER:
S i s t e r Bemice C o r e i l
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
facilities
Community h o s p i t a l s can be i n f l u e n t i a l i n l o c a l
district.
S i m i l a r t o managed competition
U n i f i e d and comprehensive h e a l t h care system.
Through "Integrated Delivery Networks, a l l persons
are provided a comprehensive b e n e f i t s package.
Networks are owned and operated by a v a r i e t y o f
e n t i t i e s i n c l u d i n g former insurance companies,
h o s p i t a l s , and physicians. Networks compete f o r
customers on basis o f q u a l i t y and s e r v i c e and
receive r i s k - a d j u s t e d c a p i t a t e d payments from
independent "State Health Organization.
National
Health Board sets o v e r a l l budget. Employer-based
f i n a n c i n g supplemented by p u b l i c funds.
11
POSITION ON
PLAN:
Supportive. Committed t o u n i v e r s a l access and
h e a l t h care reform.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n , OPL
PET ISSUES:
Universal access.
�RCV BY:
3-23-93 ;12:HPM
202 296 3997^
SOCIAL OFFICER 2
Sister Bernice Coreil, D.C.
Senior Vice President, System Integration
Daughters of Charity National Health System
\ i/
a
Vision
for
Sister Bernice Coreil, D.C. is a native of New Orleans, Louisiana.
She received her B.S. in Business Administration from Regis
College in Denver, Colorado ~ graduating Magna Cum Laude, and
her Masters in Health Care Administration from George
Washington University in Washington, D.C.
a
HealfJtx
Amrricfi
Prior to joining the Daughters of Charity, Sister Bernice had eight
years of business experience and continued to build on that
experience in the Daughters of Charity. Her positions in the
Health Ministry ranged from Business Manager to CEO. She has
served in Provincial leadership as Health Councillor and Visitatrix
of the West Central Province.
Sister Bernice has been very active in the Catholic Health
Association having served as a member of the CHA Task Force on
Healthcare for the Poor, Chairperson of the CHA Social
Accountability Budget Work Group, Chairperson of the CHA
Alternative Sponsorship Committee, Chairperson of the CHA
Finance Coinmittee, Member of the Steering Committee for
Catholic Healthcare Ministry Commission, Past Chairperson of the
CHA Board and has given numerous papers on a wide variety of
topics, written and published articles and served on too many
organizations too list.
THE
CATHOLIC HEALTH
ASSOCIATIOtl
IH I M U N i l l U S U I l i
I j ^ f c t L HEADQUARTERS
' ^ ^ K f t i s o n Road
Si I ouis. MO 63134-3797
314-42?-2bO0
Fax: 31J-437-0029
WASHINGTON OFFICF
1776KSlfect,MW. Sultt 204
Wastongton. DC 20006-2304
She is currently a member of the American College of Healthcare
Executives, Advanced Member of the Healthcare Financial
Management Association, American Hospital Association and
Catholic Health Association.
She is Chairperson of CHA
Leadership Task Force on National Health Policy Reform; member
of the CHA Task Force on Tax Exemption; Treasurer of the
Conrad W. Hilton Fund for Sisters (Hilton Foundation), Los
Angeles, California; Member of the Franciscan Missionaries of Our
Lady Health System, Baton Rouge, Louisiana; Chairperson of the
Finance Committee FMOL Health System; Chairperson of DePaul
Health Center, St. Louis, Missouri.
�RCV BY:
\ 11
: 3-25-93 ; 4:35PM ;
202 296 3997-
ORAL STATEMENT
Of
rvi
1 c - »•
<r/ vision
f(/f
THE CATHOLIC HEALTH ASSOCIATION
OF THE UNITED STATES
a
lfea/f/iv
to the
\,AM enc,
PRESIDENT'S HEALTH CARE TASK FORCE
Presented by
Sister Bernice Coreil, D.C.
Chairperson
Leadership Task Force on National Health Policy Reform
The Catholic Health Association
of the United States
and
THE
CATHOLIC HEALTH
ASSOCIATION
l*LHEADQUARTERS
dson Road
SlTwis, MO 63134-3797
314-427-2500
Fan: 314 427.M)?9
WASHINGTON OFFICE
177GK Street. NW. $uit« 204
WwhlnglOfi, OC ?0006-2304
202-296-3993
Far 507-79e-.?<M7
Senior Vice President, System Integration
Daughters of Charity National Health System
St. Louis, Missouri
George Washington University
Washington, D.C.
March 29, 1993
SOCIAL OFFICER 2
�RCV BY:
; 3-25-93 ; 4:36PM :
202 296 3997^
SOCIAL OFFICE!* 3
Good afternoon, Madame Chairperson, Mrs. Gore, distinguished Secretaries,
and other Members of President Clinton's Health Care Task Force. I am Sister Bernice
Coreil.
Thank you for your invitation to make this presentation on behalf of the
Catholic Health Association of the United States (CHA).
Questions Posed by the Task Force
CHA's response to the first question posed for this panel - "Why the $5
aspirin?" - is: the American health care system is broken. Its problems are systemic
in nature. The $5 aspirin is but one symptom of a terminally il! health care system.
Our system is no longer adequately accountable to the people and communities it
serves. !t is buiit on an irrational mix of skewed financial incentives, escalating costs,
cost shifting, and inadequate access - all of which contribute to the $5 aspirin. Since
the $5 aspirin is a systemic problem, the answer to your second question - "What can
be done about this problem?" - is: this nation must enact fundamental, systemic
health care reform.
Reform must address the three pillars on which the American
health care system is built: namely, access, quality, and cost containment.
CHA's Three Pillars of Reform
The Catholic Health Association has proposed a systemic, person-centered
approach that addresses each of the three pillars of reform about which the Task
Force is concerned.
First, the Clinton Administration is seeking health care security for every
American family.
CHA's proposal provides continuous, uniform coverage for all
persons living in the United States. No longer will coverage for health care be linked
�RCV BY:
; 3-25-S3 5 4:36PM :
202 296 3997-
SOCIAL OFFICE!* 4
to whether an individual is employed or unemployed, poor or non-poor, sick or well.
Our plan also calls for a standard, comprehensive benefit package that is acceptable
to the broad American public. We urge the Task Force to avoid a "basic" package
that becomes a floor for the middle class and a ceiling for the poor.
Second, the Clinton Administration wants to maintain quality. Quality depends,
however, on how services are organized and delivered. CHA believes that the delivery
of health care in the United States needs to be better coordinated, less costly, and
more responsive to the needs of people and communities. At the heart of our plan is
what we call the Integrated Delivery Network or the IDN.
The IDN is a set of
providers organized to render a coordinated, comprehensive continuum of health care
services. These networks receive risk-adjusted, capitated payments and are held
accountable for improving or maintaining the health status of their enrolled
populations. Individuals choose among competing networks based on quality and
service, but not price.
Third, the Clinton Administration wants to control health care costs. The CHA
reform proposal calls for a national global budget administered through capitated
payments. We beiieve that both components are necessary. A global budget allows
us as a nation to make an explicit decision about the resources we devote to health
care compared to other social needs.
Capitation is the best way to ensure true cost control under a global budget.
Capitation realigns financial incentives. It encourages primary and preventive care,
services in optimal settings, reduced unnecessary care, more appropriate capacity
�•RCV BY:
; 3-25-93 ! 4:37PM 5
202 296 3997-
SOCIAL OFFICE!* 5
levels, a more rational use of technology, and accountability for improved health
status. Rate setting does none of these. However, CHA recognizes that rate setting
may be needed as an interim cost control strategy. But, if it becomes permanent or
is not part of a larger strategy that culminates in systemic health care reform, our
nation will miss a once-in-a-lifetime opportunity to address the underlying causes of
health care inflation, not just the symptoms.
CHA's Unique Proposal Founded on Values
What I have just described may not sound like a typicai provider proposal to
some. There is a reason for this. CHA began its deliberations on health care reform
by asking w h a t values should guide reform.
Most important among the six we
identified is the following:
Health care is an essential social good, a service to persons
in need which should never be reduced to a mere
commodity exchanged for profit.
Our values led us to a proposal that would Improve the effectiveness of health care
for people. As a result, we also designed a system with accountability for costs. We
encourage you to do the same. The nation has a unique opportunity to make health
care more responsive to people, more clinicaiiy effective, and more accountable to
communities while at the same time bringing costs under control.
Conclusion
As health care leaders, we can force the aspirin d o w n to a nickel. But if all we
do is to achieve cost control, without delivery reform, I fear we will have failed our
fellow citizens.
�3CV BY:
; 3-25-S3 ! 4:35PM I
202 236 3S97-
E
'ATHOUC HEALTH
ASSOCIATION
OP IHt UNITED STATES
FAX ID NUMBER:
202-296-3997
FACSIMILE TRANSMISSION COVER SHEET
SUA.
^^53
MESSAGE FROM:
^^f^r^tC
/£s*£*&€>6Z-~
MESSAGE TO: /l^^/7\(^fW£~^0<>^l
WASHINGTON OFFICE
AZ/tZ^.
FAX I D NUMBER
1776 K Slr«fi. NW
Suite 204
Wajhinglon DC 20006
Phone 202-296-3593
Faj 202-296-3S97
^
IX
URGENT D E L I V E R Y
NORMAL D E L I V E R Y
NUMBER OF PAGES (INCLUDING COVER SHEET)
SPEC I AL INSTRUCT IONS /COMMENTS :
SOCIAL OFFICE!* 1
�NATIONAL ASSOCIATION OF CHILDREN'S HOSPITALS
AND RELATED INSTITUTIONS
MEMBERS:
131 member hospitals
REPRESENTS:
NACHRI represents free-standing, acute care
c h i l d r e n ' s h o s p i t a l s , p e d i a t r i c departments o f major
medical centers, and s p e c i a l t y c h i l d r e n ' s h o s p i t a l s
devoted t o r e h a b i l i t a t i v e and chronic care f o r
children.
Children's hospitals represent 1% o f t h e nation's
h o s p i t a l s , and care f o r more than 12% o f a l l
h o s p i t a l i z e d c h i l d r e n and 24% o f h o s p i t a l i z e d
c h i l d r e n w i t h chronic and congenital c o n d i t i o n s .
TODAY'S SPEAKER:
Lawrence A. McAndrews, President and CEO (see b i o )
SCOPE OF
INFLUENCE:
I n f l u e n t i a l i n children's h e a l t h community
APPROACH FOR
PLAN:
Managed competition
SUMMARY OF
PLAN:
A n a t i o n a l health care plan needs t o meet t h e needs
of c h i l d r e n through the f o l l o w i n g p r i n c i p l e s .
Health care reform i s accountable f o r c h i l d r e n ' s
h e a l t h care needs.
Employer-financed h e a l t h care insurance.
Minimum b e n e f i t s package f o r c h i l d r e n .
A v a i l a b i l i t y of p e d i a t r i c t r a i n e d care.
Cost containment.
Recognition of the special funding requirements f o r
providers who serve a d i s p r o p o r t i o n a t e share o f lowincome c h i l d r e n .
Administrative s i m p l i f i c a t i o n .
POSITION ON
PLAN:
Supportive
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n , Public Liaison, and Task Group
PET ISSUES:
Children's needs — preventive and primary care
HOT BUTTON ISSUES:
Benefit plan and cost containment s t r a t e g y without
t a i l o r i n g t o children's s p e c i a l needs.
�The National Association of Children's Hospitals
and Related Institutions, Inc.
Representative
Lawrence A. McAndrews
President and CEO
Lawrence A. McAndrews i s President and CEO o f NACHRI, which
he j o i n e d i n September 1992. Mr. McAndrews has devoted h i s 20
year long p r o f e s s i o n a l career t o h o s p i t a l a d m i n i s t r a t i o n . For
the l a s t s i x years p r i o r t o h i s becoming NACHRI's President, he
served as President and CEO of Children's Mercy H o s p i t a l i n
Kansas C i t y , MO. He also has served as Chairman o f t h e Governing
Council o f the Maternal and Child Health Section o f t h e American
H o s p i t a l Association.
�MflR-25-1993
13:43
FROM
TO
2024565241
P. 02
Testimony
Lawrence A. McAndrews, President and Chief Executive O f f i c e r
National Association of Children's Hospitals
and Related I n s t i t u t i o n s
"Five Dollar Aspirin and 35 Million Uninsured"
Panel 8 Health Care Task Force
Washington, D.C.
March 29, 1993
Good afternoon, roy name i s Lawrence McAndrews. I am the
Chief Executive Officer of the National Association of Children's
Hospitals and Related I n s t i t u t i o n s .
A f i v e dollar a s p i r i n catches attention in a s i m p l i s t i c way
— screams out how can any hospital charge t h i s rate for these
s e r v i c e s , that i s absurd. These kinds of charges are the d i r e c t
r e s u l t of the perverse reimbursement structure i n which hospitals
operate, a structure which does not recognize the true cost of
delivering care. The larger question i s why cost s h i f t i n g , why
should reimbursement for Medicare or Medicaid be below cost and
why shculd these costs be borne by patients fortunate enough to
have good insurance? Why are there 35 million uninsured, whose
costs are paid for through cost s h i f t i n g ?
Cold, hard cash i s
provide services to the
costs must be borne and
surface appears to be a
a demanding taskmaster. When hospitals
uninsured or the under insured, these
they end up being borne by what on the
crazy charging system.
;
To control health care costs, the reimbursement structure
and incentive system must be changed. Universal access i s
absolutely e s s e n t i a l components for f i x i n g the problem long term.
Collaboration i s an important part of the solution a t the
community l e v e l i n order t o avoid duplication of scarce resources
and inane destructive competition. Giving people a stake
f i n a n c i a l l y and a choice of their physician and h o s p i t a l , i s an
extremely important part i n making the individual responsible for
t h e i r health care. Ultimately, the goal i s for h o s p i t a l s and
other providers to d e l i v e r care even more cost e f f e c t i v e l y . For
example, children's hospitals have led the way i n d e l i v e r y care
in ambulatory c l i n i c s , home care, parental training and
prevention.
The crazy system we now have i n insuring individuals must be
changed to provide people with adequate security and appropriate
access to health care s e r v i c e s . Today, i f you change your job or
�fiAR-25-19S3
13=43
FROM
TO
2024566241
P. 03
you become seriously i l l , you may lose your insurance.
We
support uniform benefits, employer mandates, tax incentives,
public subsidies and cost sharing for insurance coverage, and
community r a t i n g .
"One
The most s i g n i f i c a n t concept I would l i k e to express i s that
Size W i l l Not F i t A l l . "
Because children have d i f f e r e n t health care needs, uniform
benefits for children should be defined by p e d i a t r i c health care
experts who begin with an assessment of Medicaid benefits for
children.
Because children have d i f f e r e n t health care service d e l i v e r y
needs, managed competition should be regulated to guarantee
a v a i l a b i l i t y of p e d i a t r i c trained care and to avoid duplication
of e s s e n t i a l regionalized professional services for children.
Because the resource requirements for children's health care
are d i f f e r e n t , inpatient cost containment p o l i c i e s should
recognize the d i f f e r e n t f i n a n c i a l requirements of children's
health care needs.
Because Medicaid i s now the health care safety net for
m i l l i o n s of children, p o l i c i e s recognizing hospitals that serve a
disproportional share of low income patients should be sustained
in the t r a n s i t i o n to reform.
children are the future of our country and t h e i r needs are
d i f f e r e n t , i t i s extremely important to keep i n mind that "One
Size Does Not F i t A l l . " Thank you.
LAM/lbg
�4:40--
PANEL EIGHT-HOSPITALS- TESTIMONY ENDS
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
^3
�4:55-
PANEL NINE-GENERAL HEALTH CARE PROVIDERS-TESTIMONY
BEGINS
Next we will be hearing from some other health care providers. They have been asked
to address the question: "How can alternative forms of health care delivery bring down costs
in the long-term?" Thefirstwitness is Val Halamandaris, President of the national
Association for Home Care.
�PANEL 9; 4:55 - 5:45
General Health Care Providers
Val Halamandaris
President
National Association for Home Care
Dr. Paul Willging
Executive Vice President
American Health Care Association
John Mahoney
President
National Hospice Organization
Stuart Eizenstat
Consultant
Health Industry Manufacturers Association
�PANEL NINE: GENERAL HEALTH PROVIDERS (II)
Question Posed:
How can alternative forms of health care delivery bring down costs in the long-term?
Groups:
National Association for Home Care
American Health Care Association (Nursing Homes)
National Hospice Organization
Health Industry Manufacturers Association
Major issue concerns:
These are primarily organizational providers rather than individual providers. It is a
diverse panel that will have a range of concerns. National Association for Home Care,
American Health Care Association, and National Hospice Organization will also want to
address long term care concerns, while Health Industry Manufacturers Association and
Group Health Association of America will focus more on how managed competition will
effect their industry.
Talking points:
1.
All sectors of the health care industry need to do their part to keep costs down.
2.
Home and community based care will be essential elements to our plan.
3.
We know that comprehensive health care reform has to include long term care.
�NATIONAL ASSOCIATION FOR HOME CARE
MEMBERS:
Home h e a l t h agencies, home care a i d
o r g a n i z a t i o n , hospices and t h e i n d i v i d u a l s
they serve.
REPRESENTS:
Home c a r e p r o v i d e r s and t h e i n d i v i d u a l s t h e y
s e r v i c e . The purpose o f NAHC i s committed t o
a s s u r i n g t h e a v a i l a b i l i t y o f humane, c o s t e f f e c t i v e , h i g h - q u a l i t y home care s e r v i c e s t o
a l l i n d i v i d u a l s who r e q u i r e them.
TODAY'S SPEAKER:
V a l Halamandaris,
P r e s i d e n t (see b i o )
SCOPE OF
INFLUENCE:
APPROACH FOR
REFORM:
SUMMARY OF
POSITION:
S u p p o r t i v e o f change i n system, advocate o f a
national plan.
Home c a r e i s t h e b e s t way t o reduce c o s t s and
increase h e a l t h care.
Home c a r e and hospice s e r v i c e s i n b o t h a c u t e
and l o n g - t e r m care s e t t i n g s .
Acute c a r e b a s i c b e n e f i t package—home c a r e
and hospice s e r v i c e s .
Access based on need and n o t age.
Provider p a r t i c i p a t i o n .
Safeguards f o r q u a l i t y assurance and c o s t
containment.
F i n a n c i n g must be p r o g r e s s i v e and b r o a d l y
based.
Benefits.
POSITION ON
PLAN:
Interested.
INTERACTION W/
TASK FORCE AND
WORKING GROUP:
Transition, o f f i c e o f Public Liaison
PET
ISSUES:
Long t e r m c a r e , acute c a r e b a s i c b e n e f i t
package.
�National Association for Home Care
Representative
Val J . Halamandaris
President
Val J. Halamandaris i s President of t h e National A s s o c i a t i o n
of Home Care, a post he has held since J u l y 1982. P r e v i o u s l y he
served f i v e years as Senior Counsel t o Congressman Claude
Pepper's House Select Committee on Aging and before t h a t he was
employed by t h e U.S. Senate f o r f i f t e e n years where he was
counsel t o t h e U.S. Senate Special Committee on Aging. Mr.
Halamandaris i s an attorney, author, and publisher. His best
known work i s the book. Too Old, Too Sick, Too Bad.
�NATIONAL ASSOCIATION FOR HOME CARE
519 C STRHET. N.E., STANTON PARK
WASHINGTON. D.C. 20002-5*09
(202) 547-7424. FAX (TiJl) 517-3540
KAYE DANIELS
niAlRMAN O T H E Bf-,ARD
VAL J. HALAMANDARIS
PRESIDENT
HONORABLE FRANK. E. MOSS
snuiORCm-'.-oci.
STANLEY M. BRAND
CiENERALCUUNSH.
Testimony o f V a l J . Halamandaris, P r e s i d e n t
N a t i o n a l A s s o c i a t i o n f o r Horn© Care
Washington, D. c.
submitted t o
WHITE HOUSE INTERGOVERNMENTAL TASK FORCE
ON HEALTH CARE REFORM
Monday, March 29, 1993
Washington, D. C.
REPREStNTLNC THE NATTON S HOME HEALTH At.FVCTCS. HOMtCARr ArDCORUANKATIONS ANO ..O^FTCES
2 D D ri
W 0 H .-1
�I am very pleased to be here today to give the White
House Intergovernmental Task Force on Health Cara Reform
my suggestions on reforming the U. S. Health care system.
Tixa National Association for Home Care supports tfrie work
of the Task Force and looks forward to working with the
Administration and Congress toward enactment of a health
care reform plan that w i l l contain tha increases i n
health care costs while achieving universal access and
high quality car©.
Health care i s a basic right of a l l Americans. A l l of
our cherished r i g h t s guaranteed by the Constitution —
the r i g h t s of l i f e , liberty, the pursuit of happiness,
freedom of the press, and others —
are meaningless
without the right to health care.
The basic r i g h t to
health care w i l l only become a r e a l i t y with the creation
of a comprehensive federal health care program that
guarantees universal access and coverage of long-term
care as an integral part of the package.
Lack of
coverage of long-term care i s one of the most devastating
problems America faces today. Approximately 10 m i l l i o n
Americans of a l l acres currently require long-term care
because of chronic i l l n e s s or d i s a b i l i t y that renders
them unable to perform basic tasks of daily l i v i n g .
Home care and hospice services have
proven to be
e f f i c i e n t , cost-effective and appropriate options f o r
millions of patients who require such services because of
acute i l l n e s s , lon^-term health conditions, permanent
d i s a b i l i t y or terminal i l l n e s s . I n addition,
opinion
p o l l s show an overwhelming consumer preference for home
care^ over the equivalent health care provided i n an
i n s t i t u t i o n . A comprehensive home
care and hospice
benefit would s i g n i f i c a n t l y constrain the rate of
increase in health care costs i n the U. S.
Home care encompasses a broad spectrum of both health and
s o c i a l services that can be delivered to the recovering,
disabled
or chronically
i l l person i n the home
environment. These services include the t r a d i t i o n a l oorc
of professional nursing and home care aide services as
well as physical therapy, occupational therapy, speech
therapy,
medical s o c i a l
sex-vices
and n u t r i t i o n a l
scrvioes.
Hospice i s a special component of home care. Hospice care
involves medical, s o c i a l , psychological and s p i r i t u a l
care f o r terminally i l l patients and t h e i r f a m i l i e s . A
concept aimed at r e l i e v i n g the pain and suffering and
providing the most comfortable environment possible,
hospice care i s designed to allow a terminally i l l person
to die with dignity.
eoo •d
wo
�Generally, home care i s appropriate whenever a person
needs assistance that cannot be e a s i l y or e f f e c t i v e l y
provided only by a f a a i l y member or friend on an ongoing
basis for a short or long period of time. There are many
situations and conditions for which bome care and hospice
are e s p e c i a l l y appropriate. Because of ever-advancing
technology that i s yielding equipment and people trained
to use the equipment, every day more people are able to
leave institutions or never enter them. They can be cared
for e f f e c t i v e l y and e f f i c i e n t l y a t home even i f they have
i l l n e s s e s that a t one time were only treatable i n a
hospital or i n s t i t u t i o n a l setting.
The importance of home care
as a cost-effective
alternative to i n s t i t u t i o n a l care has been recognized by
Medicare since i t s inception and as a required benefit i n
Medicaid since 1970. I n addition, federal requirements
for health maintenance organizations have since 1973
mandated the provision of unlimited home health services.
Home care s e r v i c e s have become even more important with
the advent of Medicare DRGs which have resulted i n
e a r l i e r discharges of higher acuity patients to home
health
care. The percent of a l l Medicare hospital
patients discharged to home health care has increased to
18 percent compared to only 9 percent i n 1981. Further,
home care has become a widely available benefit under
employer-sponsored
health
insurance plans.
A 1990
survey by the Health Insurance Association of America
found that
83-89 percent of insured employees had
coverage for home care s e r v i c e s .
Hospice services were added to the Medicare program i n
1983 as cost-effective s e r v i c e s
for terminally i l l
patients.
Coverage
for hospice
services
under
employer-sponsored
health insurance plans has grown
dramatically from 11 percent of insured employees i n 1984
to over 80 percent i n 1990.
Recent
studies
give
some
evidence
of
the
cost-effectiveness of home care. For example, Aetna l i f e
6 Casualty has reported a $78,000 per-case savings from
i t s Individual Care Management Program by using home care
for victims of catastrophic accidents. Lewin/ICF studied
differences i n the cost and effectiveness of inpatient
care plus home care versus less inpatient care and home
care for patients hospitalized with a hip fracture,
chronic obstructive
pulmonary
disease
(COPD) and
amyotrophic l a t e r a l s c l e r o s i s (ALS) with pneumonia. I t
found that for a l l three diagnoses, cutting inpatient
days and substituting more home care days reduced costs
for $2,300 for hip fracture patients, $520 for COPD
p a t i e n t s , and $300 f o r ALS p a t i e n t s .
—
* 0 0 ' ci
2 —
Ifj 0 H d
�The cost-effectiveness of long-tern home care and hospice
xs also well recognized.
Medicaid waiver programs have
increasingly r e l i e d on home care as a way t o reduce
states'
lona-term care costs.
New York
State's
experience with i t s Nursing Home Without Walls Program
round that the great majority of clients who would
otherwise need t o be placed i n a nursing home can be
cared f o r a t home a t a much lower cost. New Mexico's
waiver program f o r people with AIDS saves $1100 per month
when patients use home care rather than s k i l l e d nursing
f a c i l i t y care. The average patient plan of care costs
$1000 a month f o r home care compared t o $2100 a month f o r
s k i l l e d nursing f a c i l i t y care. Moreover, only 47 percent
of patients receiving waiver services i n New Mexico are
hospitalized i n a given year, compared t o 70 percent of
those not under waiver, giving the program the added
savings of preventive care as w e l l .
Similarly,
thirty-five
states
have recognized the
cost-effectiveness of hospice by voluntarily
adding
coverage of hospice services t o t h e i r Medicaid benefit
packages.
I hope my testimony has clearly shown the role that home
care and hospice can play i n helping bring down health
care costs i n the long-term. Home care and hospice are
benefits that are enjoyed by the vast majority of
Americans, either through public programs or employer
sponsored insurance plans. And the cost-effectiveness of
these benefits has been proven time and again. Any
health care reform delivery system that seeks t o maximize
access t o high q u a l i t y care while reducing the overall
rate of increase i n health care costs should r e l y on
these Important benefits.
~
S 0 0 'i
3 —
�AMERICAN HEALTH CARE ASSOCIATION
MEMBERS:
51 a f f i l i a t e d associations and 11,000 nonp r o p r i e t a r y and p r o p r i e t a r y long term care providers
t h a t care f o r one m i l l i o n nursing f a c i l i t y and long
term care residents nationwide
REPRESENTS:
P r i m a r i l y p r o p r i e t a r y nursing homes
TODAY'S SPEAKER:
Dr. Paul W i l l g i n g , Executive Vice President
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Powerful lobby a t f e d e r a l and s t a t e l e v e l ,
particularly i n certain states
Supportive o f Reform
AHCA has developed "Quality Care f o r L i f e " , a long
term care f i n a n c i n g reform plan which includes
nursing home care, consumer choice, q u a l i t y
incentives, and cost containment through p u b l i c and
p r i v a t e resources. Long term care needs also
include r e s p i t e care, a d u l t day care, home and
community-based care.
Concerned about t h e i r members a b i l i t y t o provide
care i n t h e new system.
POSITION ON
PLAN:
Supportive i f long term care i n b e n e f i t package
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
Transition, Office of Public Liaison
PET ISSUES:
Long term care i n b e n e f i t package
�hHCR
TEL:2028423360
Mar 2 3 ' 9 3
13:40 No.024 P.03
PAUL R. WILLGING, PH.D.
EXECUTIVE VICE PRESIDENT
AMERICAN HEALTH CARE ASSOCIATION
Dr. Willging, executive vice president and chief executive officer of the American Health Care
Association (AHCA), is the spokesman for more than 11,000 nursing and allied health facilities. He
is responsible both for the day-to-day management of the AHCA as well as for representing the
industry in the media, on Capitol Hill and before the executive branch of government.
Dr. Willging has over 25 years of extensive experience in the health care field. Before joining
the American Health Care Association, he was an officer at Blue Cross/Blue Shield of Greater New
York, and has been Deputy Administrator of the Health Care Financing Administration. He siis on
the Board and lias served as Chairman and Treauscr of Howard County General Hospital, a 200-bed
acute carefciriiityin Maryland.
Dr. Willging hold? a Ph.D. from Columbia University.
�e3/26''93
12:15
2
14978599652
PHCR
01
LONG TERM CARE: PART OF THE HEALTH CARE SOLUTION
The Problem:
America's makeshift long lerm care financing system is falling apart. Long term care costs are bankmpting
families, the states and the federal government. The states and the federal government are bickering over what
state revenues the federal government must match. Meanwhile, the wholefinancingsystem is sliding towani
fiscal meltdown. While stales struggle to meet the needs of their poorestresidents,growing numbere of affluent
elderly are using legal sleight of hand in order to qualify for Medicaid long term care coverage. A "one size
fits all" mentality stands in the way of appropriate placement along the health care continuum, while
reimbursement rigidities of government programs prevent the cost-efficient use of skilled nursing facilities as
an alternative to expensive acute care settings.
The Clinton Administration and the Congress may believe that thei: plates are too full with acute care reform.
That perception, however, overlooks a fiscal and political opportunity for constructive progress on reform
which would lead not only to a more equ itable and cost-efficient long term carefinancingsystem, but to dramatic
cost containment on the acute care side as well.
The Only Viable Solution — A Public/Private Partnership:
Long term health care must be a pan of any tmly comprehensive effort at health care reform. In a February
survey conducted by the Gallup Organization, seven out of eight Americans said that health care reform must
address the financing of nursing home costs. In the same survey, however, 76 percent of Americans said that
government should pay only for those who are unable to provide for their own long term care. Clearly, to meet
the nation' s growing long term care needs without both emptying the public purse and driving down the quality
of care, our society cannot afford — indeed, it will not tolerate — a system thatreliessolely on government
ftinding. Instead, we should encourage and enforce an expectation of personalresponsibilityon the part of those
with access to the means to plan and pay for long term care. Our goals should be to:
•
Provide appropriate access to a full continuum of long term care services,
•
Ensure thai all Americans have the means to meet the cost of long term care,
•
Move families away firom dependence on government welfare programs for long term care financing,
and
•
Address the nation's long term care needs in afiscallyresponsible way.
Cost Savings Potential:
A financing program meeting the above goals, but structured within theframeworkof a public/private
partnership emphasizing case management and more appropriate placement, can actuallyreducecosts while
preserving and even enhancing access to care. Further, through better linkages to acute care, long term care
can be a viable component of health carereformin that sector as well. Savings can come from at least three
areas:
�83^-26/93
1 2 : 16
S
14078599652
fiHCfi
03
. • Accommodatingresidentswho need intensive skilled nursing care in nursing facilities rather than in
the much more expensive hospital setting and developing less expensive assisted living programs for
those who might requireresidentialcare but not the more intense nursing care ($3 billion in Medicare/
Medicaid savings, $6 billion in total system savings),
•
Simplifying Medicaid eligibility determinations, while prohibiting all forms of "paper impoverishment" through asset transfeis ($2.5 billion in Medicaid savings), and
•
Inducing increased utilization of long term care insurance in lieu of publicly funded programs ($.5
billion in Medicaid savings).
The proposal has two basic features: first, a more equitable publicly financed program for those legitimately
in need, and, second, new inducements and education for those not financially eligible for the public program:
Improved "Safety Net'* Program:
• Guaranteed access ro appropriate long term care for those who have neither adequate financial
resources nor private insurance.
•
Eligibility based on financial need, impairment in activities of daily living and medical need.
•
Services provided along the entire long term care continuum: sub-acute care, nursing facility care,
residential care, home health care respitecare, adult day care and hospice care.
;
Help In Planning and Paying for Long Term Care:
• Public education on long term care costs, the limits of government programs, and planningfor longterm
care.
•
Federal quality standards and tax incentives for long term care insurance.
•
Federal stimulation of other long term care savings mechanisms (e.g., medical IRAs, "reveree
mortgages," etc.).
Key to the above proposal are two critical concepts. Thefirstrelatesto program eligibility, based not just on
financial considerations (although important), but on physical and mental criteria as well. By utilizing ADLs
and cognitive impairment as criteria, the government can facilitate the shift of nursing facilities "up the
continuum" of acuity and thus ease fiscal pressures on the acute care setting. Critical to that shift, of course,
are reimbursement systems oriented as much to the needs of residents as to cost containment.
The second concept emphasizes the "value" of long term care insurance. This is done not just through
education, consumer protections and tax incentives. Equally important are the prohibitions against asset transfer
to qualify for Medicaid. As long as Americans with means know thai there are loopholes in Medicaid eligibility,
long term care insurance will not be seen as having "value," and the public sector will continue to serve as the
primary source of funds for long term care. Safety net coverage must be reserved for those tmly in need.
The American Health Care Association
�NATIONAL HOSPICE ORGANIZATION
MEMBERS:
1400 p r o v i d e r members
2,000 p r o f e s s i o n a l members
REPRESENTS:
P r o v i d e r and p r o f e s s i o n a l members w i t h t h e m i s s i o n
t o advocate f o r t h e needs o f t h e t e r m i n a l l y i l l and
promote t h e p h i l o s o p h y o f hospice c a r e .
TODAY'S SPEAKER:
John Malloney, P r e s i d e n t
(see b i o )
SCOPE OF
INFLUENCE:
APPROACH FOR
REFORM:
Not committed, s e n s i t i v e .
SUMMARY OF
POSITION:
Home c a r e b e n e f i t s .
B e n e f i t s package.
I n c e n t i v e s f o r p r o v i d e r networks t o c o n t r a c t w i t h
e x i s t i n g community-based h e a l t h c a r e p r o v i d e r s .
POSITION ON
PLAN:
Wait and see
INTERACTION W/
TASK FORCE AND
WORKING GROUP:
OPL
PET ISSUES:
Long term care i s s u e .
�RCV BY:
; 3-23-93 : 3:29PM ;
703 525 5762^
SOCIAL OFFICE!* 2
BIOGRAPHY
JOHN J. MAHONEY
Mr. Mahoney is currently the President of the National Hospice Organization, a position
he has held since October, 1984. Prior to accepting the position at NKO, Mr. Mahoney was
the Executive Director of Boulder County Hospice in Boulder, Colorado. During his tenure as
NHO President, the organisation has tripled in membership and revenue.
Mr. Mahoney also has experience as an Assistant City Manager in a small town on the
eastern plains of Colorado, and as a teacher at the United Cerebral Palsy School in
Denver. Mr. Mahoney received his undergraduate and graduate degrees from the University
of Colorado.
Mr. Mahoney has been involved with hospice for over ten years, and has made numerous
presentations regarding hospice care before various organizations in the United States and
abroad. Additionally, Mr. Mahoney has published a number of articles regarding hospice
management and reimbursement.
�NAR-26-1993 08:27
FROM NPTIONAL HOSPICE ORG.
TO
2024566241
P.02
Testimony to the President's
Health Care Task Force
March 29, 1993
By
John J. Mahoney, President
National Hospice Organization
The National Hospice Organization is a non-profit, public benefit organization established
in 1978 and located in Arlington, Virginia. Our mission is to be an advocate for the needs of
the terminally ill. This mission is supported by over 1400 hospice member programs across the
country and more than 2000 individual members who are engaged in providing hospice care at
the bedside of the dying every day. Prior to working with NHO I was the director of a hospice
in Boulder, Colorado.
The question the Task Force has asked this panel to address is "How can alternative
forms of health care delivery bring down costs in the long term?*' We would submit to the Task
Force that hospice care is already bringing down health care costs, and if included in any future
basic benefit package would have an even greater impact as our population ages. Currently,
hospice care is provided in all 50 states primarily by community -based, not-for-profit hospice
programs.
THE BASICS OF HOSPICE CARE
Using a comprehensive case management approach, an interdisciplinary team of hospice
professionals develop and follow a patient-centered care plan that is individualized, and includes
input from the patient and family. Hospice services are provided by this team primarily in a
patient's home, most often with the assistance of family and friends.
Hospice care is based on a philosophy which embraces six significant concepts:
•
Death is a natural part of life. When death is inevitable, hospice will neither
seek to hasten nor to postpone it.
•
Hospice care establishes pain and symptom cnnrrnl as an appropriate clinical goal.
Hospice recognizes death as a spiritual and emotional as well as a physical
experience.
�FROM NAT IDNPL HOSPICE ORG.
TO
2024566241
P.03
•
Patients and their families are the unit of care. We have learned that to
effectively care for patients we cannot separate patients from their environment.
That environment includes their homes, their families and their friends.
•
Bereavement care is critical to supporting surviving family members and friends.
•
Hospice care is made available by most hospices regardless of ability to pay.
Currently, for most Americans hospice care is available as a covered health benefit,
either through their Medicare Hospice Benefit, Medicaid, the Veteran's Administration, or
private insurance. We understand that more than 80% of the employees in medium and large
companies have hospice coverage, and in preparing for this testimony we were told by one
hospice in Florida that they had worked with over 400 different private health plans.
COST SAVINGS
As I said earlier, hospice has already proven itself to be cost effective and a major factor
in reducing the cost of terminal care. As you know, approximately 28 percent of Medicare
expenditures go toward care delivered in the last year of life and almost 50 percent of those
costs are expended in the last two months of life. The majority of these costs are associated
with hospitalizations and the associated costs of high-tech interventions.
A recent article in the Journal of the American Medical Association reports that the
majority of patients with certain cancers admitted to the intensive care unit die before discharge.
Those who survive the hospitalization spend a minimal amount of time at home before dying.
This often marginally beneficial treatment is provided at great cost to the health care system as
well as to patients and families.
The same article noted that those patients not enrolled in hospice care spent 23 of their
last days in the hospital while patients enrolled in hospice spent only 8 days in acute care
settings. The cost savings associated with hospice care is in its ability to substitute for hospital
days, and when acute care is required, to provide such care without the high tech interventions
of an intensive care unit. To quote a February, 1992 Health Services Research article, "Clearly,
patterns of care for terminally ill patients are amenable to considerable substitution..." It has
been the mission of NHO to make that fact more readily understood by health care professionals
and the general public.
Our success in reducing the cost of health care to date is demonstrated in another 1992
Health Services Research article on hospice costs. In this article Dr. David Kidder looked at
Medicare Part A expenditures for hospice and non-hospice patients in 1985 and 1986. He found
that for every dollar spent cn hospice care. Medicare Part A saved $1.26.
�MPIR-26-1993
08:28
FROM
NATIONfiL HGSPICE ORG.
TO
2024566241
P.04
SPECIALIZED PROGRAMS
Although hospice care is most often associated with caring for people with cancer,
hospice programs have evolved over the years to meet the needs of the entire community.
Hospices have developed specialized programs of care to serve people with AIDS, people dying
from Alzheimer disease, and terminally ill children. And, recognizing that not ail people can
be kept safely in their own homes, hospices have begun to develop special substitute care giver
programs and to serve patients in congregate living homes, AIDS residential facilities, nursing
homes and even prisons.
COMMUNITY FOCUS
The strength of hospice care in this country is the community's involvement.
Historically, hospices have been started by community volunteers and are reflective of the
communities in which they exist. The community's investment in quality health care for the
dying is seen in the enormous philanthropic support that hospices have enjoyed over the years
and the over 5 milhon hours of service contributed each year by volunteers.
Much of the ability of alternative forms of health care to reduce health care costs is
drawn from this type of community base. We believe that it would be tragic to create a new
health care system that does not continue to value the community-based provider.
CONCLUSION
In conclusion. Hospice care works, because it puts the people it serves first. Hospice
care is a community-centered, patient/family focused, cost-effective way of humanely caring for
terminally ill people when curing the patient is no longer possible. It is an important alternative
to both the high-tech impersonal approach of traditional care and the desperation of euthanasia,
most recently publicized by the rash of Jack Kevorkian physician-assisted suicides. When one
examines the elements of what is generally considered to be important to health care reform and
representative of what is working well in today's health care system, hospice care deserves
consideration.
You have posed the question how can alternative forms of health care delivery bring
down costs. The answer is we cannot, if we are not pan of your plans, therefore I respectfully
urge you in your deliberations to include hospice care, as currently defined in the Medicare
Hospice Benefit, in any benefit package that is part of health care reform, and that you value
the ability of existing community-based providers to best deliver such care.
Wc Oiauk you fur the opportunity to speak with you today, and we otter our most sincere
appreciation for your efforts.
�HEALTH INDUSTRY MANUFACTURERS ASSOCIATION
MEMBERS:
300
REPRESENTS:
Manufacturers o f medical devices, d i a g n o s t i c s , and
h e a l t h care i n f o r m a t i o n systems.
TODAY'S SPEAKER:
Stuart Eizenstat, counsel
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Associations
I n f l u e n t i a l . Major i n d u s t r y group employing a
s i g n i f i c a n t number o f i n d i v i d u a l s .
Market-based approach
Believe malpractice/ t o r t reform should apply t o
them through p o l i c i e s r e s t r i c t i n g product l i a b i l i t y .
They generally f e e l wary of budgeting mechanisms and
resource evaluation/planning, f e a r f u l t h a t
diagnostic services and medical equipment and
devices may be r e s t r i c t e d . They were very concerned
w i t h Oregon's waiver plan.
POSITION ON
PLAN:
Generally supportive, w i l l w a i t and see
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
I r a Magaziner
HOT BUTTON ISSUES:
Budget, caps, technology assessment a c t i v i t i e s
�Mr. Eizenstat is an advocate for IcgisJativc policy, including trade, tariff, and antitrust legislation, on behalf of nuraercus clients. His clients include major
companies in the computer and electronics industries, exporters, a major
asbestos manufacturer, and a major petrochemical corporation. He represents a
number of significant associations and coalitions.
Mr. Eizenstat brings years of governmental experience to his law practice,
including White House positions in the administrations of Presidents Lyndon
Johnson and Jimmy Carter. Hefrequendyprovides expert testimony before U.S.
House and Senate committees on a variety of public policy issues. Author of
numerous articles on federal policy, Mr. Eizenstat writes frequently for such
publications as The New York Tunes, The Washington Post, The Los Angeles
Tunes, The Christian Science Monitor, The Atlanta Constitution, Newsweek, and
Fortune Magazine. liefrequentlyappears on television on a variety of topics. He
co-founded and co-directed .American Agenda, a unique bipartisan commission
chaired by former Presidents Carter and Ford to provide advice to the PresidentElect.
An adjunct lecturer at Harvard University's JFK School of Government, Mr.
Eizenstat is also afrequentlecturer to business groups, colleges, and civic
organizations.
Mr. Eizenstat is involved in a number of civic activities, including CLAL (The
National Jewish Center for Learning and Leadership), the National Academy of
Public Administration, and the Center for Excellence in Government.
�MPR 25 '93 05:12PM
202 624 7222
P.2/5
MA
HfAiTM !NDUSW MANUFACTUriERS ASSOCIATIOM
Statement of Stuart S. Eizenstat, Esq.
on behalf of the
Health industry Manufacturers Association
The question before us today i s "How can alternative forms
of health care delivery bring down the costs i n the long-term?"
This i s a most appropriate topic f o r today's discussion.
The Health Industry Manufacturers Association ("HIMA**)
believes t h a t s i g n i f i c a n t health care savings can be achieved by
national p o l i c i e s that r e f l e c t a balanced mix of government
action and responsible individual decision making. The
government should do what the private sector cannot; for example,
develop the rules governing the organization of large purchasing
groups and the rules governing a data c o l l e c t i o n system f o r
outcomes research. On the other hand, the system should
emphasize decentralized decision making, personal choice, and
market-based incentives. Attending physicians should continue t o
make p a t i e n t care decisions, patients should have a choice of
care, and patients should receive incentives t o choose
appropriate care.
Several of the general principles of managed competition are
consistent with these broad goals. These include the use of
market incentives t o promote the provision of good q u a l i t y care
at a f a i r p r i c e , the elevation of patients' r e s p o n s i b i l i t y f o r
making informed health care decisions based on cost and q u a l i t y ,
and the creation of health insurance purchasing cooperatives t o
provide s i g n i f i c a n t purchasing power f o r t h e i r enrollees.
Managed competition has the potential t o i n s t i l l rational
behavior i n our health care system.
Technology Assessment
Within the framework of a health care delivery system t h a t
contains incentives f o r cost conscious behavior, HIMA believes
that the proper u t i l i z a t i o n of innovative, value-added health
care technology i s essential. The federal government should play
an appropriate leadership r o l e i n the dissemination of the
information that w i l l enable a managed competition system (or any
new health system) t o function e f f e c t i v e l y .
We believe technology assessment can be an effective means
of informing purchasers and providers as t o which treatments are
most appropriate i n p a r t i c u l a r situations. Technology assessment
i s the analysis of both the short and long term consequences of
V/or/d Leaders in Health Care Innovation
1 200
G STREET.
N.W.. S U I T E
WASHINGTON.
D.C.
20005
( C 2 ) 7 3 3 ft 7 0 0
FAX ; 2 C 2 ) 7 6 3
8750
400
�MAR 25 '93
05:12PM 202 S24 7222
P.3/5
individual medical technologies. The more information that i s
available about a particular technology, the better decisions can
be made as to i t s utilization. For example, information about
technologies that are shown to either prevent
institutionalization or avoid reinstitutionalization would be
valuable to both provider and patient alike. We believe the
federal government should use i t s resources to develop a
centralized clearinghouse on assessment information - drawing
together the results of the many individual assessments that are
conducted around the world. I t should then use high-speed
electronic and communication technology to provide such
information instantly to any providers, payers, and employers who
need i t .
But we believe the government's role should stop there.
After i t creates this data avenue, i t should l e t providers,
patients, and insurers decide how to use the information.
Judgments about which technology to use in treating patients - in
essence, the day-to-day delivery of care - must remain in the
hands of the individual providers and their patients. I f the
government uses the information to make final, top-down decisions
about which technologies should be permitted, i t would undercut
the individual decision making and personal choice that l i e at
the heart of today's medical system and which form an important
tenet of the managed competition concept. I t would also s t i f l e
the very innovation that can demonstrate the effectiveness of
alternative delivery systems.
Outcomes Information
I t should be noted that only five percent of our annual
health budget i s spent on purchasing health technology.
Technology, by i t s e l f , i s not a significant contributor to rising
health care costs. The inappropriate use of technology, however,
constitutes a separate cost that i s d i f f i c u l t to quantify and
deserves careful analysis. Thus, we urge the adoption of a
policy to improve quality and remove unneeded and inappropriate
care, and encourages the use of the best technology and
procedures for specific patient conditions. In our view, this
would entail the following:
expand outcomes research and practice guidelines
development to provide patients and providers with
better information about the c l i n i c a l value of
particular treatments;
confront the growing pockets of underutilization of
health resources, including the need for prenatal care,
preventive and wellness services, and inner-city and
rural health treatment; and
�MAR 25 '93 05:13PM
202 624 7222
P.4/5
assure that a l l Insurance payment and regulatory
decisions by the Administration taXe into account the
long term effects on the quality of care for patients.
Adoption of New, Cost-Bffectivo Technologies
To further cost effective delivery systems, health care
reform should ensure that new, effective technologies used
outside the traditional hospital setting can be easily adopted.
We should avoid the example of the Medicare program, which has
not adjusted well to advances in treatment, technologies, and
care settings. Treatments or technologies performed outside the
traditional hospital setting - which are often the most costeffective treatments available - are not readily sanctioned by
Medicare. We urge the adoption of a coverage system that selfad justs as care moves to appropriate, cost-effective settings, so
that such care can be readily available to as many patients as
possible.
Health Information Systems (HIS)
Under our current insurance system, administrative costs
account for some 20 percent of the health care dollar. One way
to address this problem i s through electronic data interchangeautomated exchange of f i l e s and records among health providers.
This w i l l f a c i l i t a t e faster, more efficient handling of
administrative paperwork, and save significant health costs as a
result. Facilitating this system-wide capability for health care
should be government's responsibility. I n concert with this
central action by government, individual actions by hospitals,
physicians, and insurers can help improve management of health
care's administrative data.
HIMA member companies involved in health information systems
(HIS) can assist in developing policies that will reduce
administrative costs and revolutionize the management of patient
care data. HIMA HIS companies have working relationships with a
wide variety of public and private policy makers interested in
legislation that can f a c i l i t a t e the government's constructive
role i n patient data management. We would be pleased to work
with Administration o f f i c i a l s on these issues.
Basic Benefits Package
Finally, we believe that i f a standard benefits package i s
part of the health care system, i t should stipulate broad
categories of care by site and duration. A comprehensive package
that sets forth a broad array of commonly accepted services and
technologies w i l l provide providers and payers with the raw
material to explore the most cost-effective means of providing
�MAR 25 '93 05:13PM
202 624 7222
P.5/5
those services and technologies. Also, a more skeletal system
would surely result in a two t i e r system of health care delivery,
which we believe i s counter to the s p i r i t and the stated goals of
health reform.
HIMA appreciates this opportunity to contribute to the
discussion on health reform, and stands ready to assist the Task
Force i n i t s on-going efforts to develop a comprehensive reform
proposal.
Mr. Eizenstat, a partner in the law firm of Powell,
Goldstein, Frazer, Murphy, i s counsel to HIMA.
�5:45--
PANEL NINE-GENERAL HEALTH CARE PROVIDERS-TESTIMONY
ENDS
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Administrative Material on Constituency Groups and Ethics Working Groups – Folder 2
Creator
An entity primarily responsible for making the resource
Task Force on National Health Care
White House Health Care Task Force
Charlotte Hayes
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 2
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 15
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2006/2006-0885-F-2.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12093114" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
2/6/2015
Source
A related resource from which the described resource is derived
42-t-12093114-20060885F-Seg2-015-002-2015
12093114
-
https://clinton.presidentiallibraries.us/files/original/a4b4a9d81f3edd914611826924b1b4cd.pdf
7e1393601f8ee5379f76a5f70524577e
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Hayes
Subseries:
OA/ID Number:
3015
FolderlD:
Folder Title:
Admin. Material on Constituency Groups & Ethics Working Groups-Folder 1
Stack:
Row:
Section:
Shelf:
Position:
S
56
3
5
1
�Health Care Reform
Charlotte Hayes
OVP
Administrative material on constituency groups including African
Americans, Latinos, Indians, and on ethics working groups.
Briefing notebook for Health Care Task Force public hearing.
�THE PRESIDENT'S TASK FORCE ON HEALTH CARE REFORM
George E. Smith Center, George Washington University
Washington, DC
Monday, March 29, 1993
TABLE OF CONTENTS
lab
Schedule
1
Format of Task Force Meeting
2
Talking Points: Today's Task Force Meeting
3
Health Care Briefing Information
Talking Points: Health Care Reform
Talking Points: Task Force and Tollgate" Process
Health Care Briefing: Rising Costs
Health Care Briefing: Peace of Mind
"Road to Health Care Reform'' (Washington Post 1/26/93)
4
Panel One: CONSUMERS
•
Message
•
Participants
Overview of Organization
Biography of Presenter
Testimony
5
Panel Two: BUSINESS
•
Message
•
Participants
Overview of Organization
Biography of Presenter
Testimony
6
Panel Three: UNDERSERVED
•
Message
•
Participants
Overview of Organization
Biography of Presenter
Testimony
7
�TASK FORCE ON HEALTH CARE REFORM
Table of Contents (Continued)
March 29, 1993
Page 2
lab
Panel Foun GENERAL HEALTH CARE PROVIDERS
•
Message
Participants
Overview of Organization
Biography of Presenter
Testimony
8
Panel Five: PHYSICIANS
•
Message
•
Participants
Overview of Organization
Biography of Presenter
Testimony
9
Panel Six: INSURANCE
•
Message
•
Participants
Overview of Organization
Biography of Presenter
Testimony
10
Panel Seven: PHARMACEUTICALS
•
Message
•
Participants
Overview of Organization
Biography of Presenter
Testimony
11
Panel Eight: HOSPITALS
•
Message
•
Participants
Overview of Organization
Biography of Presenter
Testimony
12
�TASK FORCE ON HEALTH CARE REFORM
Table of Contents (Continued)
March 29, 1993
Page 3
lib
Panel Nine: GENERAL HEALTH CARE PROVIDERS
•
Message
•
Participants
Overview of Organization
Biography of Presenter
Testimony
13
Panel Ten: LABOR
•
Message
•
Participants
Overview of Organization
Biography of Presenter
Testimony
14
Panel Eleven: CONSUMERS
•
Message
•
Participants
Overview of Organization
Biography of Presenter
Testimony
15
Panel Twelve: BUSINESS
•
Message
•
Participants
Overview of Organization
Biography of Presenter
Testimony
16
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
�THE PRESIDENT'S TASK FORCE ON HEALTH
CARE REFORM
AGENDA
8:00 --
THE VICE PRESIDENT CALLS HEARING TO ORDER
AND GIVES OPENING STATEMENT ON LOGISTICS
[statement to end before LIVE coverage.]
8:05 --
THE VICE PRESIDENT GIVES OPENING STATEMENT
AND INTRODUCES FIRST PANEL
[Networks and C-SPAN will begin LIVE coverage at approximately 8:05.]
8:10 --
PANEL ONE-CONSUMERS-- TESTIMONY BEGINS
9:05-
PANEL ONE-CONSUMERS- TESTIMONY ENDS
9:10 -
PANEL TWO-BUSINESS-TESTIMONY BEGINS
10:10 -
PANEL TWO-BUSINESS- TESTIMONY ENDS
10:15-
PANEL THREE-UNDERSERVED- TESTIMONY BEGINS
11:1511:20-
PANEL THREE-UNDERSERVED- TESTIMONY ENDS
PANEL FOUR-GENERAL HEALTH CARE PROVIDERS- TESTIMONY
BEGINS
[MEG ARRIVES ]
12:20-
PANEL FOUR-GENERAL HEALTH CARE PROVIDERS- TESTIMONY
ENDS
12:35-
PANEL FIVE-PHYSICIANS- TESTIMONY BEGINS
1.35-
PANEL FIVE-PHYSICIANS- TESTIMONY ENDS
[MEG DEPARTS ]
1:40-
PANEL SIX-PHYSICIANS- TESTIMONY BEGINS
THE VICE PRESIDENT DEPARTS
[CAROL RASCO PRESIDES ]
[F.Y.I.
2:45-3:35
PANEL SEVEN-PHARMACEUTICALS]
�3:40-
THE VICE PRESIDENT RETURNS AND PRESIDES
[SECRETARY SHALALA IS PRESIDING AS THE VICE PRESIDENT
RETURNS]
PANEL EIGHT-HOSPITALS-TESTIMONY BEGINS
4:40-
PANEL EIGHT-HOSPITALS- TESTIMONY ENDS
4:55-
PANEL NINE-GENERAL HEALTH CARE PROVIDERS-TESTIMONY
BEGINS
5:45-
PANEL NINE-GENERAL HEALTH CARE PROVIDERS-TESTIMONY
ENDS
5.50-
PANEL TEN-LABOR-TESTIMONY BEGINS
[MEG ARRIVES.]
6:50-
PANEL TEN-LABOR-TESTIMONY ENDS
6:55-
PANEL ELEVEN-CONSUMER-TESTIMONY BEGINS
7:55-
PANEL ELEVEN-CONSUMER-TESTIMONY ENDS
8:00-
PANEL TWELVE-BUSINESS-TESTIMONY BEGINS
9:00-
PANEL TWELVE-BUSINESS-TESTIMONY ENDS AND
THE VICE PRESIDENT CLOSES HEARING
[THE VICE PRESIDENT DEPARTS.
MEG DEPARTS ]
�PANHT,
1: 8:05 - 9:05
Consumers
Daniel Schulder
C 5"H M u - -v&O
Director of Legislation
National Council of Senior Citizens
Phyllis Torda
Director of Health and Social Policy
Families USA
Max I . Richtman
Executive Vice President
National Committee to Preserve Social Security/Medicare
Peter Thomas
Attorney, Representing Members of CCD
Consortium for Citizens with Disabilities
Lavola Burgess
President
£ L/f - vo - ^ A 1
American Association of Retired Persons
Bill Keane
Board member of coalition member organization (on behalf of)
Long-Term Care Campaign
�PANEL 2: 9:10 - 10:10
Business
Gary Frank Petty
Treasurer and Member of the Board of Directors
Small Business Legislative Council
Margaret Smith
Chair, Legislation
National Small Business United
Samuel Carradine
Executive Director
Minority Contractors Association
Stephen Elmont
Vice President
National Restaurant Association
Andra Bennett
_ D£A J
Executive Director
National Association of Private Enterprise
�PANEL 3: 10.15 - 11:15
Underscrved
Larry Naake
Executive Director
National Association of Counties
Anne Hill
Director of Program Development
National Urban League
Nancy Danielson
Legislative Representative
National Farmers Union
Raul Yzaguirre
President
National Council of La Raza
Michael Anderson
Executive Director
National Congress of American Indians
�O
PANEL 4: 11:20 - 12:20
General Health Care Providers
Virginia Trotter Betts
President
American Nurses Association
Dr. Jack Harris
President
American Dental Association
Ann Elderkin
President Elect
American Academy of Physician Assistants
Reeve Askew
Member, Board of Governors
American Chiropractic Association
Sheldon Goldstein
Executive Director
National Association of Social Workers
Bryant Welch
Executive Director for Professional Practice
American Psychological Association
�PANEL 5: 12:35 - 1:35
Physicians
Dr. Raymond Scaletter
Chairman of the Board of Trustess
AMA
Dr. Jane Orient
Executive Director
American Association of Physicians and Surgeons
Dr. Richard Butcher
President
National Medical Association
John M. Tudor
President
American Academy of Family Physicians
Howard Pearson
President
American Academy of Pediatrics
Melvin Sabshin
Medical Director
American Psychiatric Association
�PANEL 6: 1:40 - 2:40
Insurance
Bill Gradison
President
Health Insurance Association of America
Eric Gustafson
President
Independent Insurance Agents of America
Mary Nell Lehnhard
Senior Vice-President
Blue Cross Blue Shield Association
Jack Moynihan
Executive Vice President, Group Insurance, Metropolitan Life Corporation
on behalf of
Alliance for Managed Competition
James Doherty
President
Group Health Association of America
�PANEL 7; 2:45 - 3;35
Pharmaceuticals
Robert F. Allnutt
Executive Vice President
Pharmaceutical Manufacturers Association
Dee Fensterer
President
Generic Pharmaceutical Industry Association
Dr. Charles West
Executive Vice President
National Association of Retail Druggists
G. Kirk Raab
Board of Directors, Chair on Health Care Reform
Industrial Biotechnology Association
Dr. John Gans
Executive Vice President
American Pharmaceutical Association
�PANELS: 3:40 - 4:40
Hospitals
Dick Davidson
President
American Hospital Association
Michael Bromberg
Executive Director
Federation of American Health Systems
Jerry Dykman
Executive Vice President
American Protestant Health Association
Sister Bemice Coreil
Senior Vice President
Catholic Health Association
Lawrence A. McAndrews
President
National Association of Children's Hospitals
�O
PANEL 9; 4:55 - 5:45
General Health Care Providers
Val Halamandaris
President
National Association for Home Care
Dr. Paul Willging
Executive Vice President
American Health Care Association
John Mahoney
President
National Hospice Organization
Stuart Eizenstat
Consultant
Health Industry Manufacturers Association
�O
PANEL 10: 5:50 - 6:50
Lahoi
Karen Ignani
Director of Employee Benefits
AFL-CIO
John J. Sweeney
International President
Service Employees International Union
Gerald McEntee
Inertnational President
American Federation of State, County, and Municipal Employees
Cindy Zehnder
International Representative
International Brotherhood of Teamsters
Robert Georgine
President
Building Trades Council
Alan Reuther
Legislative Director
UAW
�(| O
PANEL 11: 6:55 - 7:55
Qmsuinei
Cathy Hunvitt
Legislative Director
Citizen Action
Carol Reagan
Director of Health
Children's Defense Fund
Mary Cooper
Associate Director
National Council of the Churches of Christ in the USA
Leslie Scallett
Chair
Mental Health Liaison Group
Joan Kuriansky
Executive Director
Campaign for Women's Health
William Shaker
Executive Director
American Council for Health Care Reform
�PANF.L12:
8:00-9:00
Business
Jerry Jasinowski
President
National Association of Manufacturers
Robert C. Winters
Chairman, Health, Welfare, and Retirement Income Taskforce
The Business Roundtable
Robert Patricelli
Chairman, Health and Employee Benefits Committee
Chamber of Commerce
Tracy Mullin
President, Government and Public Affairs Division
National Retail Federation
Dr. Mary Jane England
President
Washington Business Group on Health
4)
Ellen Goldstein
Director of Health Policy and Communications
Association of Private Pension and Welfare Plans
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
�FORMAT OF TASK FORCE HEARING
As you know the Health care task force will be holding itsfirstpublic meeting on
Monday, March 29th. The event will be held at the George E. Smith Center (600 22nd
Street, N.W.) on the campus of George Washington University. The hearing will begin
promptly at 8:00 a.m. and conclude at 9:00 p.m. Since this is an open hearing, the audience
will be made up of the general public on afirstcomefirstserve basis.
The forum will follow a Congressional hearing type format. The day will be broken
into a series of twelve panels each lasting approximately one hour. Each panel consists of up
to six individuals representing similar consituencies such as consumers or business. Each
panelist will have three minutes to present an oral statement. After all panelist have made
their presentations, for the balance of the hour, the task force members present will have the
opportunity to ask questions and engage the panelists in discussion.
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
3
�TALKING POINTS FOR THE FIRST HEALTH CARE TASK FORCE MEETINC
#
•
As part of an exhaustive outreach process, the President's Health Care Task
Force, chaired by First Lady Hillary Rodham Clinton, will convene its first
meeting on Monday.
•
We are going to start early Monday morning and go until the Oscars start.
•
Over the course of 13 hours, the Task Force will listen to over 65 organizations,
representing a diverse group of consumers, health care providers, and businesses,
present their proposals and their concerns about how to control health care costs,
provide security to every American family, and maintain the highest quality of
care in the world.
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
�TALKING POINTS DEFENDING PROCESS
•
This i s the most open policymaking process i n h i s t o r y . Let's
put t h i s i n context. Decisions i n government have
t r a d i t i o n a l l y been made by a few people s i t t i n g i n a room.
I n c o n t r a s t , we have brought together the r e a l - w o r l d
e x p e r t i s e o f more than 500 people from a l l over t h e country.
These are people — doctors, nurses, s o c i a l workers,
a d m i n i s t r a t o r s and consumers — who know f i r s t h a n d t h e
problems i n our h e a l t h care system.
•
D i f f e r e n t agencies a r e f o r k i n g together w i t h H i l l s t a f f t o
formulate a proposal. This e f f o r t i s unprecedented i n two
important ways: 1) Instead o f the usual interagency
squabbling, people from a l l d i f f e r e n t agencies have come
together t o get something done. 2) Over 90 H i l l s t a f f e r s are
involved, making t h i s a t r u l y c o l l a b o r a t i v e e f f o r t between
the executive and l e g i s l a t i v e branches o f government.
•
I n t e r e s t groups are being included. Mrs. C l i n t o n , I r a
Magaziner and other White House o f f i c i a l s have met w i t h over
4 00 groups since the Task Force was formed. However, given
the p o s s i b i l i t y of c o n f l i c t of i n t e r e s t , we cannot l e t
i n t e r e s t groups make p o l i c y . For example, i f we were t o
give the AMA a permanent r o l e , we would have t o do the same
f o r every drug company or insurance f i r m t h a t wanted i n .
•
The one-hundred day deadline i s necessary because o f the
urgent need f o r a c t i o n . We've had enough studies and
r e p o r t s . I t ' s time t o take a c t i o n t o fundamentally overhaul
our nation's h e a l t h care system.
•
The people on the working groups have r e a l - w o r l d h e a l t h care
experience. I n f a c t , we have over 100 h e a l t h care
p r o f e s s i o n a l s i n c l u d i n g 60 doctors, 20 nurses, 6 s o c i a l
workers. [ I f pressed on doctors, almost h a l f o f them were
p r a c t i c i n g medicine before they took a leave t o help t h e
Task Force.]
The Lawsuit ( i f i t i s brought up):
•
The l a w s u i t i s c u r r e n t l y under appeal, but we are not here
t o t a l k about t h e l a w s u i t . We are here t o t a l k about how t o
make the health-care system work.
�HEALTH CARE TALKING POINTS
Summary
Americans are getting killed by skyrocketing health care costs. What you're charged
for health care is rising four times faster than your wages. That doesn't make sense and it threatens your family's future and the future of every business, large and small.
•
President Clinton is committed to fundamentally reforming our nation's health care
system. The Clinton plan will control your health care costs and provide security to
every American family. We will preserve what is best in the American system - the
highest quality medical care in the world and the individual's right to choose a doctor.
Within days of taking office, President Clinton established the Task Force on National
Health Care Reform, chaired by First Lady Hillary Rodham Clinton, to develop a
comprehensive health care reform proposal. Hundreds of health care experts ~
doctors, nurses, professors and businesspeople — have been brought in from around
the country to work with officials from government agencies and White House staff in
a series of policy working groups that have been set up to advise the Task Force. In
addition, diverse panels of consumers and health care professionals will be brought in
regularly to advise the working groups as they develop their recommendations.
•
Powerful lobbies and special interests are already lining up to defeat any plan we
develop. They oppose change because they profit from the waste and inefficiency of
today's system. But we are committed to breaking the gridlock.
•
The American people demand and deserve change now. Washington can delay no
longer. Interest groups can obstruct us no longer. Without immediate reform, the
annual cost of health care for American families will more than double by the end of
the decade - to a whopping $14,000 per family -- while workers will lose an
anticipated $650 increase in their incomes.
•
It won't be easy and it won't happen overnight. But we will stand with you and take
on the special interests. No American will feel secure again unless we bring health
care costs under control now ~ and make it possible for your family to get ahead
again.
Goals
•
The Clinton health reform proposal will:
• Control the rapid spiralling of your health care costs.
• Provide security and peace of mind, so that you don't have to worry about losing your
insurance when you change jobs or being denied coverage because you're sick.
• Root out fraud and overcharges.
• Simplify the system and reduce paperwork.
• Maintain the highest quality medical care in the world and preserve your health care
choices.
�TALKING POINTS ON HEALTH CARE TASK FORCE
AND THE "TOLLGATE" POLICY DEVELOPMENT PROCESS
WHAT THE TASK FORCE IS . . .
President Clinton established the Task Force on National Health Care Reform to
develop a proposal that would bring spiralling health care costs under control and give
American families the peace of mind and security they deserve. The President gave his
Task Force a clear charge: by building on the work of the campaign and the transition,
and incorporating suggestions and advice from all comers, prepare health care reform
legislation that he can submit to Congress within 100 days. President Clinton's Joint
Address to Congress emphasized that Washington can delay no longer: the American
people demand health care reform now.
Demonstrating his level of commitment to solving this complex problem, the President
appointed First Lady Hillary Rodham Clinton to chair the Task Force. As President
Clinton said, the First Lady is not only experienced but is capable and effective at
bringing people together around complex and difficult issues to hammer out consensus
and get things done.
The Task Force also includes representation from the highest levels of the government including the Secretaries of Health and Human Services, Labor, Treasury, Commerce,
Defense, and Veterans Affairs ~ as well as senior White House officials.
POLICY DEVELOPMENT: THE "TOLLGATE" PROCESS . . .
The overall policy evaluation effort of the Task Force is being coordinated by the
President's Senior Adviser for Policy Development, Ira Magaziner, and is based on the
'Tollgate" system ~ a research and evaluation process commonly used in the business
world for large-scale projects that need to be completed quickly. To advise the Task
Force, Mr. Magaziner has formed over 25 working groups. These working groups, which
are divided into health policy subject areas, will guide their research efforts through a
series of tests, or "tollgates", before a comprehensive set of options is presented to the
Task Force for consideration.
The first series of tollgates ~ the broadening phase ~ require the working groups to put
all serious options "on the table" - ensuring that all issues are considered, all questions
are discussed, and that the correct methodology is being used. The next phase of the
tollgate process narrows this broad group of options and makes draft recommendations,
which will later be synthesized into a comprehensive set of proposals. At that point,
auditors will check to ensure that all cost and savings projections are sound, and that all
legal concerns are addressed.
�TALKING POINTS ON HEALTH CARE TASK FORCE (Continued)
PROCESS . . .
The President feels strongly that this be an open and inclusive process, and has
structured the system to encourage participation from all levels of government, all
segments of the health care industry and the business community, and the American
people.
Hundreds of people - including officials from various agencies. Congressional staff,
health care experts, and White House personnel ~ are directly involved in developing
policy within the working groups.
In an attempt to make health care reform respond to the concerns of both those who
receive health care and those who provide health care, there are doctors, nurses, social
workers, and hospital administrators working on and contributing to many of the working
groups. In addition, diverse panels of consumers and health care professionals will be
brought in regularly from around the country to advise the working groups as they
develop their recommendations.
Representatives from several White House departments ~ including Congressional
Relations, Inter-Governmental Affairs, and the Public Liaison's Office ~ are actively
reaching out for advice from members of Congress, state and local governments,
organized health care interest groups, representatives from small and large businesses,
and the American people. All groups have been encouraged to submit written proposals
and many are being brought into the White House to meet personally with Ira
Magaziner and other working group members.
In addition, the Task Force operates a round-the-clock "War Room" ~ which receives the
thousands of speaking requests, policy papers, letters and phone calls from Americans
concerned about solving our health care problems. And whether it be a hospital
administrator's treatise on malpractice reforms or a widow's handwritten letter expressing
outrage at her skyrocketing prescription drug costs, each inquiry is taken seriously,
channeled to the appropriate working group, and given immediate consideration.
The First Lady has been travelling throughout the nation talking to the American people
about their health care concerns and their suggestions on how to reform the system. In
the past month, she has attended several roundtable discussions sponsored by the Robert
Wood Johnson Foundation across the country, where she has listened to the
recommendations of all the people ~ consmners, providers, and special interests - who
are eager to contribute to the Task Force as it develops its proposal for comprehensive
health care reform.
�HEALTH CARE: RISING COSTS
Message:
Urgency. It is important to stress what these costs mean for American
families and business, the consequences of inaction, and why we must act now.
COSTS TO FAMILIES:
•
American families are getting killed by skyrocketing health care costs.
Health care spending per capita has skyrocketed from $1,063 in 1980 to
$3,160 in 1992 - a 197% increase. [CRS based on HCFA and Bureau of
Economic Analysis]
COST TO BUSINESS:
•
Small businesses are hit proportionally harder by these rising costs than are large
businesses. Small business premiums are high to begin with and drastically increase
if one employee falls ill.
Small businesses have experienced annual health benefit cost increases of 20
to 50% recently. In 1991, one-third of small business owners experienced
health care cost increases of more than 25%. [Washington Post 1/26/93,
Arthur Andersen, 7/92]
•
Large businesses, and American competitiveness, suffer too under added costs to
their products.
American Telephone and Telegraph spends $3 million a day on employee
health benefits. [Christian Science Monitor. 11/21/91]
For the first time in American history, health care costs exceed business aftertax profits. [Health Care Finance Review. Winter 1991]
Health benefits consume 8% of payroll today. Left unchecked, they will
consume as much as 17% by the end of the decade. [Karen Davis, Johns
Hopkins University, 1992]
Auto companies spend more on health care than steel: In 1990, GM spent
$3.2 billion in medical coverage for its 1.9 million employees and retirees.
This was more than the company spent on steel. It amounts to $772 for every
car and truck made in the USA. ["Condition Critical", TIME, 11/25/92;
Christian Science Monitor, 11/21/91]
�HEALTH CARE: RISING COSTS (Continued)
THE CONSEQUENCES OF INACTION/WHY WE MUST ACT NOW:
•
Families: Rising at four times the rate of wages, health care costs threaten to
bankrupt the families of this Nation. We must act now to free American families
from the burden of health care costs.
Without reform, experts estimate that the annual cost of health care for an
American family will more than double by the end of the decade ~ to a
whopping 14,000 per family ~ while workers lose an annual $655 in income.
[Famihes USA and OMB]
•
Jobs: These costs are passed on to consumers stagnating the economy, slowing job
growth and hurting our competitiveness abroad.
Failure to adopt a cost-control strategy could result in the loss of 1.5 million
jobs over the next five years. [Ken Thorpe, University of North Carolina,
8/92]
•
Workers: If health care costs and wages continue to increase at their current rates,
a worker's salary will soon seem like a fringe benefit to his/her main source of
compensation - health care insurance.
Some estimate that, by the year 2000, the average employer could be paying
$20,000 a year for each employee's health benefits. [A. Foster Higgins cited
in Christian Science Monitor]
Workers have lost 58 percent of wage increases since 1980, and will lose 100
percent in coming years, because ofrisinghealth benefit costs for employers.
[Henry Aaron, Brookings Institution, 1992; President's Advisory Council on
Social Security, 12/91]
�HEALTH CARE: PEACE OF MIND
Message:
The Clinton Administration's reform proposal will provide security and peace
of mind, so that you don't have to worry about losing your insurance when you
change jobs or being denied coverage because you're sick. We must act now
to provide the peace of mind to all Americans who live in fear of losing their
coverage. No American will feel secure again unless we bring costs under
control ~ and make it possible for families to get ahead again.
THE GROWING RANKS OF THE MIDDLE-CLASS UNINSURED:
•
As costs continue to skyrocket, today's uninsured are increasingly working, middleclass families.
Over one million (1.067) of those who lost health insurance in 1991 were
Americans earning between $25,000 and $49,000. [Himmelstein and
Woolhandler, "The Growing Epidemic of Uninsurance", 12/92]
Seventy percent of the uninsured are above the poverty level. [OMB Director
Darman, testimony to House Committee on Ways and Means, 10/91]
•
Hundreds of thousands of Americans are losing their health care coverage each year.
100,000 Americans move into the ranks of the uninsured each month.
[Washington Post. 1/26/93]
•
Those who still have insurance have seen their benefits cut.
MIDDLE CLASS FEAR LOSING INSURANCE:
•
Millions more live in fear that tomorrow they will be uninsured or, worse yet,
uninsurable.
61 percent of Americans worry a great deal that health insurance will become
too expensive for them to afford. 48 percent of Americans worry that benefits
under their current health care plan will be cut back substantially.
[Kaiser/Commonwealth/Harris, 4/92]
•
And millions more Americans are afraid to change jobs for fear of losing coverage.
Thirty six percent of Americans earning between $30,000 and $50,000
reported that they or someone in their household stayed in jobs they wanted
to leave because they were afraid of losing their health care coverage.
["Health Benefits Found to Deter Job Switching," New York Times. 9/26/91]
�HEALTH CARE: PEACE OF MIND (Continued)
PRE-EXISTING CONDITION EXCLUSIONS:
•
One of the most distressing flaws in our current system of health care is that those
in greatest need of care Eire least able to obtain it. Nowadays, insurance companies
only provide insurance once they've made sure you don't need it. We must demand
that insurance companies change the underwriting practices which serve to avoid risk
instead of provide insurance.
One in twenty Americans has been denied coverage for a pre-existing medical
condition. [Kaiser/Commonwealth Harris, 4/92]
EMERGENCY ROOM CARE:
•
In many cases, the emergency room, the most expensive care in the world, deUvers
the treatment of last resort for the uninsured. Here people do not receive primary
care or preventive care. They become sicker and require even more expensive care
in the future.
Forty-three percent of the 99 million patients seen in emergency rooms in
1990 had minor ailments that could have been treated elsewhere. [Robert
Wood Johnson Foundation]
•
Uncompensated care increases costs to an already overburdened system. The cost
of uncompensated care is shifted to those who do have health insurance causing them
to pay more.
CHILDREN: IMMUNIZATION AND PREVENTIVE CARE:
•
Nationwide access to health care and immunization for infants and toddlers is a key
goal of health reform.
A child in Miami, who had contracted bacterial meningitis, incurred over
$46,000 dollars in medical bills. The disease could have been prevented with
a $21 inoculation. [Robert Wood Johnson Foundation]
Preschoolers are less likely to be immunized for DPT and polio today than
they were 20 years ago. [Robert Wood Johnson Foundation]
•
Lack of insurance and access to primary care ~ especially pre- and post-natal care - leads to higher infant mortality and morbidity rates as well as high costs for
preventable illnesses. We have to begin to refocus our health care system on
preventing illness and injury rather than just on treating them.
�T h i . m . « . n - ~ y b . P - o u c - by copynaht l . w . C M . 17. U.S.
x
^
WASH.P0ST:Q1Z2S£2
Road to Health Care Reform
BY DANif PRIEST
be statistic is straightforward: one
i every seven dollars spent in this coontry each year—an
estimated $939 UHoii in 1993—goes to hospitals, doctors,
insurance and drug companies, equipmeat makers, bureaucrats and others in the U.S. health care system.
But that is where straightforwardness stops. The "system' is not a system at all It is a collection of dissimilar and
often wasteful practices that has left 37 million Americans
uninsured. Unrestrained health spending has climbed to 14
percent of the Gross Domestic Product.
The caO for reforming the U.S. health care system—the
moat costly and advanced to the world—is fueled by startling contradktioDs:
While individuals, corporations and federal and state governments continue to spend an ever-increasing amount of
money oo health care—costs grew 11.5 percent last
year— 100,000 individuals a month continue to move into
the ranks of the uninsured. They lack coverage because
their jobs do not offer it or because they can no longer afford to buy it on their own, or are dumped by insurers when
they become iD or old.
While the United States spends more per capita oo health
care than any other country, its infant mortality rate is the
among the highest in the industrialized world, and publicized persona] appeals lor mooey too often determine
whether somecoe can afford a life-saving procedure such as
a transplant.
WhDe private companies and the Medicare and Medicaid
piograms have set price controls oo medical services and
negotiated volume discountsfromhospitals and insurers,
spending oo health care hasrisenfrom$250 billion in 1980
to $838 bOboa in 1992. Family spending on health care has
tripled in the past decade.
As candidate BQl Clinton said in his major health care
address during the presidential campaign: "We are the only
advanced nation in the world that does not provide basic
health care to aB its citizens. We spend 30 percent more of
our income than any other country in the world on health
care at a time when we desperately need to spend more oo
new plants, new equipment, new businesses, reinvesting in
education and training of our citizens. . .We cannot go on
like this.*
•
Hie reasons health care in the United States costs so
muck are numerous and interconnected. They include ever
more complicated medical procedures, a largely unfettered
consuBfT demand far services, an aging pofwlatko that
requires more care,fraudand abuse b programs Eke Medicare cxl Medicaid, wasteful and overlapping administratiao
costs anoog hospitals, doctors and insuren. Most important, Ae incentives for those providing care are to spend
mare ather than less in every area of medicine and in almost every case.
These incentives, moreover, have influenced the everydayralescf thumb that doctors use in deciding about tests,
bospitaEzatioo, operatxms, and so oo,' writes Princeton
University sociologist and Pulitzer Prize-winning author
Paul Starr in his book. The Logic of HealtM Care Reform.
' . . -American physicians' practice styles are partly the
prodnct offinancialarrangements that for decades rewarded the decisioa to treat even if there was no good evidence the treatment would work."
With no logical and effective cost restraints, American
hospitals have been built too big, with expensive equipment
that is under-used. There are too many costly specialists
and aot enough primary care doctors.
"The result," says Starr, "is not just incidental waste and
a fewfiagrantabuses but a vast misaDocatioa of resources.'
Far these reasons many policy experts, and Clinton, believe that only comprehensive reform can solve the twin
problems of containing costs andfinancinguniversal access
to affordable, high quality services.
IVcemeal legislation, argue experts, will only result in
piecemeal changes that will not gofarenough to reverse
the systemic problems in the health care system. A piecemeal qiproacfa may also dampen the momentum in Congress and the public for more complete reform—momentum that CUntoo created by highlighting the issue during
and after the campaign.
But systemic reform means taking oo the powerful, effective and diverse special interests al at once. Registered
lobbyists are already at work for more than 750 different
health care organizations,fromthe largest medical societies to the smallest manufacturers of disposable medical
equipment. Industry giants are already mounting their media campaign to shape public opinion in their favor. Business
groups have begun meeting with new members of Congress
to express their coocetns.
It is not only the lobbyists and industry leaders that Clintoo and Congress will have to contend with, however.
About 10 milbon people work in the health carefieldand
can be counted oo to make their feelings known to any legislator who supports changes that would dose a local hospital or pot the local insurance agents out of work. Reducing health care spending means reducing health care jobs.
So how has Chntoo premised tofixsuch a mess?
He has said repeatedly that he would propose a reform
plan within the first 100 days of his administration. During
his pre-maugural ecooomic summit, be emphasised the
need to get health costs under control in order to reduce
the federal deficit, heightening public expectations that real
reform is around the corner.
The two primary goals of his campaign proposal were to
provide everyone access to health care and to contain sky-
�T f M m t f r t t l m»y b t prst«e(*d by copyiieW l»w. (Tit)* 17, U.S. Codtl
WASH.POST:2i£2fii2i
KIKfKnfiE OF Oi. GROSS MTMMNL
PtOMJCT STOff ON NEMIN CMS
I960
70
'80
'90
2000
SOURCE: Health Cire Finincin( Mministratnn
NUMBOt OF NONOOERUr AMEKKUNS
WITHOUT HEMIM C0VDUGE,
WMIUNNS
1988
'89
'90
rodtetng costt. He tlso embraced the managed competitioo model aa the way to structure the system.
His promises include the foDowing elements:
• Require insurance companies to provide the same coverage to everyone in the same region for about the same
price (called "coomunity rating") and prohibit them from
denying coverage to individuals because they have pre-existing illnesses.
• Create a government board that would set annual national spemfing targets for public and private beakh care. The
goal is to Emit health cost increases to the rate of inflation.
• Instruct the board to establish a comprehensive, standard benefit package that all insurers would have to offer.
• Adopt an employer mandate that would require employers to provide port of then* employees' health premnniL
This requirement would be phased in to lighten the burden
on small businesses, and government subsidies would be
available to some businesses.
• Expand government health care subsidies for the unemployed and poor.
• Create kisurance-purchasmg cooperatives through which
companies and individuals could pun^ase a health {te. The
cooperatives would negotiate the best price and quality
from competing plans.
• Create incentives—most likely lower costs and special
tax benefits—for people to join managed care networks,
which are more cost-effective.
• Establish primary and preventive health care cfinics in
the nmer cities and rural areas.
• Emphasbe health education and prevention m schools
and the workplace.
• Invest more in health care research.
•
'91
SOURCE: Enployee Benefit Reuatch institute
tabulation of tne Ctfrwit reputation SuTwy,
Mami W. * ) . '91. "92
Gearing Up for the Fights
he status quo is out Change is in. Just about
every health care group imaginable now says it
endorses change and most say they endorse
reform "sunilar* to President Clinton's
proposals. That's the hitch. "Similar" but not quite the
same. In fact, major kuock-down-drag-outfightsare
expected in some critical areas, indudnig:
T
GLOBAL BUDGETS. There is not a health care
business group around, toduding doctors, hospitals,
insurers, etc^ that supports a goveimuent-imposed annual
health care budget that might require price coctrok. The
ardntects ol managed cotnpetitjoo, such as Stanford
Umveisrty prctfessor Alain Euthoven. befieve government
price-setting is incompatible with their model and wiD
significantly distort the market's ability to weed out
inefficient health providers and drive down costs. Others
believe savings are not possible without
govemment-imposed controls.
TAXING EMPLOYEE BENEFITS. Labor unions,
consumers and many business groups are opposed to
changing the tax treatment of health benefits. It is a
lucrative benefit they do not want to give up.
MANDATING THAT EMPLOYERS PROVIDE
COVERAGE. Employers cf all stripes, and most
federatioos that represent them, oppose such a manfate,
as do proponents of a sst^e-payta system who say
coffexage should not be employer-based.
HOW TO FINANCE UNIVERSAL COVERAGE. Eves
with an employer mandate, major disagreement i i
expected over how fast the government should commit
new resources tofinancinguniversal coverage.
The problem isfinkedto how CSoton deals with the
federal defidL If be deddes to wait and use the savngs
from reforming the entire health care system to help
suhsiffap expdiiJcil access, then it wiD be several yearc
befiae the ^"^fnwi^wt c^n do pw ^ If he ^^^^s to
savings to reduce the deficit, an even longer wait is ahead.
tbc oCbcrfr^n*^be could impose strict prj^f f^pK yp
achieve quick avings or increase deficit spending aod pxy
for expanded access more qiocUy.
�Thi» matcnaJ m«Y
p r o l t c t c d by eopynghi l*w.
rrm» 17, U.S. Cod*)
WASH. POST:01/26/93
What It Wfll Take to Cure Health Care
Leadership, Sacrifices and Defiance of Powerful Interest Groups Are Needed
national tragedy." Health spending in 1992
rose at nearly four times the rate of
general inflation. Yet millions saw their
health benefits shrink or disappear as
an President Clinton control our employers
cut back or abandoned coverage,
ruinous health costs in order to
and the ranks of the waiting rose at
cure the health system and the
crumbling public hnspitak and dimes.
economy?
AIDS and an ever aging popolatioo
Can anyone?
aggravate the problem. "Health care is
The answer is "no"—unless...
• Unless ke and Congress act fimlj endeating our lunch," said Hem; Aaron,
Brookings Institution economist. "There
courageously.
During the transition, Clinton said. I f we isn't going to be money to do
don't do something on health care... it's anythingVnot educate, not rebuild
going to bankrupt the country." For aeady industry, not clean the
25 years American presidents have tried to environment—"unless health care costs are
tame health costs and failed. To get control brought under control."
will require a degree of leadership, a
"The longer we wait the more expensive
defiance of powerful interests and a public this will be," said Kenneth Thoipe cf the
willingness to make sacrifices that have so University of North Carolina. Without
far been lacking.
comprehecsive reform, predicts the
• Unless Ote reform proceeds with aB Coogressienal Budget Office, by the year
pmdeni speed
2000 health spending wfflreach|1.66
trillion, coosunung nearly afifthof the
PATIENT'S ADVOCATE
nation's gross product
.
George Lundberg, the physician who
Candidate Clinton promised a plan in "the edits
the Journal of the American Medical
first 100 days." Some health experts are Association,
sees the resnh then as
urging caution, lest a hasty plan fafl. Tet a "meltdowB"—still
fewer covered, hospitals
credible effort must at least begin while
going bankrupt, desperate emergency
there is momentum.
• IMcss the effort is total, for (ken is no appropriations to maintain bare-boaes
services. Congress win then panic, he
one magic buUet
No plan now getting attention can alone predicts, and nationalize aU health care.
At this point. "Welcome to
do the job. A successful one must attack
many villains: the huge profits now being Canada"—Canada's government-paid
health care—said Rep. James Cooper
extracted by many businesses and
(D-Ky.), health reform advocate. Canada's
entrepreneurs, over-use of costly
provincial governments pay all the bills out
technologies, medical ignorance of what
truly works, the malfunctioning malpractice of tax dollars, but pay oo more each year
than budgeted. No one goes without basic
system—and a lack of primary cue
doctors, of prevention and of information to care, but, compared with Americans,
Canadians get less heart surgery and
tell patients who provides good care.
advanced imaging, less treatment by
• Unless the American people, and many
tntensts, accept the fact that true rtfom specialists and some irksome waits.
will involve pain.
Canada's way of curbing spending while
Pain means less money for many doctors covering everyone is advocated by sane
and others. Loss of jobs if 1,500 insurors
Americans, although not enough today to
are squeezed down to a more ef&ieat 50 make it a leading reform candidate.
and hospitals are forced to dose
There are in fact only so many waystocut
unneccessary beds. Almost surely new
any nation's medical expemes, namlr
taxes in some guise to cover the uninsured • Requiring those with health insaranoe,
and curb use of the system. And mufical
Medicare, to pay more for it
pain, being told, "YouU get less care than including
• Reducing health benefits—or domg less
you'd Gke. You can no longer see any
for the sick. One way to do less is doing
doctor you want."
only procedures proved medically
True, there is enough money in the
system—approaching a trillion dollars this beneficial a nice goal bat one that B years
year—to give everyone reasonable care, if away since so little is known now for tack of
enough research. Another way would be to
drastically reshuffled. But doing so could
stop keeping very skk, often aged patients
take years.
ahve a few more days, weeks or months.
The choices are hard, and "Americans
have DO stomach for hard chokes," in the "No other society would take a 90-year-old
with congestive heart failure out of a
words of former Colorado Gov. Richard
nursing home and put him into an intensive
Lamm, head of a University of Denver
care unit to die," Lamm wrote in Medical
policy center.
Economics.
Yet the nation has no choice but to act
• Cutting payments to hospitals, closing
There can be no control of the national
some, since the nation has too many
deficit—and no care for all—without
control of the health costs that wiS cause hospital beds. On the average day a third
half of the deficit's projected increase in the are empty.
nextfiveyears.
• Cutting payments to doctors. Medical
The situation now. Lamm said, is "a
groups argue against this, sajing that
By Victor Cohn
C
�T S t m a t . n d m.Y b* prot.ct«) by eopyriflM law. f T i t l . 17. U.S. Cod.)
(«
WASH.POST:filZ2fi/a2
ELEMENTS OF 'MANAGED COMPETITION'
• resident Clinton has endorsed a fonn of health careretormcaM "manaesd
p
competition'. Under the broad outiines o( the concept, most people nwuld
purchase health insurance from large, HMO-lite managed-cafe nehwte that
would compete for customer in a given region. A federally created board would set
up nonprofit insurance purchasing organiations to bargain with networte for the
most favorable rates.
wow* wr min KXOTB
.or,directly from
either through
KEJUTN MSUMNCE
OOOKMDWB
i
a govemmerrt-estatt: '
nonprofit agency acts
as a price negotiator
between the consumer
who needs health
benefits and approved
health plans who sell it
i
AmOVEDHEUnPUNS
The various approved health plans would probably be organized by insurws who
create large networks of doctors, hospitals, clinics, and the like. It is likely that
most of these would evolve into "super-HMO's*, in which medical services and
physician practices are scrutinized for cost-effectiveness and medical
appropriateness.
• AHP's Cannot baserateson medical history or pre-existing conditions.
• All AHP's must at least offer the same basic benefits.
HmOMLHENIH
• Standardize accounting and paperwork; establish a standard benefits padoflB
• Provide consumer infromation on the quality ot AHP's, including price and
outcome information
^
• Make a subsidy payment to plans with a large number of sick deople so that no plan suffers disproportionately
: ;
cutting doctors' incomes by 20 percent
would cut the nation's health bill by a mere
2 percent But doctors order 75 percent of
all care, so cutting payments for
procedures and restricting their use can
also help curt the rise in medical costs. So
can changing practice incentives.
Currently, doctors as a group—by no
means every one—tend to do more of the
things that pay them well. There is a trend
already toward paying them so much per
patient, or paying them salaries, rather
than added dollars for every procedure.
• Delivering care more efficiently, with
less personnel and less of the paperwork
- iiL"
demanded by too many rules by too many :,
insurers. By various estimates, between 18.
and 24 percent of U.S. health dollars are.
spent on administratiao while countries' "'
with government health systems spend
around 10 percent Lamm told of a 300-bed
Bellingham, Wash., hospital with 42 billing
clerks, while a few miles away m
Vancouver, B.C., a 300-bed hospital had
one.
The trick for health reform is to
incorporate all or most of these
cost-cutting measures while assuring
decent care for everyone.
�Thi« n v t u r i ^ m»y b« p r o i u t x ) by copyright law. (Titla 17. U.S. Coda)
•
Few people think Coogress can pass any
extensive health reform bill before 1994.
Few think any plan could then be phased in
and begin to affect costs in less than three
to five years. And it might take 10 years to
get the reforms working.
Minnesota Physician Paul EDwood. an
advocate for the so-called "managed
competition" approach, has said *we may have
onlyfiveyears'to control costs before
Congress gives up and goes the Canadian way.
Henoe, many health thinkers argue for a
federally set nabooal health budget a la
Canada—this and no more to be spent, with
controlled payments to doctors and hospitals.
wASH.posT:5m2fizaa
m f t C H M S * MTWMLKM.n
STOIWK, * M U M S * M U A B
A firm lid on spending might have a quick
effect. But, historically, price controls tend
to break down. And they would do nothing,
critics say, to affect long-term inflationary
pressure by changing medicine's culture,
encouraging doctors to do not just less, bat
less of the ineffective and unneccessary.
Etwood and the like-minded call a
marriage of managed competition and an
overall spending limit incompatible. There
is much talk, however, of such a wedding,
or at least a combination using annual
spending targets rather than firm Ms, with
more drastic action possible if the targets
1965
1985 1992 2000
aren't met. Proponents of an annual lid or
tough target include Brookings' Aaron;
SOURCE: Conpeslonal Budget Offica
Stuart Altman, former Nixon
NOTE. ! 9 9 2 . 2000 l i t p r c r c W
Administration health official and Clinton
adviser, Paul Ginsberg, director of
deliver on his promise to achieve universal
Congress' Riysiciar Payment Review
access that will not boost federal spending."
Commission; Karen Davis, former Carter
Aaron contended.
Administration health official, and Senate
The opposition to any true reform will be
Majority Leader George Mitchell
fierce. Much of the health industry win fight
to keep profits, wfakh must be trimmed or
Some reform advocates say they can
manage to cover everyone without addding dimmated if health care mfiaboc is to be
trimmed. Taxpayers wiD resist any new taxes.
to the nation's health bill, except in a few
Even affluent seniors wiD resist paying more
start-up years. Some say their plans can
save as much as $40 billion a year within a for Medicare or being taxed more for Social
few years of enactment, enough to cover aD Security benefits.
"Choices wiD be difficult," said Sea Mrtche!
those now uncovered.
"Mistakes wiD be made that need correction.'
Other authorities believe that covering
Yet, said Judith Feder, head of the
all of America's unprotected could cost
Clinton health transition team. T o wait for
somewhere between $22 billion and $135
billion yearly, depending on how the reform consensus.. .is to do nothing.. .What's
needed is leadership.'
•
is designed. "There is no way Clinton can
�Th». tTMUrial may ba protactad by copyright law. (Titla 17. U.S. Coda)
•
\0
WASH. POST :21i2fiZ93
A Survival Guide to Health Care Terms
anaged Compedtkn. Not to be confused with managed care, this refers
to the type of reform Clinton advocated during the campaign to overhaul
the country's health care system. It requires the government to regulate
insurers so that oo individual can be denied coverage and everyone buying
the same plan in the same regwc would pay nearly the sameforit.
Most emitayers and individuals would purchase insurance from a nonprofit
agency (a Health Insurance Purchasing Cooperative or HIPQ that would negotiate
the best price and service from competing health plans. Health plans would likely
be organized by insurers or managed care companies (such as health maintenance
organizations, or HMOs) that would own or contract with hospitals, doctors, clinics,
etc^ to provide care for the people who choose their plan. Experts agree most plans
would likely evolve into "super-HMOs.'
AO health plans would have to offer a standard benefit package, the contents to
be established by a government board. The government would collect information
from health plans on their medical effectiveness and on customer satisfaction,
which consumers couid use during open enrollment periods to choose a plan.
M
Maaaged Care. Refers to health care organizations—such as Health
Maintenance Organizatioos or Preferred Provider Organizatkms—that "manage" or
coatrol the cost of health care by dosely monitoring how doctors treat specific
Qbesses, by limiting referrals to costly specialists and requiring preautborizatiou
for hospital care, amoog other measures.
P»y or Ptay. A way tofinancehealth care for everyooe, this proposal calls for
employers to provide health insarance for their employees or pay a tax to help the
government provide it Most advocates of this approach also support some type of
government-imposed cost controls.
Single Payer. A system that has a single-payer—the government—for all bealtfa
care. The government would impose a health tax of some sort to pay for it
Doctors, hospitals and other medical services would remain in private hands,
although the government would impose various forms of price controls on them.
This is also often referred to xs the "Canadian model" or "natiooal health
insurance,* although many pobtidans have used the latter phrase simply to mean
that all people should be able to buy health insurance.
bstmnce Reforn. Refers to a number of new regulations most likely to be
imposed upon the insurance industry under any type of reform model The changes
ndude: prohibiting insnrers from denying coverage to sick people (exdusioo for
pre-existing conditions);fromcharging substantially lower rates to healthy young
people (cherry-picking) or higher rates based on an individuars health history or
occupation (experience rating); allowing people to bring their insurance with them
when they change jobs (portability).
Tax Tteatoeat Refers to two separate proposalsforchanging the tax treatment
of health benefits. Currently, employees do not pay taxes on the health insurance
their employers pay for them. Some healthreformproposals caO for
taxing, Gke mcoene, the amount of an employer-provided health premium that is
over the amount needed to purchase the lowest-cost standard benefit package in a
given regiofL
The secood type of tan proposal deals with changes in the deductibility of beahb
premiums. Currently, employers can deduct from taxation the entire value of the
health premiums they give their workers (self-employed individuals can deduct 25
percent). Somereformproposals include limiting the amount an employer can
deduct to the cost of the least-expensive standard benefit package in a regiou.
Both proposals aim to dampen the demand for high-priced—reformers say
excessive—health benefit packages by malting them relatively more costily.
Employer Mandate. When the government requires that employers provide
health insarance to their employees. Hawaii is the only state in the country with an
employer mandate. Usually, advocates of mandates have proposed that employers
pay a portion—often 50 to 80 percent—of the premium, depending on the size or
profitability of the firm.
Global Budgets. A vague term that refers to having the government monitor or
control private and public beahb care spending. In its most modest form, global
budgeting means having the government establish a national spending target that
can be adjusted from year to year. In its strongest form, the government sets a
national spending ceiling and apportions the national budget to the states. Each
state divides the sum between hospitals, doctors and other health care providers
and enforces the spending hmit by setting prices and imposing penalties on facilities
and physicians that do not comply.
�T I M m a t * r i 4 may ba protactail by copyright law.
(Tida 17, U.S. Codal
WASH.POST:21i2fiZ23
v i c u i wraasrtjntjn
T
manrOMcU*
i ki M V i can that hytnf to fart than M cut cm ba Ba e
paMcal p«h *»m tha c u m t trOat b • n f c m d ana It na j t ^ «
o»ttiartiato«tealia(wi»>iil>
r. Bwportlaafturb
mtpovabynaw
DOCTORS: The American
Medical Association, the largest
physicians' group, opposes price
controls of any form. It supports
an employer mandate to require
coverage and major changes in
health insurance to prohibit
abusive practices. It also wants
to have a strong say in shaping a standard benefit package
and in developing ways to monitor and measure physician
performance. Managed competition worries many doctors
because they fear it will lead to more regulation by nonphysicians over whU they do. Physicians are not a unified
front: some speciality groups differ from the AMA, and the
American College of Physicians endorsed a plan similar to
Clinton's.
• There are 560,000 doctors in the United States. Their
average salary is about $170,000. Slightly more than onethirt) are primary-care doctors, the rest are specialists.
HOSPITALS: They oppose price controls and other
govemment-imposed cost controls. Hospitals support
employer mandates; they are especially
concerned about the growing number of
people they treat who have no one to
pick up the tab. They favor most other
Clinton proposals and wanttomake
sure hospitals have a large role in
organizing community-based health
networks that would provide people.
with a complete range of medical care.
• There are 738 for-profit hospitals, most represented by
the Federation of American Health Systems, and 5,342
not-for-profit hospitals. The largest hospital group, the
American Hospital Association, represents about 4,500
for-profit and not-for-profit facilities. Hospitals earned
$235 billion last year. They were not compensated for
$10.8 billion worth of care to indigent patients. Hospital
care is the single largest category of national health care
spending. About 3.5 million people work for hospitals.
INSURANCE COMPANIES: This is
a fractious group. Generally, they
oppose govemment-imposed price
controls, especially on insurance
premiums. They also will oppose a
comprehensive standard benefit
package, which they believe to be too
costly to provide,The largest companies
are resigned to significant regulation of
insurance practices, including a
prohibition on charging lowerratesto healthy young
people and excluding coverageforpre-existing illnesses.
The large companies, which already have moved into the
managed care business, would prosper under Clinton's
campaign proposal. Many small companies will likely go
out of business altogether, a threat many of them will
fight.
• The average monthly cost of a family policy has gone
from $210 in 1987 to $355 in 1991. The indusby
employs about 900,000 people.
R
DRUG COMPANIES: Frequently
criticized for its prices and profits, the
drug mdusby is preparing for a major
fight to stave off price controls. A few
large companies voluntarily have been
holding their price increasestothe
inflation rate to show they can police
themselves. But influential critics on
the hill, mainly Sen. David Pryor (D-Aik.), a Clinton friend,
believe the government must limit prices. The
Pharmaceutical Manufacturers Association is debating
whether to endorse Clinton's managed competition
proposal and wants to make sure drugs are covered under
the standard benefit package.
• Spending on pharmaceuticals reached $51.3 billion in
1992. Drug companies spent about $10 billion on
research. The industry employs about 300,000 people.
CONSUMERS: The main organized
consumer advocacy groups, including
Families USA, Citizen Action,
Public Citizen, Consumers
Union, the Consumer
Federation of American and
Neighbor to Neighbor, back a
single-payer, government-financed
plan. They believe that everyone,
regardless of income or job status, should
have access to quality health care. They criticize Clinton's
proposal because insurance companies would continue to
play a major role, the system would still be market-based
and there is no guarantee everyone would be covered
immediately.
• About 37 million people have no insurance and many
more have policies with exceedingly high deductibles and
copayments.
BIG BUSINESS: By no means monoTrthic, important
business coalitions, including the Washington Business
Group on Health and the Business Roundtable, back
efemerrts of Clinton's proposals,''
includingreformof health
insurance. Most oppose employer
mandates, government price
regulation and limiting the tax
deductibiTrty of health benefits. Most
companies that are self-insured
would also oppose government regulations requiring their
employees to purchase coverage from regional purchasing
cooperatives.
• About 140 million people, 57 percent of the U.S.
populatior, get health insurance from their employers.
About 83 percent of full-time employees atfirmswith
more than 100 workers get health insurance from their
employee. Large employers have experienced annual
increases in health premiums of 15 to 20 percent.
rt
�T h i . m«t.ri«l in«v b* prowet»d by eopyTiaht
CTitl* 17. U.S. Cod»)
WASH.POST:Qii2fi/a2
,»
p i
SMALL BUSINESS: Represented by such
K { rational grassroots organizations is the
KJ\
Ntfional Fedenbon o( Independent
Businesses and the National Association ol
Manufacturets, small businesses wttbised
to mount a major fight against an anpteyer
mandate or other forms of health care taxes.
They support other aspects of Clinton's
proposal and welcome insurance purchasing arrangements
and insurance industry reforms that will make it less
expensive for them to buy Insurance. But NFIB members
generally oppose any regulation on businesses.
• About 69 percent of full-time employees at firms with
fewer than 100 workers get health insurance from the
companies. Small firms have experienced annual health
benefit cost increases of 20 to 50 percent recently
m
LABOR: Lucrative labor union agreements on health
benefits have been the benchmark for most large .
employer-provided benefit packages and the AFL-CIO is
determined to hang ontothem. Corporate give-back
requests were at the heart of severalrecentmajor strikes.
Some unions favor a single-payer system and others
support parts of Clinton's general proposal. But ttiey
oppose taxing health benefts because it would Kkety mean
employees would pay higher taxes or see fair benefit
packages shrink. They favor an employer mandate and
want to drop the Medicare eligibility;
to 60, which would lighten the
financial burden on companies' and
unions' retiree health plans.
About 15 million workers. 18
percent of the labor force belong to
unions.
THE PLAYERS
J \ handful of lawmakers are strongly identified with one
brand of reform or another. To get their support, Ointor
will have to either make enot(gh compromises to satisfy these powerbrokers orfiodways to make it polrbcaBy too
costly for any member ib deral his plan. With a supposed
end to the era of gridlock, voters expect health care reform.
Once legislation is proposed, members of Congress will
have no one but themselves to blame for inaction.
There are six major health committees and about 70
other committees and subcommittees with jurisdiction over
some pot of health money and policy. Here are the top
health care players on Capitol HHI:
IN THE SENATE:
GEORGE MITCHELL (D-Malne):
Majority leader Mitchell
. introduced a "pay or play" bill
last session but has put his
legislation on hold. He heads a
working group of more than 20
Democratic members and their
staffs who have divided
themselves into sectionstowork
on crucial areas in the coming
debate, such as the concerns of
small business and ways to
impose national spending limits.
The staff met with Clinton's
health transition team. Mitchell's hope is to merge his
team with the administration's to begin work on legislative
language for a bill that Qinton, House majority leader
Richard Gephardt and Mitchell can all bless.
EDWARD KENNEDY (D-Masi.):
As chairman of the Labor and
Human Resources Committee,
Kennedy has long served as the
unofficial spokesman for health
carereform.His position has
evolved from supportfarthe
single-payer Canadian model to
one doser to the pay or play
model He has two goals that he
insists on: universal access and
containing health costs. He will
have to be convinced that Clinton's plan wiU achieve these
things before he signs oil on iL
JAY ROCKEFELLER (D-W.Va.):
In three years, Rockefeller has
become the Senate's health care
reform salesman and
conscience, a role he played
tirelessly during the presidential
campaign. He has close ties to
Clinton's health advisers and is
likely to be one of the presidents
unofficial liaisons with the
Senate. He believes some form
of government regulation is
necessary to control costs and to
guarantee health coverage for all
Americans.
�T h i * material may ba protactad by copyright law. fTitla 17. U.S. Codal
WASH.POST:01/26/93
DANIEL PATRICK MOYNIHAN
(D-N.YJ: K« becomes rfiairmen
al me Hnance CommSlee this
year, which has responsibility for
tax matters. Moynihan replaces
the more conservative Uoytf
Bentsen (D-Texas), Clinton's
secretary-designate for the
Treasury Department. Although
Moynihan has not been a leader
in the health care held, he wants
to be supportive of Clinton.
NANCY KASSEBAUM (RKansas): She takes over as the
ranking minority member or
Kennedy's Labor and Human
Resources Committee.
Kassebaum is interested and
committed toreform,much more
so than her predecessor on the
committee, Orrin Hatch (RUtah). She supports the general
managed competition concept,
wants to impose caps on
insurance premium increases but is opposed to employer
mandates that require businesses to provide coverage and
rate or fee setting for hospitals and doctors.
BOB DOLE (R-Kansas): Well
versed and experienced in health
care matters, he is poised to be
the stalking horse for the
conservatives. He has been an
advocate of market-based,
incremental reform similar to that
proposed by President Bush
during the campaign. Dole is
expected to oppose most forms of
government regulation, most
especially mandates on businesses, but has not entirely
closed the door on some type of price controls to control
costs. He wants to make sure that rural areas fare well
under any plan.
health coverage for ttie
unktared. M Roahntowshi is
also under Mestiption ty ^ ^
federal grand jury and dealing'
with his legal problems might
take him out of the debate, ff
Rostenkowski were to give up his
chairmanship it would fall to
Sam Gibbons (O-Florida), whose
approach is more radical. He
favors eliminating the age ^
requirement for Medicare are"
bringing all Americans into that
system. He does not believe competition can work. "Did
you ever see anyone bargain with a doctor?" he said to
explain his position.
FORTNEY "PETE" STARK (DCalif.): Stark, chairman of the
Ways and Means health
subcommittee, brokerankswith
a leadership request not to
introduce any health legislation
by reintroducing the GephardtStark bill, minus Gephardt The
300-page bill would impose
government cost controls over
public and private health outlays,
with a national limit on total
spending, enforced by government fee schedules. A
committed liberal who has spent his whole career on
health issues, Stark wants to be cooperative but also warts
to remain in an activist role.
JOHN DINGELL (D-Mich.):
Dingell, chairman of the Ener^
and Commerce Committee, is
considered one of the more
independent of the health
committee chairmen. Long a
supporter of national health
insurance financed through a
value added tax and a payroll tax.
he has indicated that he will wait
and see what Clinton proposes
before endorsing or criticizing it
IN THE HOUSE:
RICHARD GEPHARDT (D-Mo.):
Majority leader Gephardt has
asked House members not to
introduce health policy
legislation until after Clinton's
bill is sent to Congress. He tried
hard but failed last sessiontoget
consensus on health care reform;
his own proposal emphasized
voluntary spending limits on
doctors and hospitals with
govemment-imposed price
controls to back it up. He is
expected to help Clinton steer a plan through Congress and
intends to introduce the new president's legislative
proposal.
DAN ROSTENKOWSKI (D-IH.)-. The chairman of the Ways
and Means Committee, which has jurisdiction over tax
matters, supports government price regulation and the
"pay or play' model. He is skeptical of any managed
competition plan that cannot guarantee enough
government savings that could then be used to pay for
HENRY WAXMAN (D-Caiif.):
Waxman was the chief cosponsor on Dingell's bill last
session. He chairs Energy and
Commerce's health
subcommittee and has been a
respected crusader for national
health insurance. He cares very
much about reforming the
system and is expected to be an
active consumer-minded
watchdog over Clinton's
legislation.
�Ttai material may ba protactad by copyright law. (Titla 17, U.S. Codal
WASH.POST:01/26/93
JIM MCOERMOTT (D-W.Va.).
He takes over the single-payer
mantle for Marty Russo (D-IU.),
who lost his reelection bid.
McDermott has dose ties to the
grassroots and consumer groups.
While Clinton moved the debate
significantly away from a
government-financed system
during the campaign, the idea
continues to have appeal to many
consumer groups. McDermott is
one of a handful of doctors in the
House. He is a psychiatrist
JIM COOPER (D-Tenn.): Over the
last year Cooper's stock in the
health care debate has skyrocketed
nearly as rapidly as health care
costs because he is a principal
author of the Conservative
Democratic Forum's "managed
competition" bill. After Clinton
became an adherent, Cooper has
stumped tirelessly for the model.
He will pressure Clinton not to
impose a global budget. A junior
member, his clout is derived from
the COF, which counts more than 40 members in the
House and support from a fair number of Republicans.
THE ADMINISTRATION
0 „ne thing is certain.- Clinton will make the most crucial
decisions himself. Most of the other people who will have
prominentroleshave been long-time friends and/or
associates of both Bill and Hillary Clinton, a factor that
became all the more significant this week when the White
House announced that Hillary Clinton would head the
health care task force charged with writing Clinton's plan.
Judging from the size of the undertaking—the
conceptualization, the numbers crunching and the public
relations effort required to sell the evenhial legislative
proposal to Congress and the public—there will be plenty
of work to go around.
Administration players include:
HILLARY RODHAM CLINTON:
While not an expert on health
policy and economics, the First
Lady begantosteep herself in the
intricacies of health care reform
during the campaign. Her role as
leader ol an interagency task force
would give the subject an instant
high profile. The coordinating role
would be a familiar onetoher;
Clinton named his wifetoan
Arkansas commission to improve
the education system there. She
held hearings, drew up a final proposal and testified before
the legislature. Her work with the Children's Defense Fund
leads some insiders to believe that her first priority would
be to provide health coverage to uninsured children.
IRA MAGAZINER: His official title is "senior adviser to the
president on policy development* in the White House. As
successful business consultantfromRhode Island and a
former anti-war activist at Brown University, Magaziner's
relationship with Clinton goes back to their days as Rhodes
scholars. He was influential during the campaign in
convincing the candidate to adopt a more market-oriented
approach to reform.
DONNA E. SHALALA: The new
secretary of the Department of
Health and Human Services is a
longtime friend of Hillary Clinton.
Her last job was as chancellor of
the University of Wisconsin at
Madison. While familiar with
health care matters, she too, is
not a policy expert on the subject.
HKShastraditionaltybeenin
charge of health policy; it has
jurisdiction over Medicare and
Medicaid as well as the National Institutes of Health and
the Food and Drug Administration. Shalala has made it
dear she intends to be prominent in health care reform.
CAROL RASCO: Also a longtime associate of both the
Clintons, Rasco is assistant to the president for domestic
policy, a large portfolio. She has said her priority will be
•health, health, health." Rasco was an adviser to Qinton
for 10 of his 12 years as Arkansas governor.
JUDITH FEDER: Feder is the
only professional health care
policy expert in the group. Before
joining the campaign as an
adviser, and then heading the
health care transition team, she
cochaired the Center for Health
Policy Studies at Georgetown
University. Feder is Shalala's
principal deputy for health care.
She became well known on the
Hill and elsewhere as the staff
director of the Pepper Commission, a bipartisan
congressional commission that studied health care reform.
She has close ties to Sen. Jay Rockefeller (D-W.Va.), who
headed the commission after Sen. Claude Pepper (D-Fla.)
died.
��^„
8:00 --
THE VICE PRESIDENT CALLS HEARING TO ORDER
[Also seated with The Vice President are: HHS Secretary Shalala
Ira Magaziner, Special Assistant to the President, Carol Rasco,
Domestic Policy Adviser to the President.]
VICE PRESIDENT GIVES STATEMENT ON LOGISTICS FOR
THE DAY
��8:05 --
VICE PRESIDENT GIVES OPENING STATEMENT
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
^
�8:10--
PANEL ONE-CONSUMERS- TESTIMONY BEGINS
Now, we will begin the first panel with testimony from consumers. Each panel of
witnesses has been asked to address a question as they prepared their remarks for today. For
this panel we have asked: "Given the need to control costs, how can we incorporate long-term
care into a comprehensive health reform package?" Ourfirstwitness is Mr. Daniel Schulder,
Director of Legislation for the National Council of Senior Citizens.
�PANEL ONE: CONSUMERS (SENIORS/DISABILITIES)
#
Question Posed:
Given the need to control costs, how can we incorporate long-term care into a
comprehensive health reform package?
Groups:
National Council of Senior Citizens
Families USA
National Committee to Preserve Social Security/Medicare
National Association of Developmental Disability Councils (on behalf of CCD)
Consortium of Citizens with Disabilities
American Association of Retired Persons
Long-Term Care Campaign
Major issue concerns:
1.
2.
3.
Long term care
Retirees health benefits
Prices of prescription drugs
AARP has a health plan fairly similar to our framework; NCSC is strong for single-payer
(See Message Sheet for Panel Eleven: Consumers); others don't have overall plans but
only really care about the above three issues. Long term care is the highest priority by
far.
Talking points:
1.
Long term care: Supporting comprehensive health reform means that all health
issues, including long term care, must be and will be addressed. We want to
emphasize home and community based care.
2.
Retirees benefits: Our plan will ensure that aUAmericans, regardless of
employment status or health, will have healtfilfisurance:—
3.
Price of prescription drugs: It is wrongjthat_Americans pay more for prescription
jimgsjhan do people in otheTcou^es^Ql^ianwill stop~drug overcharges and"
excessive profiteering.
�NATIONAL COUNCIL OF SENIOR CITIZENS
MEMBERS:
Over 5 m i l l i o n Older Americans.
REPRESENTS:
5,000 a f f i l i a t e d clubs and State Councils
nationwide. Mostly r e t i r e d union members.
TODAY'S SPEAKERS:
Daniel Schulder, D i r e c t o r o f L e g i s l a t i o n (see
bio)
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Very organized grass roots o r g a n i z a t i o n ,
influence and a b i l i t y t o m o b i l i z e q u i c k l y .
Single payer, but f l e x i b l e
The NCSC supports the f o l l o w i n g items f o r
health care reform
• p r e s c r i p t i o n drug b e n e f i t
•long term care b e n e f i t
•retiree benefit
•cost sharing
• q u a l i t y assurance
•cost containment
•health planning
•patients r i g h t s
•program Administration
•payment mechanism
•no opt out o f HIPCS
•system leading t o 2 T i e r system
Do not abandon o b j e c t i v e s .
POSITION ON
PLAN:
Wait and see, w i l l i n g t o work w i t h us.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
President, Public Liaison and T r a n s i t i o n
PET ISSUES:
Passage o f h e a l t h care reform, r e t i r e e
b e n e f i t s , long term care, and p r e s c r i p t i o n
drug p r i c e s .
�Eugene Qlovsr
sMrapm
w
itf
/o2«fc2£\
m.T
1
•!
Lawrence T. Smedley
/wiflOK\ Nationfll Council
of Senior Qtizens
1331 F Street, N.W. • Washington, DC 20004-1171 • (202) 347-8800 • FAX (202) 624-9595
Panel 1 - Health Care Task Force
March 29, 1993 Public Hearing
Washington, D.C.
Personal Data of Presenter
Daniel Schulder
Director of Legislation
National Council of Senior Citizens (NCSC)
1331 F Street, N.W.
Washington, D.C. 20004-1171
Mr. Schulder manages the public policy and legislation activities of the Council on
behalf of its five million members in local and state clubs and councils. He was
formerly the Director of Public Policy for the National Council on the Aging and
a Special Assistant for Aging and Disability Policy to Governor Milton Shapp of
Pennsylvania. He served on the staffs of the White House Conferences on Aging
in 1971 and 1981 and was a Field Representative of the Retired Workers
Department of the United Steelwoikers of America, AFL-CIO. He was also a
Special Assistant for Regional Economic Development to U.S. Secretary of
Commerce Juanita Kreps in the Carter Administration.
Firat Vtae PrHMent , Dr. Mary C. Mulvey, Provldoncs, Rhode Island Second Vice PreeMent, George J. Kourplas. Wtshington, DC
Third Vice PraeideM , Dorothy Walker, Detroit Mtohtgen Fourth Vice Preetdent , Everett W. Lehmann, WesMngton. DC
lewetary-Treeawer , jack Turner, Detroit, Michigan Qeneral Ceunael , Robert J. Mcuar, New York
9 #!H0Nn00 0IH0N003 lVN«-96S6r29Z0Z
7""z»:El ! E6-S2-E i
0S0N:AS 1N3S
�ssar
National Council
of Senior Qtizens
1331 F Street, N.W. • Waahington, DC 20004-1171 • (202) 347-8800 • FAX (202) 624-9595
Summary
Presentation by Daniel J. Schulder,
Director of Legislation
National Council of Senior Citizens
Washington, D.C.
Before the
Public Hearing of the
President's Task Force on
National Health Care Reform
George Washington University
Washington, D.C
March. 29,1993
Panel 1: Consumers "Incorporating
Long-Term Care into a Comprehensive
Health Reform Package"
Pint Vie* PrMktent , Dr. Mary C Mulvay, Provldanc*. Rhotto laland Sacond Vlca PreeMent , George J. Kourpias, WaehinQton, DC
Third Vlee PreeMent , Dorothy Walker, Detroit, Michigan Fourth Vtee Prealdent , Everett W. Lehmann, Washington, DC
•eerettryTreavrer , Jack Turner. Detroit, Mlohigen Oenerel Ceuneel , Robert J. Mozer, New York
z aniONnoo OIWONOO3 ivN^seserzgzoz
iV:fii i £6-sz-e :
OSON:AQ IM3S
�The National Council of Senior Citizens (NCSO is honored to share
with this Task Force our thoughts on incorporating long-term care into
a comprehensive health reform package.
It is our belief that long-term care is a fundamental component of
any national health system. No health reform package would be
"comprehensive" without long-term care services.
We believe that the goal of all "health" services is the functioning
integrity of human beings. "Health" care refers to the pre- and post-natal
care provided to mothers and highly dependent children. It includes the
full range of acute care services, surgical interventions, pharmaceuticals,
preventive services, healthy lifestyles, care by medical personnel and
social and family support for persons with chronic and disabling
conditions.
We know that this Task Force will assure the citizens of this nation
that acute care services will be at the core of the comprehensive program;
that is appropriate. It is no less appropriate that home- and communitybased care services, such as respite care, home health care, adult day care,
physical, speech and other rehabUitative therapies, medical social
services, homemaker services and special transportation services will be
at the same core.
�All of these and other services, including institutional care,
constitute basic support for the families of impaired persons of all ages.
Family care is the bedrock of the long-term care system. Public
policy must be directed to support such families, especially parents, adult
children and spouses, as they continue to provide the human dimension
of personal care that cannot be duplicated or supplanted by professionals,
institutions or agencies.
Much has been said about the cost of a comprehensive long-term
care system. The total outlay for basic long-term care costs probably
exceeds $60 billion. We haved read that some persons associated with the
Task Force already view a four-year phase-in of services as
"prohibitively expensive."
We believe that a phase-in of long-term care services is
appropriate—the "system" must be constructed out of a too-frequent
pattern of fragmentation. However, it is our belief that 15 billion in 1993
dollars would provide a comprehensive set of home- and communitybased services for most persons who would be eligible based on ADL
deficits and cognitive impairments. If we could reach such a level of
outlays within three to five years, we could claim the first step in making
the national health system truly comprehensive.
-2-
t «iH0Nn00 0IW0N003 lVN«-S6S6tZ9Z0Z
i
lt:Sl ! E6-S!-e !
0S0N:AS 1N3S
�We should recognize that at least half of such a national home- and
community-based care budget is already provided through public outlays
of the Medicare and Medicaid programs. An additional $30 billion
annually in public funds are already being spent on institutional longterm care.
We believe that the citizens of this nation are willing to shoulder
the financial burden of a comprehensive long-term care system* They are
already spending scores of billions of dollars in out-of-pocket costs
which will continue even under a reform program. Our organization
supports the current single-payer health bills in the Congress, H.R. 1200
and S. 491, which will require the deeper taxation of Social Security
benefits and a $65 a month premium to be paid by older persons.
We also support the full use of the tax code for progressive taxes
which should be dedicated to national health reform.
NCSC believes that we have reached an historic moment The
President and the Congress are about to close the health care gap in our
national community of concern for the national welfare*
We know that you and the President are committed to
comprehensive reform. Long-term care is an integral part of that reform.
Thank you.
-3-
S #!H3Nn00 0IW0N003 lVN^S6S6tZ9Z02
! Zftfil ! SB-SZ-E \
0S0N:AG INaS
�RCV BY:
3-24-93 ;i::QCAM !
1 2C2 347 2417-
SOCIAL OFFICE;* 2
BIOGRAPHICAL SKETCH
Phyllis Torda
Phyllis Torda is Director of Health and Social Policy at Families USA
Foundation, where she directs the Foundation's research and policy activities relating
to health and long term care, and income security. Her work at the Foundation ;has
included writing and managing the production of over a dozen reports including k
Comparaxive Analysis of the Presidential Candidates' Health Plans; Health Spending:
The Groyving Threat to the Family Budget; The Health Cost Squeeze on Older •
Americans; and Nursing Home Insurance: Who Can Afford It? She is the Director of
the Administration on Aging's National Hdercare Institute on Health and Income
Security and participates in the National. Leadership Coalition on Health Care Reform,
a coalition of business, union and consumer organization leaders created to address
health and long term care reform. She coordinated beneficiary groups' participation
in the development of physician payment reform.
i
i
i
Prior to coming to Families USA Foundation, Ms. Torda was Coordinator for
Health Policy at the American Federation of State, County and Municipal Employees.
She has completed all requirements except the dissertation for a Ph.D. in History
from the University of Wisconsin.
i
�FAMILIES USA
MEMBERS:
No number a v a i l a b l e
REPRESENTS:
American f a m i l i e s - - F a m i l i e s USA i s a l i b e r a l
h e a l t h care consumer group working f o r
a f f o r d a b l e , h i g h - q u a l i t y h e a l t h c a r e and l o n g
term care.
TODAY'S SPEAKER:
P h y l i s s Torda, D i r e c t o r o f H e a l t h and S o c i a l
Policy
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUP:
PET
ISSUES:
Combines s o p h i s t i c a t e d g r a s s r o o t s a c t i v i s m
w i t h media savvy. Reports w e l l r e p o r t e d i n
Media and on C a p i t o l H i l l ( e f f e c t i v e l y
promotes agenda w h i l e m a i n t a i n i n g nonp a r t i s a n , quasi-academic s t a n c e ) .
Active
coalition builder.
S o l i d s u p p o r t f o r A d m i n i s t r a t i o n approach.
• u n i v e r s a l coverage
•basic b e n e f i t s comparable t o t h o s e o f most
Americans
• q u a l i t y standards
•cost-containment
•long term c a r e
L i k e l y t o be behind t h e A d m i n i s t r a t i o n
T r a n s i t i o n , I r a Magaziner, O f f i c e o f P u b l i c
Liaison
• u n i v e r s a l h e a l t h coverage
• q u a l i t y care
•long term c a r e
�I 3-25-93 I 6:48PM !
RCV BY:
1 202 347 2417-
Families
SOCIAL OFFICE!* 2
DRAFT 3/25/93
STATEMENT OF PHYLLIS TORDA
DIRECTOR OF HEALTH AND SOCIAL POLICY
HEALTH CARE TASK FORCE
MARCH 29, 1993
Americans are looking to health reform to provide them peace of mind that they can
afford to take care of their health care needs. Americans will have this peace of mind only
when they have the same protectionfromthe cost of caring for a relative with Alzheimer's
i
disease as they have from the cost of caring for a relativerecoveringfromheart surgery.
Americans do not make a distinction between care for acute episodes of illness and care for
chronic disability.
The greatest unmet need is that for home and community-based care. Such care is
currently available only to some of the very poor through Medicaid and to those able to pay
i
for home care on their own.
j
Families USA is in the process of analyzing some new data on use of home care
services, which we plan to publish in mid-April. Preliminary results indicate die weaknesses
of our current system. Less than one-third of our population with disabilities used paid home
care services as of 1987. The vast majority of people with disabilities eitherreliedj
exclusively on family orfriends,or had to get along without assistance, presumably because
of the difficulty offindingand affording appropriate assistance.
Those persons with disabilities who received paid home care services in 1987 paid for
just under half of those services directly out-of-pocket, on average. These out-of-pocket
expenditures amounted to over $2000 annually for many. Thefinancialburden was heaviest
for moderate and middle income people.
1334 G STREET. NW • WASHINGTON, DC 2000S • 2 0 2 - 7 3 7 - 6 3 4 0 • FAX 202-347-2417
�; 3-25-93 I 6:48PM !
RCV BY:
1 202 347 2417*
SOCIAL OFFICE!* 3
j
2
Families USA urges the Health Task Force to design a home care benefit that begins
to address the unmet needs andfinancialburdens of persons with disabilities of all ages who
i
are struggling to continuetolive in their homes and communities. Such a benefit would
i
support sendees provided by informal caregivers and provide assistance when no informal
j
caregiver is available.
j
Many persons with disabilities and their families live with great insecurity about how
they will afford nursing home care if they need it. It is a myth that there is a safety net for
nursing home care in this country. In 18 states. Medicaid assistance with nursing home costs
i
is unavailable to individuals with incomes over a modest, flat dollar amount.
In these states, there are persons who need nursing home care, but cannot get it
j
because their incomes and assets are less than the cost of nursing home care. Each year,
more states consider limiting their nursing home expenditures by adopting such eligibility
limits.
!
The decision to enter a nursing home is one of the most stressful and emotional
decisions for individuals and their families. When making this decision, all Americans are
i
entitled to the security of knowing that they Hill have access to nursing home care if, they
otherwise cannot afford it.
Private insurance is not the answer to making long term care affordable for most
i
Americans. Families USA recently analyzed whether nursing home insurance would make
nursing home care affordable. We looked at this issue for today's elderly persons and
i
middle-aged persons who buy insurance policies now, as well as for persons who will be
elderly in 2005 andfirstpurchase insurance at that time. Nursing home insurance failed to
�I 3-25-93 I 6:49PM
RCV BY:
1 202 347 2417-
SOCIAL
OFFICE;*
4
malce nursing home care affordable for 84 percent of current elderly persons; for almost twothirds (64%) of persons currently age 55-64; and for four of everyfive(19%) persons who
will be ages 65 to 79 in the year 2005.
Over the years Families USA has done it's own research and has tracked public
opinion surveys about long term care. Consistently, Americans have expressed oveijwhelming
support for protecting American families against the costs of long term care. This support is
i
for a government social insurance program. Solid majorities of Americans are willing to pay
additional modest taxes for long term care protection.
j
This Task Force must not miss the opportunity to put in place thefirstbuilding blocks
of a social insurance program for long term care. The Task Force can develop a meaningful,
but modest, package of long term care benefits that would cost in the range of $15-20 billion
in net new federal spending. These benefits could be phased-in after the reforms in pur acute
care system have been implemented, with benefits beginningfirstfor the most needy. We
believe that the public is looking to the Task Force to provide them with this protection. In
exchange, the public is willing tofinanciallysupport a program that will spare them from
confronting afinancialcrisis when they or a family member can no longer care for
themselves.
�NATIONAL COMMITTEE TO PRESERVE SOCIAL SECURITY AND MEDICARE
MEMBERS:
Six m i l l i o n members and supporters
REPRESENTS:
Grassroots senior c i t i z e n s ' advocacy and
education association. I t i s the nation's
second-largest senior lobbying group and i s
dedicated t o p r o t e c t i n g the e n t i t l e m e n t s
which older Americans r e l y on.
TODAY'S SPEAKERS:
Max Richtman, Executive Vice President
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Working t o overcome poor image created by
t a c t i c s used t o encourage membership and
f i n a n c i a l c o n t r i b u t i o n s by vulnerable
seniors. While not p a r t i c u l a r l y respected on
the H i l l , they are feared f o r t h e i r PR
apparatus and t h e i r a b i l i t y t o generate
tremendous volumes o f m a i l .
Flexible.
The National Committee supports the goals o f
the health care reform t o cover a l l Americans
f o r acute and long-term care. Their main
p r i o r i t i e s are the i n c l u s i o n of long-term
care and p r e s c r i p t i o n drugs i n the b e n e f i t s
package. Other issues o f i n t e r e s t i n c l u d e
coordination w i t h Medicare, cost containment,
broad based f i n a n c i n g , maintaining q u a l i t y
care and preventive services.
POSITION ON
PLAN:
Supportive depending on b e n e f i t package.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n , OPL
PET ISSUES:
Long term care. P r e s c r i p t i o n drugs.
Safeguarding Medicare
HOT BUTTON ISSUES:
Being asked t o help finance h e a l t h reform
without expanding t h e i r b e n e f i t s .
�RCV BY:
: 3-25-93 11 1:58AM !
Naiional Coniinirr.cc ro
Pu'scrvc Social Security
and Medicare
1 202 822 9512-
SOCIAL OFFICE!,* 2
BIOGRAPHY
I^IAV RICHTMAN
Executive Vice President
A former staff director of the Senate Special Committee on Aging and 16year veteran of Capitol Hill, Max Richtman Is executive vice president of the
National Committee to Preserve Social Security and Medicare, the nation's
second-largest senior advocacy and education organization. Richtman,
who joined the organization in 1989 as director of government relations,
was named executive vice president in 1991. He also serves as director of
the National Committee's political action committee.
During his congressional career. Richtman directed a lengthy investigation
of the Equal Employment Opportunity Commission's enforcement of agediscrimination statutes and played key roles in reforms of the multi-billiondollar federal and Indian oil and gas royally collection system and Indian
health care system.
Richtman began his career on Capitol Hill in 1975 as a staff assistant and
counsel to the American Indian Policy Review Commission, chaired by
Sen. Jim Abourezk (D-S.D.). In 1977, Abourczk selected him as counsel to
the Senate Select Committee on Indian Affairs, which Abourezk chaired. In
1979, Richtman assumed the position of staff director of the committee
under new chairman, Sen. John Melcher (O-Mont.)
In 1987, Richtman was named staff director of the Senate Special Committee
on Aging, a position he held until 1989, when he joined the Nalional
Committee
Richtman was born in Munich, Germany, and grew up in Omaha, Neb. He
graduated cum laude from Harvard College in 1969 and received his law
degree from Georgetown University Law School in 1973. He is a member of
the District of Columbia Bar.
Mr. Richtman w i l l t e s t i f y a t t h e March 29th H e a l t h Care
Task Forccj Hearing i n p l a c e o f Martha A. McSteer.
2000 K Stn-ct, N.W., Suite 800 • W.isliiiisjtoii. IVC. 20006 • 20r-622-9459
�03/26.'93
69:59
O l 202 822 9612
NATIONAL COMM
\;i[ioi)i)I Coiiimiiia' to
rtvscrvv .SOCH! Scaniiy
and Medicaic
1
Statement of
Max Richtman
Executive vice President
National Committee to Preserve
Social Security and Medicare
Submitted to
White House Health Care Task Force
Regarding
Long-Term Care
March 29, 1995
TOOO K Stk'ei, Y\Y.. S'jiic 800 • Wa.-^innuw. D i. 20000 • 202 i22 M?>
121002
�03/26/93
09:59
©1 202 822 9612
NATIONAL COMM
I am Max Richtman, Executive Vice President of the National commitlee to
Preserve Social Security and Medicare. I welcome the opportunity to lestify on behalf
of the approximately six million members and supponcrs of the National Committee
on the critical issue of incorporating long term care into health care reform.
The National Committee fully appreciates the enormously complex challenges
before the President's Health Care Task Force. Never before has an undertaking of
such proportions taken place in the health care arena, and we trust that your talent
and dcterminaiion will result in a sensible health care system for this country.
Seniors stand cither to gain or to lose under a new health care system, but
nothing is likely to remain exactly the same. Nonetheless we would prefer to see
Medicare continue to serve seniors. After managed care is implemented for the rest
of the population, we can better gauge how Medicare should fit in. We hope that
managed competition can reduce the out-of-pocket cost burden for seniors.
Heading the National Commit lee's health care agenda is the cull for proteaion
against the financial devastation of long-term care. Close to 100 percent of the nonMedicaid population has no coverage for long-term care, while the need for acute
care proteaion must be the first priority, the approximately ten million Americans of
all ages who need assistance with daily living must not be forgotten. Individuals
with functional impairments may require home care, adult day tare, nursing homecare or a combination of services.
The National Committee's 1992 member survey overwhelmingly confirmed the
desire for a comprehensive long-term care public program including respite care for
exhausted family caregivers. Kespondenis strongly supported a full nursing home
benefit that would cover more than just three months of benefits. Even if the benefit
covered all but ihe first three months of nursing home care, six out of ten disagreed
that seniors can even afford the first three months. However, when given the choice
between a nursing home benefit or a home care benefit of equal value, respondents
choose home care by more than eight lo one.
Based on this and many other surveys of our members, we recommend that
long-term care begin with home and community-based care including adult day care.
With the assistance of these services, many seniors arc able to remain in the
community and prevent or postpone institutionalization. Over time, a wide spectrum
81003
�03/26/95
10:00
©1 202 822 9612
NATIONAL COMM
of benefits must be added including rehabilitative services, insiitutional care, assisted
living and other housing options and transportation. To contain costs, long-icrm
care benefits should be delivered through a care management system with set rates
for services and an overall set budget. Care managers should determine eligibility,
. do comprehensive assessments and develop, implement, monitor, reassess and
modify care plans.
Eventually, we would like to see a continuum of care bridging the gap
between acute and long-term care. Individuals in need of long-term care use about
twice as much acute care as do their same aged peers. It may therefore be more
efficient and cost-effective io create a coiuinuum of care which allows for better
coordination across care settings. As a beginning to this end, we recommend an
expansion of programs such as the Social Health Maintenance Organizations
(SHMOs) and the Program of All-inclusive Care for the Elderly (PACE). These
programs are working models of capitated, comprehensive, risk-based acute and
long-term care programs. The PACE Includes the entire spectrum from preventive
care to long nursing home siays-if necessary, whereas the SHMOs are somewhat
more limited in terms of nursing home stays. On the other hand, SHMOs are open to
all seniors and not limited to the frail, it should be feasible to integrate these
managed care long-term aire options into managed competition.
Fair funding mechanisms are necessary tofinancea comprehensive long-term
care program. This approach could encompass federal taxes, state and local
resources, and nominal co-payments according to the beneficiaries ability to pay. To
find the right combination, is clearly a challenge.
When presented with five financing options, National Committee members
give the highest preference to increasing taxes on alcohol and tobacco (51 percent).
Another thlriy-uinc percent give the highest preference to taxing estates and gifts
above $200,000 and another 11 percent give it the second highest preference. Upper
income respondents expectedly give this proposal a lower preference. Such taxes
should probably be considered before value added taxes and income taxes.
A public long-term care program is imperative. However, such a program is
not likely to fully protect everyone. Private long-term care insurance will continue to
play an increasingly important role. There are many reasons why people are not
flocking la purchase these policies, but one of them is that the products need to be
81004
�03/26/93
10:01
©1 202 822 9612
NATIONAL COMM
improved. According to Consumers Union, none of the long-term care insurance
policies currently on the market provide adequate protection. We urge that you
include federal standards for long-term care insurance products in the health care
reform package.
Again, we appreciate the opportunity to present our views-and we most
certainly appreciate your hard and dedicated work towards health care reform. We
stand ready to help in any way we can.
8)005
�CONSORTIUM OF CITIZENS WITH DISABILITIES
MEMBERS:
C o a l i t i o n comprised o f over 75 consumer, service
provider, and professional organizations which
advocate on behalf o f persons w i t h d i s a b i l i t i e s and
t h e i r f a m i l i e s . Over 42 n a t i o n a l organizations are
members o f CCD's Health Task Force i n c l u d i n g may
disease organizations.
REPRESENTS:
The Consortium represents more than 43 m i l l i o n
Americans w i t h d i s a b i l i t i e s include i n d i v i d u a l s w i t h
physical and mental impairments, c o n d i t i o n s , o r
disorders, severe acute o r chronic i l l n e s s which
l i m i t or impede t h e i r a b i l i t y t o f u n c t i o n .
TODAY'S SPEAKER:
C h r i s t i n a Metzler (see attached
SCOPE OF
INFLUENCE:
S i g n i f i c a n t grassroots p o t e n t i a l
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
bio)
Non s p e c i f i c . Some c o n s t i t u e n t members back s i n g l e
payer approach.
Acute care b e n e f i t should be comprehensive and
include long-term care services.
Significant
concerns regarding the responsiveness o f managed
care t o people w i t h d i s a b i l i t i e s . Reform must
ensure non-discrimination and f u l l y p a r t i c i p a t i o n by
people w i t h d i s a b i l i t i e s , appropriateness o f
a v a i l a b l e services ( p a r t i c u l a r l y f o r younger
disabled i n d i v i d u a l s ) and equal access t o h e a l t h
services.
Wants t o be a p a r t o f the discussion and a player i n
h e a l t h care reform.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n , OPL, Shalala
PET ISSUES:
Comprehensive b e n e f i t package. Long-term Care
HOT BUTTON ISSUES:
Non-discrimination o f b e n e f i t s . Special needs o f
population.
�FROM'WHITE. UERUILLE. FULTON
TQ:
2024562B7B
MAR 26. 1993
5:35PM
BIOGRAPHY OF PETER W. THOMAS. ESQ.
Peter W. Thomas is an attorney practicing federal law and legislative advocacy in the
areas of health care, rehabilitation, disability, and employment with the Washington, D.C. firm
of White, Verville, Fulton & Saner. Mr. Thomas graduated cum laude from Boston College
and attended Georgetown University Law Center where he served as Associate Editor of the
Journal of Uw and Technology. After practicing civil defense litigation at Siff, Rosen and
Parker, P.C, in New York City, Mr. Thomas became President and General Counsel of the
American State of the Art Prosthetic Association in Washington, D.C. and lobbies for
rehabilitation research, particularly for the technological advancement of prosthetic and orthotic
devices (artificial limbs and braces). He currently is a member of the Advisory Board for the
National Center for Medical Rehabilitation Research at the National Institutes of Health and is
the Legislative Director of the Amputee Coalition of America. Mr. Thomas has personal
experience with disability and consults businesses and individuals with disabilities as to their
rights and obligations under the Americans with Disabilities Act and other federal civil rights
laws. He is a co-author of an employment and accessibility guidebook for compliance with the
Americans with Disabilities Act published in February, 1993. Mr. Thomas is a member of the
New York and D.C. Bars and participated in the 1992 Democratic Convention as a Party Leader
and Elected Official member of the Platform Committee by representing disability and health
care issues affecting of persons with disabilities.
P.03
�AMERICAN ASSOCIATION OF RETIRED PERSONS
MEMBERS:
34 m i l l i o n Americans over age 50.
REPRESENTS:
Provides l e g i s l a t i v e advocacy, research, information
programs and community services as w e l l as providing
such membership b e n e f i t s as mail order p r e s c r i p t i o n
drugs, supplemental insurance p o l i c i e s and t r a v e l
discounts. Has chapters i n a l l 50 s t a t e s .
TODAY'S SPEAKER:
Lavola Burgess, President
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
HOT BUTTON ISSUES:
Has f i n a n c i a l strength, huge membership base,
i n f l u e n t i a l i n media and on h i l l (although damaged
somewhat by t h e i r strong backing o f c a t a s t r o p h i c ) .
Lack o f u n i f y i n g p r i n c i p l e s o f membership undermines
t h e i r effectiveness.
Blended approach o f s i n g l e payer, employer based and
tax incentives. Remain open.
Four goals f o r reform: u n i v e r s a l access t o
a f f o r d a b l e q u a l i t y health care and long-term care,
system-wide cost containment, p r e s c r i p t i o n drugs,
and f a i r and affordable f i n a n c i n g . B e n e f i t s package
should include preventive, primary, acute,
t r a n s i t i o n a l and long term care. Cost containment
through global budget.
Open t o Administration plan, as long as
comprehensive.
T r a n s i t i o n , OPL, I r a Magaziner, President C l i n t o n
Long term care and p r e s c r i p t i o n drugs, seniors
bearing f i n a n c i a l burden w i t h o u t added b e n e f i t s .
�121002
03/26/93
10:16
©
A,A.R.j^
AARP
NEWS
For farther inquiry, contact Arnmcmi Assnciatiun of Retired Penum • Ctmtnunications Division
601 E Street, K. Vi''. • Wajfonffrnn, D C. 20049 • (201) 434-2560
BIOGRAPHIC SKETCH
LOVOL^ WEST BURGESS
President
American Association of Retired Persons
Lovola West Burgess of Albuquerque, New Mexico, succeeded
to the position of President of the American Association of
Retireid Persons (AARP) at the organization's 1992 biennial
convention i n San Antonio, Texas. She w i l l serve i n that
position for two years.
touring the previous two years, Mrs. Burgess was
Presidient-Elect of the association, and for two years before
that, jVice President following her election a t the 1988
convention i n Detroit, Michigan.
In addition to her r e s p o n s i b i l i t i e s as president, she
w i l l serve on AARP's Board Finance Committee and as Chair of
the AARP Andrus Foundation's Board of Trustees.
She has been a member of the AARP Executive Committee (on
which she continues as president) and the National L e g i s l a t i v e
Council. She has been Chairman of the Area Vice Presidents
Advisory Committee and the AARP Board Committee on Member
Services. She has also served as a trustee of the AARP Voter
Education Fund and AARP Investment Program from Scudder.
Previously, she served on the AARP Board of Directors.
She wa^ also Chairman of the New Mexico State L e g i s l a t i v e
Committee and State Officer of the New Mexico Association of
Educational Retirees and remains i t s Executive Committee.
MifS. Burgess represents AARP on the Medicine-Business
Coalition of New Mexico, and served on the Policy Advisory
Committ|ee of the New Mexico State Agency on Aging. U n t i l
recently, she represented the association on the Governor's
Health Care Cost and Access Commission and the New Mexico
Medicaid Advisory Committee. She was a founding board member
of the jCoalition for Children and continues to serve as an
Honorar|y Board Member. She serves on the Take Pride i n
America!, Advisory Board of the Department of the I n t e r i o r ,
having been appointed by Secretary Manuel Lujan.
(MORE)
�©003
03/26 93
10:16
©
A.A_.R.P.
LOVOL^ WEST BURGESS - 2
I n October, 1989, Mrs. Burgess was honored w i t h the
"Distinguished Woman Award" from the U n i v e r s i t y of New Mexico
Mortar Board Alumni Group. The award i s given each year t o a
woman!whose achievements have been a c r e d i t t o the s t a t e .
I n 1990, she received the Zimmerman Award, the highest
honorigiven by the u n i v e r s i t y ' s Alumni Association.
A native of C l a r k s v i l l e , Iowa, Mrs. Burgess graduated
w i t h a Bachelor's degree i n journalism from the U n i v e r s i t y of
Iowa v^here she was elected t o the Phi Beta Kappa honorary
societjy. U n t i l 1948, she was a teacher of English and
journalism i n Iowa schools and also worked as a r e p o r t e r on
l o c a l jnewspapers. A f t e r moving t o New Mexico, she earned a
Master's degree i n guidance and counseling from t h e U n i v e r s i t y
of New^ Mexico.
Firom 1953 t o 1978, Mrs. Burgess was a teacher and
guidance counselor i n Albuquerque p u b l i c schools and was
p r i n c i p a l o f Rio Grande High School a t the time she r e t i r e d
from tpe system.
With her husband, she has published a r t i c l e s on health
and n u t r i t i o n i n various magazines and p r o f e s s i o n a l j o u r n a l s .
In 1983 she served as a senior i n t e r n i n t h e Washington o f f i c e
of Representative Manuel Lujan of New Mexico.
Mrs. Burgess and her husband have homes i n Albuquerque
and Taos, New Mexico. They have two daughters.
AARP i s the nation's leading o r g a n i z a t i o n f o r people age
50 and over. I t serves t h e i r needs and i n t e r e s t s through
l e g i s l a t i v e advocacy, research, informative programs, and
community services provided by a network o f l o c a l chapters
and experienced volunteers throughout the country. The
o r g a n i z a t i o n also o f f e r s members a wide range o f special
membership b e n e f i t s , i n c l u d i n g Modern M a t u r i t y magazine and
the monthly B u l l e t i n .
#H
Editors:
Photo o f Mrs. Burgess and f u r t h e r i n f o r m a t i o n about
AARP are a v a i l a b l e from the Communications D i v i s i o n ,
(202) 434-2560.
11/92 •
�SENT BYJXerox Telecopier 7020 ; 3-25-93 ; 6:06PM ;
-NAT ECONOMIC COUNCIL!* 2
DRAFT
(3/25/93)
ORAL STATEMENT - LQVOLA BURGESS* AARP PRESIDENT
Thank you.
My name is Lovola Burgess and I am the President of
the American Association of Retired Persons.
Thank you for
permitting us to testify on these important issues*
First, let me state that AARP is strongly committed to
comprehensive health care reform that contains costs/ addresses
the needs of a l l Americans and includes a wide range of benefits,
including prescription drugs and long-term care. Efforts to
control costs will be defeated i f we leave any group out of
particular benefits. As President Clinton has stated repeatedly,
we cannot effectively deal with our economy without also
addressing our health care crisis.
There are four major points I would like to make about the issue
of long-term care. First, long-term care clearly is a family
issue. The vast majority of recipients and providers are women
who make up almost 75 percent of nursing home residents as well
as informal caregivers. Caregivers generally do so without any
assistance, but with great physical, emotional and financial
sacrifice.
Many struggle as part of the "sandwich generation,"
caught between meeting the needs of their children and their
parents. Effective long-term care will support, not replace,
informal caregivers, will delay the need for institutionalization, and will help keep families together during these
�SENT BY:Xerox Telecopier 7020 ; 3-25-83 ; 6:D6PM ;
physically and emotionally trying times.
-NAT ECONOMIC COUNCIL:* 3
I t is not surprising
that persons age 50 to 65 are the most concerned about long-term
care.
Second, truly comprehensive health care reform must provide for a
f u l l continuum of health and supportive services over a person's
l i f e span,
i t makes no sense to address our citizens' acute care
needs without also addressing their chronic care needs.
To a
family, there i s no difference between spending $30,000 on
hospital care and spending $30,000 on nursing home care. A
proposal that fails to integrate care needs in a seamless web
will not work. Long-term care easily could become a huge "escape
hatch" from overall cost constraints. I f long-term care i s not
an integral part of health care reform, incentives w i l l be
created to circumvent cost controls by shifting costs to already
growing "sub-acute" settings. We previously experienced a
similar shift when the DRG hospital prospective payment system
caused "quicker and sicker" discharges.
Third, long-term care — like the rest of the health care system
~
must include strong cost containment. We have previously
shared documents with the Task Force that set forth a proposal
that incorporates several essential components:
o A reasonable phase-in schedule, beginning with home and
community-based care, that addresses the needs of those in
greatest need;
o A care management system that i s subject to budget targets, end
discourages overuse of services and inappropriate
�SENT BYJXerox Telecopier 7020 ; 3-25-93 : 6:07PM ;
-NAT ECONOMIC COUNCIL!* 4
institutionalization; and
o An equitable reimbursement system that promotes cost
containment, rehabilitation and appropriate placement and
discourages cost shifting.
It is important to keep in mind that in a system based on
individually sold private insurance, system costs would escalate
because there would not be sufficient risk sharing; providers
would have l i t t l e incentive to reduce private pay rates; and
about 30 percent of the money taken in would go to pay for
insurance companies' advertising costs, agent commissions and
profits. Not only would this add to the cost spiral, but i t
would also leave millions uncovered.
Finally, i f meaningful long-terra care protection is included,
people will be more willing to pay increased taxes for the reform
package. Shis finding was supported in a survey conducted last
year by the Daniel Yankelovich Group. Surveys and recent
experience have also shown that Americans are reluctant to make
sacrifices in the area of health care unless they receive
something concrete in return.
For the approximately 85 percent
of Americans with insurance protection against acute care costs,
providing access to the uninsured and containing hospital and
physician costs may not be enough to promote a willingness to
make significant sacrifices.
Thank you. I will be happy to respond to any questions you might
have.
�LONG-TERM CARE CAMPAIGN
MEMBERS:
138 n a t i o n a l organizations representing 60 m i l l i o n
people.
REPRESENTS:
Large c o a l i t i o n representing a diverse range o f
i n t e r e s t s i n c l u d i n g r e l i g i o u s denominations,
business, labor unions, r a c i a l and e t h n i c groups,
youth, people w i t h d i s a b i l i t i e s , e l d e r l y , veterans,
nurses and consumer groups.
TODAY'S SPEAKER:
B i l l Keane, board member o f member o r g a n i z a t i o n
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Huge grass roots network.
crowds. Media savvy.
A b i l i t y t o p u l l large
Non-ideological on approach as long as long-term
care i s included as b e n e f i t .
Dedicated t o enacting comprehensive long-term care
b e n e f i t which provides f u l l range o f services but
p a r t i c u l a r l y home and community-based care.
E l i g i b i l i t y based on determination o f d i s a b i l i t y
r a t h e r than age o r a b i l i t y t o pay.
POSITION ON
PLAN:
Depends on b e n e f i t package
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
Transition
PET ISSUES:
Long-Term Care
HOT BUTTON ISSUES:
Reform package w i t h no movement toward Long-term
care coverage even w i t h extended phase i n .
�The Long Term Care Campaign
Representative
B i l l Keane
B i l l Keane, spokesperson f o r the Long Term Care Campaign, i s
a member o f the National Board o f D i r e c t o r s o f the Alzheimer's
Association and former v i c e c h a i r o f i t s Public Policy Committee.
The Association i s a n a t i o n a l voluntary h e a l t h agency
representing the i n t e r e s t s o f four m i l l i o n Americans w i t h
Alzheimer's disease and t h e i r f a m i l i e s . I t operates through 220
Chapters and 35,000 volunteers i n the 50 s t a t e s . Mr. Keane spent
12 years caring f o r h i s mother and aunt who had Alzheimer's
disease. He l i v e s i n Doylestown, Pennsylvania.
�03/25/93
16:32
©202 393 2109
ALZHEIMER S ASSN
3003/005
STATEMENT OF B I L L KEANE
DOYLESTOWN, PENNSYLVANIA
submitted to the Health Care Task Force
on b e h a l f Of THE LONG TERM CARE CAMPAIGN
March 2 9 ,
1993
I am here today on behalf of the Long Term Care Campaign, a
coalition of 138 aging, disability and other consumer
organizations that have come; together to support a comprehensive
social insurance approach to; long term care.
The membership of
the Campaign underscores the fact that long term care i s a family
issue that cuts across age and disability.
I serve on the Board of Directors of the Alzheimer's
Association, which with AARP! i s a lead sponsor of the Campaign.
T speak to you from 12 years! of experience helping to care for my
mother and aunt, both of whom had Alzheimer's disease. My
parents spent their l i f e savings on long term care.
My father
died, trying to take care of I the woman he loved.
The Campaign has specific responses to the question you
posed to this panel.
I
P.O. BOX 27394 • WASHINGTON, D.C; 20038 • (202)434-3744 • FAX (2021 43445477
�03/25/93
16:33
© 2 0 2 393
2109
ALZHEIMER'S ASSN
81004/005
F i r s t , adding long term care to the health reform pac)cage i s
cost control.
I f you leave i t out, you w i l l simply add
unnecessary costs to the acute care system — avoidable
hospitalizations and emergency room v i s i t s , illness and
injury to persons who have no care and to caregivers who
have no help.
Second, you must begin with a comprehensive social insurance
approach to long term care.
I f you try to start with
private insurance, you w i l l exclude millions of Americans
i
who are most threatened today.
And you w i l l be creating the
same kind of mess in long term care that we are now trying
to straighten out on the acute care side.
Third, you cam phase i n a long term care system over time.
That i s important, not just to control costs but to make
sure we are building a solid delivery system.
Fourth, you can get rid; of the institutional bias i n the
current system.
The place to start i s with home and
community care.
That i s what people want,
i t i s more
appropriate. And i n most cases i t i s far less expensive.
Long term care services and supports i n the community allow
families to continue their role as caregivers, instead of
turning the whole job oyer to paid providers.
And they
allow many persons with! disabilities to l i v e independently
and productively.
�03'-25/93
•
16:33
O202 393 2109
ALZHEIMER'S ASSN
12005/005
Fifth, you can stop over-medicalizing long term care.
Consumers and their families need to be able to choose the
services and supports that w i l l most effectively meet their
needs, at the best price.
Sixth, you can make certain that the consumers of long term
care are directly involved in the overall design of the
system, and in their own individual plans of care.
No one
has a greater interest in cost control than the people who
are paying the b i l l .
The President has clear goals for health care reform: to
control health care costs, to provide security and peace of mind
to every American family, and to maintain quality. The only way
he can accomplish those goalk i s to include long term care in his
comprehensive health reform package. The Long Term Care Campaign
i s committed to working with! you and the President to accomplish
those objectives.
�_
9:05--
PANEL ONE-CONSUMERS- TESTIMONY ENDS
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
�9:10--
PANEL TWO-BUSINESS-TESTIMONY BEGINS
Thank you to all the witnesses on panel one.
Now, we turn to panel two with representatives from business.
The question we
posed to this panel was: "What is the best way to ensure that employees of small business get
health coverage?"
I will note here that the National Federation of Independent Business was
invited to testify but declined to participate in today's hearing. Our first witness is Mr. Gary
Frank Petty, the Treasurer and a member of the Board of Directors of the Small Business
Legislative Council.
�W
9:10--
PANEL TWO-BUSINESS--TESTIMONY BEGINS
Thank you to all the witnesses on panel one.
Now, we turn to panel two with representatives from business. I will note here that
the National Federation of Independent Business was invited to testify but declined to
participate in today's hearing. Our first winess is Mr. Gary FRank Petty, the Treasurer and a
member of the Board of Directors of the Small Business Legislative Council.
�PANEL TWO: SMALL BUSINESS
Question Posed:
What's the best way to ensure that employees of small businesses get health coverage?
Groups:
Small Business Legislative Council
National Small Business United
Minority Contractors Association
National Restaurant Association
National Association of Private Enterprise
M^jor issue concerns:
t
These groups are generally opposed to employer mandates, and feel that those
businesses who don't pay for insurance don't pay for it because they can't afford it.
Although community rating, insurance pools, and cost controls will economically benefit
them, some of them have such a strong anti-government ideology that they amy even be
leery of those parts of our plan.
Talking points:
70% of small businesses provide health insurance for their employees. That 70%
will always be at a competitive disadvantage unless everyone has health insurance.
What small business needs more than anything is to stop the explosion of health
care costs, and the uncertainty of the current insurance market.
�Small Business L e g i s l a t i v e Council
Representative
Gary Frank Petty
Treasurer and Member of the Board of D i r e c t o r s
[Gary Frank P e t t y ] i s t h e Treasurer and a member o f t h e
Board o f D i r e c t o r s o f t h e Small Business L e g i s l a t i v e C o u n c i l
(SBLC). He i s one o f SBLC's v o l u n t e e r o f f i c e r s . He i s t h e
P r e s i d e n t and CEO o f t h e N a t i o n a l Moving and Storage A s s o c i a t i o n
(NMSA), one o f t h e t r a d e a s s o c i a t i o n members o f SBLC.
Mr. P e t t y has served as t h e P r e s i d e n t and CEO o f NMSA s i n c e
1988.
He has a background i n a s s o c i a t i o n management, l a w and
h i g h e r e d u c a t i o n . He h o l d s a J u r i s Doctor degree from Delaware
Law School, a Doctor o f Philosophy from t h e U n i v e r s i t y o f
M i c h i g a n , a Master o f A r t s and Bachelor o f A r t s from Western
Michigan U n i v e r s i t y .
Mr. P e t t y w i l l be accompanied by John S. S a t a g a j , t h e
P r e s i d e n t o f t h e SBLC. Mr. Satagaj has served as t h e P r e s i d e n t
o f t h e Small Business L e g i s l a t i v e C o u n c i l s i n c e 1986. He began
r e p r e s e n t i n g s m a l l business i n t e r e s t s i n Washington i n 1978 when
he served as a s p e c i a l counsel t o t h e f i r s t C h i e f Counsel f o r
Advocacy f o r Small Business, M i l t o n D. S t e w a r t . Mr. Satagaj i s a
p a r t n e r i n t h e law f i r m o f London and S a t a g a j . He has a J u r i s
D o c t o r degree from t h e U n i v e r s i t y o f C o n n e c t i c u t and an L.L. M.
i n T a x a t i o n from George Washington U n i v e r s i t y .
�03/25/93 12:01
,
MULLiukiNtit
ItaillATIVf
S 2022965333
0 2
Oral Presentation of Gary Frank Petty
on Behalf of the
Smll Business Legislative Council
council
Thank you for this opportunity to present the views of the Small Business
Legislative Council (SBLC) . In accordance with your request, I w i l l not
describe our organization and we are submitting a written statement for the
record.
Let me begin by saying we approach this debate with great optimism because i f
the election of the President sent one signal to us, i t i s that the country would
f i n a l l y be united in agreeing upon the need for irmediate, conprehensive health
care reform. For at least two years, we have been preaching the need for
conprehensive reform led by meaningful cost containment and the pews have been
almost erpty. We are pleased they are now f i l l i n g up fast.
The question today i s "what i s the best way to ensure that enployocs of small
business get health coverage?"
The answer begins and ends with the statement "control costs, * We are well
aware of the number of Americans enployed by small business without health care
coverage. That fact, however, must be placed in context. What about the many,
many millions of Americans who do receive their health care benefits through a
small business employer? In conparison, this l a t t e r figure is a rather
significant number.
We are convinced the gap would shrink even further i f small enployers had the
comfort of knowing that the costs of coverage would not became a quagmire from
which they could not extricate themselves. Further, we are more concerned about
a l l those currently providing coverage. They have simply run out of options for
controlling costs by their own actions; tht^y have changed programs, t r i e d
managed care, self-insurance and cost sharing. They have absorbed a l l the costs
they can. Unless we control costs, a l l i s for naught.
For that reason, we have concluded that i n the short-term, some form of fee
and price controls i s necessary to rein in health care provider costs. The t r u t h
i s , we need to separate the health care profession from the health care
business. We wish the marketplace would make these adjustments, but we are not
so naive to believe free enterprise guarantees the perfect system. Since 1977,
SBLC has been an outspoken advocate of antitrust policy, taxation policy (such
as the President's investment tax credit) and procurement policy that allow the
government to smooth out the market "inperfections' to permit a competitive
econony to thrive. In this health care debate, we have come to the conclusion,
the government must undertake a role to control costs.
We think the health care provider commnity should be asked to defend or
oppose a particular cost control approach, rather than the enployer community.
I t i s time to recognize the market is not going to produce cost containment by
itself.
I know the subject of using mandates to require sirali businesses to provide
coverage i s under consideration. Let me say, i t is hard for us to iiragine that
anyone couid warmly embrace the concept of mandatory participation,
particularly small business owners, for whom economic freedom, the right to
-2-
�Extended Page 2.1
Having said that, let me f i r s t make two observations and then some
suggestions about mndates.
In our on-going discussions with our members, i t is apparent to us that most
small businesses have come to view access to health care as almost a fundamental
right. I t is something they do expect a l l Americans to have. Second, most small
business owners would t e l l you they believe i t is their responsibility to
provide i t . The barrier, as noted, is cost and the framework for undertaking the
responsibility is the freedom to determine how to do i t .
These observations, combined with the recognition we are asking others, such
as health care providers to make dramatic changes in their contribution to the
system, lead us to the conclusion we cannot sumrrarily rule out any alternative
tliat adversely effects us, i f i t is part of a conprehensive solution,
notwithstanding our reservations. Six years ago i t may have been appropriate.
Now is the time to be agents for change, not shackled servants to the past.
After a l l , is i t not the nature of the successful entrepreneur to take the risky
road to pursue a better tomorrow?
First, as noted above, cost controls would have to be put in place as a
condition precedent. I t does get a l i t t l e t i r i n g to us for others to suggest
enployers need to do more. We are prepared to make further sacrifices, but not
before others in the system have been made to do their f a i r share. Let's not
forget we are currently responsible for providing coverage to many Americans.
Second, any nendatory responsibility would have to be a shared
responsibility. The eirplcyer and enployeemust share the responsibility for
health care. At best, price and fee controls or global budgeting are short- to
mid-term solutions; without getting the individual directly involved in seme
financial way, we w i l l never inpose the long-term discipline necessary to
restrain our health care appetite. We believe taxation of the excess cost of
benefits to the enployee would be an excellent starting point. I f there is to be
a mandatory participation requirement, i t should be bome by both the employer
and enployee.
Third, resolution of the growing problem of workers corrpensation costs must
be part of a conprehensive solution. We are certain cutting workers
corrpensation costs would be a very attractive inducement for accepting any
mandatory responsibility.
A small business moving and storage corpany in Des Moines, Iowa lias six local
drivers making annual salaries i n the range of $20,000 to $25,000 each. The
conpany does not provide health insurance for these drivers, primarily because
of the high cost of workers compensation insurance. At the state rate of $20 per
$100 of payroll, a driver earning $25,000 would cost the conpany $5,000 a year i n
workers conpensation insurance premiums. On the other hand, that same driver,
30 years old and single, would cost the conpany $190 per month, or $2,280 per
year, for health insurance, i f offered hy the conpany. I f the conpany paid both
workers conpensation insurance and health insurance, the t o t a l annual cost
would be almost 30 percent of the driver's salary.
For the six drivers on an annual basis, the conpany pays about $27,000 for
workers conpensation, or more than the annual salary of any single driver. Even
assuming $250 a month for health care insurance per driver, the conpariy's annual
cost would be $18, 000. Obviously i f the ccrpany provided both types of
-3-
�Extended Page
I f the task force presents a proposal to the President that i s credible on
these counts, we believe you w i l l be able to make a strong case to small business
that they need to be a part of a conprehensive solution.
There are several other conponents of the health care debate I would l i k e to
touch upon b r i e f l y . The f i r s t i s the delivery system i t s e l f . We have supported
the basic concept behind •nonaged carpet i t ion. • The idea of buying groups
appeals to us. What we have not been able to reconcile i s a mandatory
requirement for small businesses to join such a group. As I indicated earlier,
small business owners want to retain the f l e x i b i l i t y to choose their approach to
assuming this responsibility.
Associations, for exairple, have offered one alternative approach for many
snail businesses to provide health care benefit coverage. Further, we do not
think one can rule out self-insurance, i n whole or part, i f there i s a way to
ensure i t s legitirracy under conprehensive reform. We do not know how one
reconciles self-insurance options with managed conpetition, but we are always
struck t y the number of smaller businesses that do provide meaningful benefits
Lo their enplpyees with some type of self-insurance arrangement. We believe
small business w i l l want to retain some f l e x i b i l i t y i n that, regard.
At this time, we are not sure what role the insurance industry w i l l play i n
the new world after comprehensive reform. I f we build on the current system,
some administrative reforms are necessary, to reduce the high cost of
administering small business programs. We do know that using pre-existing
conditions and other underwriting devices to "cherry-pick" the market are not
acceptable i f we are to have conprehensive reform, universal access, and cost
control.
Even i f we have mandatory responsibility for coverage, shared by enployers
and errplcyees, we s t i l l have those who are unemployed, are part-Lime enployees,
and others who, for one reason or another, do not f a l l within the employer-based
system. As you know, the price tag for universal access i s significant.
How we pay for universal access, even with some mandatory shared
responsibility, i s rapidly replacing the irandate issue as a major concern. We
dc not have a specific revenue proposal in mind, but we do believe i t must be one
that i s absorbed by the citizenry as a whole, rather than one that i s rolled
directly into the costs of health care that must be bome by the enployer
community.
There are many other aspects of health care reform I have not touched on i n
our rerarks. For exanple, we believe reforms of public sector programs.
Medicare and Medicaid, are i n order. We believe strongly tliat medical
malpractice reforms are necessary. We believe significant cost savings can be
achieved by fundamental c i v i l justice reform.
In conclusion, we believe i t i s inportant for small business to be part of a
solution, not an obstacle to reform. Clearly, controlling costs i s our
paramount concern. In our minds, this debate i s "a work i n progress" and wc
cannot take any option off the table. We look forward to working with the
members of this task force and the President to find a solution that works for
a l l Americans i n a f a i r and equitable manner.
/S2595A
2. 2
�NATIONAL SMALL BUSINESS UNITED
MEMBERS:
65,000 small business owners.
REPRESENTS:
NSBU represents small business owners i n many
service and i n d u s t r i a l sectors. NSBU places
a major emphasis on small business advocacy,
taking a b i - p a r t i s a n approach t o working w i t h
Congress and other elected o f f i c i a l s .
TODAY'S SPEAKER:
Gary Kushner, Treasurer and Chair (see b i o )
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Limited influence on Congress,
media.
Good w i t h
I n d i v i d u a l mandates; i n d i v i d u a l
r e s p o n s i b i l i t y as the cornerstone o f any
health care reform e f f o r t .
I n the past, they have been the more l i b e r a l ,
progressive group (more open t o discussing
employer mandates as long as cost containment
and i n d i v i d u a l r e s p o n s i b i l i t y are addressed).
Within the l a s t year, however, they have
become more adamantly opposed t o an employer
mandate.
NSBU's membership includes several models f o r
small employer purchasing cooperatives. They
support the r i g h t f o r small business t o
organize t h e i r own HIPCs and t o manage t h e i r
own h e a l t h care a c t i v i t i e s .
Streamlining o f d e l i v e r y system necessary,
not j u s t r e f i n a n c i n g and c o n t a i n i n g costs.
Contain costs w i t h emphasis on u n i v e r s a l
coverage and through provider/payor
i n t e r a c t i o n s a t community l e v e l not f e d e r a l l y
imposed r e s t r i c t i o n s .
Including workers' compensation w i t h h e a l t h
care reform could be valuable t o small
business owners and employees, but t h e r e are
concerns about how i t w i l l be implemented.
Oppose p a y r o l l taxes f i n a n c i n g p r e f e r broadbased taxes, i n c l u d i n g consumption. They
have expressed support f o r an increased
�income t a x t o help finance coverage.
POSITION ON
PLAN:
L i k e l y t o oppose mandate, but perhaps not
actively.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n , I r a Magaziner.
HOT BUTTON ISSUES:
Employer mandate.
�RCV BYiThe White House
3-26-93 ; 4:23PM
;# 1
SOCIAL OFFICE-
Biography
NATIONAL SMALL BUSIN'ESS UNITED
tusiJwJnttr.x.w
Margaret A. Snath
SUITE 710
WA$HD«TW,D.C 20005
202-J9W8JO
Mai^aict Smith is an attorney who specializes la
Mt: 202^72*43
representing small and nvdium-sixed businesses. She
malDtains oSBoes in Silicon Valley and Sao ftantisco,
Califbmia, with an a£Siiate office in Washington, D.C In
additioa to her lawfiim,she owns two other small businesses; one ofibtbg business
consulting sendees ^tlwinten^^
small, professional companies,
Ms. Smith is a member of the Board of TrusteesforNational Small Business United
(NSBU), ameraberoftbeBoanl ofDiiectoraoftheNadfloalFcajndatioQofWomeJiBusiness
Owners ardamen^ oftteU.S.CfcaffiberofG^
Ms. Smith seives on the Board oftla Women's RindfortheSantaOataCounty Community
Foundation and is a member of several local busiittss organizations. She also serves as a
Judge Pro Tem in the Small Claims Division of the California Municipal Court
Ms. Smith has beenrecognizedboth locally and nationally for her involvement in and
dedication to the small business community. She has pttsensed Congressional testimony on
issues affecting email business, and has been interviewed by numeious print and broadcast
media regaiding her views on small business issues. She is a guest speaker on radio talk
shows and a frequent guest lecturerforsmall business seminara.
Prior to the practice of law, Smith gained extensive professional and business experieoce
in Washington, D.C in both the political and private busmess sectors. She iervedittpuU3c
affair coordinator and legislative specialist for a nationalrealestate trade association; as a ac
executive assistsotfteaearcher for th» oucutiv* ctaffc of two nugor nowapopors; and as a
member of the mediarelationsstaff of the nation's largest oil company.
Ms.Smlthretur^toschodasaSO-yearaW
law school at night while raising two sons and working fun time. She received her
, D.C, and her
Juris Doctoratetemthe Uhivereity of Santa OaraLaw Scfcx* Santa aara,C*iifoniia.
�MINORITY CONTRACTORS ASSOCIATION
MEMBERS:
Contracting owners.
REPRESENTS:
Construction b u i l d e r s w i t h small c o n t r a c t i n g
businesses across the United States.
TODAY'S SPEAKER:
Samuel Carradine, Executive D i r e c t o r (see
bio)
SCOPE OF
INFLUENCE:
Black community.
APPROACH TO
REFORM:
Play or pay.
SUMMARY OF
POSITION:
Contain a high percentage o f very small and
f i n a n c i a l l y vulnerable businesses.
Organization opposes employer mandates and
f e e l t h a t those businesses who do n o t pay f o r
insurance don't pay f o r i t because they can't
afford i t .
Stand t o b e n e f i t from insurance reforms such
as community r a t i n g , insurance pools, as w e l l
as cost c o n t r o l s .
POSITION ON
PLAN:
Supportive.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
None.
PET ISSUES:
Employer mandates e s p e c i a l l y i f imposed
without subsidies f o r a t r i s k e n t e r p r i s e s .
HOT BUTTON ISSUES:
Employer mandate.
�National A s s o c i a t i o n of Minority
Representative
Contractors
Samuel A. Carradine, J r .
Executive D i r e c t o r
Sam C a r r a d i n e was a p p o i n t e d t h e new E x e c u t i v e D i r e c t o r o f
the N a t i o n a l A s s o c i a t i o n o f M i n o r i t y C o n t r a c t o r s (NAMC) on
January 4, 1993.
A n a t i v e o f L o u i s i a n a b u t r a i s e d i n New York
C i t y , Sam i s no s t r a n g e r t o Massachusetts having l i v e d most o f
h i s a d u l t l i f e i n Boston and S p r i n g f i e l d . A f t e r a s t i n t i n t h e
Peace Corps i n N i g e r i a and g r a d u a t i o n form C o r n e l l U n i v e r s i t y
w i t h a degree i n p o l i t i c a l s c i e n c e , Sam f i r s t came t o Boston i n
1970 t o pursue h i s Ph.D i n Government a t Harvard. Soon a f t e r
a r r i v i n g he began d o i n g c o n s u l t i n g f o r Abt A s s o c i a t e s and by 1974
had managed major p r o j e c t s f o r Abt i n t h e areas o f economic
development, t e c h n o l o g y t r a n s f e r and communications.
I n 1974 Sam moved t o Washington f o r t h e f i r s t t i m e t o become
the D i r e c t o r o f Research o f t h e Booker T. Washington Foundation,
t h e n an arm o f t h e N a t i o n a l Business League - t h e o l d e s t Black
b u s i n e s s development o r g a n i z a t i o n i n t h e U.S.
I n 1977, Sam was
asked t o serve as an A s s o c i a t e on t h e White House R e o r g a n i z a t i o n
Project, President's Carter e f f o r t t o reorganize the Executive
O f f i c e o f t h e P r e s i d e n t . Sam was s p e c i f i c a l l y r e s p o n s i b l e f o r
e v a l u a t i n g the effectiveness of the then O f f i c e of
Telecommunications P o l i c y , known as OTP.
Sam's recommendations,
w h i c h became law under The R e o r g a n i z a t i o n Act No. 1, was t o
d i s s o l v e OTP and p u t i t s f u n c t i o n s i n t o a n e w l y - e s t a b l i s h e d
N a t i o n a l Telecommunications and I n f o r m a t i o n A d m i n i s t r a t i o n i n t h e
Department o f Commerce.
I n 1978, Sam r e t u r n e d t o Harvard and i n 1983 was an Economic
Development A s s i s t a n t t o Senator Paul Tsongas. I n 1984, Sam
e s t a b l i s h e d h i s own c o n s u l t i n g f i r m , C a r r a d i n e A s s o c i a t e s i n
S p r i n g f i e l d , Massachusetts, p r o v i d i n g p l a n n i n g , b u d g e t i n g and
o r g a n i z a t i o n a l a s s i s t a n c e t o c l i e n t s i n t h e areas o f economic,
b u s i n e s s and r e a l e s t a t e development.
Sam r e t u r n e d t o Washington i n 1991 t o s e r v e as s e n i o r
a s s o c i a t e f o r s t r a t e g i c and f i n a n c i a l p l a n n i n g f o r t h e
I n t e r n a t i o n a l Science and Technology I n s t i t u t e .
A t NAMC, Sam succeeds Ralph Thomas, who l e a v e s NAMC a f t e r 7
y e a r s t o become a s s o c i a t e a d m i n i s t r a t o r a t NASA f o r s m a l l and
disadvantaged business.
�63^26/93
10S15
S
292
428
1 876
NPlMC
P.02
NATIONAL ASSOCIATION OF MINORITY CONTRACTORS
i|
1333 F Sircet, N.W.
• Suite 500
• Washington. D.C 20004 • (202) 347-8259
HEALTH CAKE REFORM TESTIMONY
by
Samuel A. Carradine, J r .
Executive Director
National Association of Minority
Contractors
Washington, D.C. - March 29, 1993
The National Aaaooiation of Minority Contractors (NAMC) i s a f u l l service minority business trade association representing over 3,500
minority contractors, subcontractors, construction managers, local
minority
contractor
associations,
technical
assistance
organizations, and other support e n t i t i e s in the construction
industry.
NAMC i s certainly heartened by President Clinton's intent to reform
the health care system in the United States because so many of our
constituents have either inadequate health care coverage, health
insurance that i s far too costly, or no health insurance at a l l .
On the other hand, we are concerned as to the direction that these
reforms take with respect to small business i n general and the
small, minority construction business i n particular.
Ours i s a
highly transient workforce and reform options such as employer
mandated coverage are especially problematic
in terms of
implementation, equity and cost.
Most of our membership are small construction businesses employing
fewer than 10 employees and our estimate i s that l e s s than half of
these employers provide any form of health insurance to their
workers. Furthermore, over the past five years, the construction
industry has been disproportionately h i t by the recession and only
now are there fledgling signs of recovery, making i t even more
d i f f i c u l t for those employers who are providing health insurance to
continue to do so at the same level of support. I n addition, the
nature of the construction industry demands mobility of workers
from s i t e to s i t e and often from employer to employer, based on who
wins certain bids for work and where that work i s located. While
work may be seasonal or workers may change employers frequently,
the need for health insurance i s year-round and the cost of
employers either continuing to cover their workers i n periods of
downtime or having to frequently cancel and r e i n s t a t e workers,
would be f i n a n c i a l l y disastrous, not to mention being an
administrative nightmare of the f i r s t order.
I n short, the
effective r e s u l t of mandated coverage on our membership would be
reductions i n the number of employees, a quagmire of costly
paperwork and red tape, and i n many cases, closing of the
businesses.
A FULL SERVICE MEMBERSHIP CONSTBCCTION ASSOCIATION
�MAR 26 '3? 11 ••26 PRUDENTIAL INSURANCE
P. 4/4
THE PRESIDENT HAS SAID HE WANTS TO REDUCE HEALTH CARE COSTS TO MAKE
OUR NATION MORE COMPETITIVE. BUT I F THE GOVERNMENT RAISES BUSINESS
TAXES WHILE EMPLOYER HEALTH CARE COSTS CONTINUE TO RISE, EVEN I F
MORE SLOWLY, THAT CAN ONLY HURT AMERICAN WORKERS.
1
WE SHARE THE ADMINISTRATION S DESIRE TO CREATE A BETTER HEALTH CARE
SYSTEM. WE HAVE BEEN STRUGGLING FOR DECADES TO DESIGN A SYSTEM
THAT CHANGES THE INCENTIVES THAT NOW EXIST.
WE HAVE THROUGH
MANAGED CARE WORKED TO CONTROL OVER-UTILIZATION, AVOID DUPLICATION,
AND REDUCE COSTS.
NOW THE TASK FORCE HAS A UNIQUE OPPORTUNITY TO DESIGN A SYSTEM
BUILT ON THE MANAGED CARE MODEL THAT LETS BUSINESS DEVELOP
INCENTIVES TO CONTROL COSTS AND ELIMINATE COST-SHIFTING. THERE'S
MUCH KNOWLEDGE FOR YOU TO DRAW UPON. WE URGE YOU TO PUT THAT
KNOWLEDGE TO WORK.
�e3/26.'93
10116
S 282 628 1876
NRMC
P.03
NAMC supports the need for reform but we also acknowledge that
reduced costs and increased a v a i l a b i l i t y of health care are, with
the present delivery system, essentially competing agenda.
Fundamental changes i n the way the health care industry operates
should be at the core of any reform and we are pleased that the
Task Force i s examining a variety of options to address these
problems.
I n general, NAMC endorses the intent of the
Administration to reduce hospital, physician and pharmaceutical
costs, to promote insurance underwriting and medical malpractice
reform, and to establish a system that would increase competition
among providers with the hopefully attendant r e s u l t of reduced
costs to the consumer.
Yet, regardless of these reforms and related costs savings,
universal health coverage, however defined, w i l l have a hefty price
tag. To the extent the government subsidizes or otherwise supports
a form of health coverage for a l l Americans, our membership, l i k e
every other taxpayer w i l l be impacted. But i t i s in the s p e c i f i c s
of how such coverage w i l l occur that concern us.
Rather than employer mandated coverage, NAMC supports the "managed
competition" model promulgated by the Administration and endorsed
by a number of other small business groups. NAMC would l i k e to see
individually mandated coverage which removes the burden from the
employer and requires each individual to obtain coverage, with
provisions being made for graduated subsidies based on income as
well as provisions to cover the indigent and unemployed. Employers
may, i f they choose, participate in the costs of such coverage, but
some form of tax r e l i e f or other redress should be available to
employers who do participate. This approach would also provide the
kind of "portability" of coverage that i s p a r t i c u l a r l y necessary,
given the seasonality and extreme mobility factors inherent in the
construction industry.
NAMC also feels that there could be a more creative use of r i s k
pool structures to lower costs for certain groups of insured
individuals.
Relatedly, NAMC supports the idea of health care
purchasing groups, but provisions should be made to maintain the
v i a b i l i t y of association plans that trade and professional
associations now offer to their members and that provide excellent
coverage at affordable rates because of well-negotiated contracts
with providers, quality management, and economies of scale.
NAMC supports the following cost containment reforms: elimination
of state b a r r i e r s to managed care; elimination of c o s t l y state
mandates; r a i s i n g the tax deduction for health coverage from 25 to
100 percent; reforming the medical malpractice system; and
increasing consumer awareness so as to control costs.
We look forward to an extended dialogue with the Clinton
Administration and members of Congress on health care reform issues
and w i l l continue to v i g i l a n t l y promote our position on behalf of
our membership.
�NATIONAL RESTAURANT ASSOCIATION
MEMBERS:
15,000 f o o d s e r v i c e o p e r a t i o n s
REPRESENTS:
Nine m i l l i o n f o o d s e r v i c e employees w i t h a
l a r g e number o f e n t r y - l e v e l and p a r t - t i m e
employees. Founding member o f t h e H e a l t h c a r e
E q u i t y A c t i o n League (HEAL), designed t o f i n d
market-based s o l u t i o n t o h e a l t h c a r e c r i s i s .
TODAY'S SPEAKER:
Stephen Elmont, V i c e
President
Large o r g a n i z a t i o n ,
conservative.
I n f l u e n t i a l and
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
Managed c o m p e t i t i o n
HIPCs no l a r g e r t h a n necessary t o spread r i s k
equitably. Continuation o f self-insurance
f o r l a r g e employers. Insurance r e f o r m s
i n c l u d i n g community r a t i n g w i t h r i s k
adjustment f a c t o r s , e l i m i n a t i o n o f p r e e x i s t i n g c o n d i t i o n c l a u s e s once coverage
i n i t i a l l y e s t a b l i s h e d . Standard b e n e f i t
package. L i m i t s on employees t a x e x c l u s i o n
f o r h e a l t h b e n e f i t s . Federal clearinghouse
on technology assessments. No g l o b a l
budgets. No employer mandates - v e r y
concerned about p a r t - t i m e workers.
W i l l n o t support employer mandate.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
HOT BUTTON ISSUES:
Employer mandate, p a r t i c u l a r l y coverage o f
p a r t - t i m e employers
�STEPHEN B. ELMONT
Stephen E. Elmont i s the proprietor of Mirabelle, a
contemporary European restaurant located in Boston's Back Bay
neighborhood. He i s also the founder of Creative Gourmets, today
the largest caterer i n New England.
After holding a variety of commercial and i n s t i t u t i o n a l
foodservice management positions, Elmont established Creative
Gourmets i n 1975 when he opened a soup and salad restaurant in a
Boston office building. This led to the s o l i c i t a t i o n of Creative
Gourmets to manage the employee cafeteria of the building's major
tenant. As Creative's reputation grew, the company became a
major regional contract foodservice organization that today
operates 55 i n s t i t u t i o n a l cafeterias, a bakery and catering
division with accounts ranging from Fortune 500 firms (Reebok and
General Cinema) to Harvard's Kennedy School of Government and the
Dana Farber Cancer I n s t i t u t e . Events catered by Creative
Gourmets include the Maria shriver/Arnold Schwarzenegger wedding,
Leonard Bernstein's 70th birthday party at Tanglewood and a
dinner for President Bush at Boston's World Trade Center. I n
1989, Creative Gourmets was acquired by Gardner Merchant Food
Services, a division of Forte PLC.
Recently, Elmont and h i s wife, Linda Schwabe, founded The
Food Group, Ltd. The major focus of the new company has been to
open a neighborhood restaurant, Mirabelle, serving breakfast,
lunch and dinner seven days a week.
Elmont has been elected to serve as president and chairman
of the National Restaurant Association for the 1993-94 term. He
has been a director of the association since 1984 and i s a past
president of the Massachusetts Restaurant Association.
�:
FROM SIZER. C.
TO:
2024567739
MAR 25, 1993 1:07PM
MARCH 29TH
PUBLIC HEARING
TASK FORCE ON HEALTH CARE REFORM
STATEMENT OF
STEPHEN ELMONT
PRESIDENT, THE FOOD GROUP, LTD.
ON BEHALF OF THE
NATIONAL RESTAURANT ASSOCIATION
Nalional Rcsiaurani Association, 1200 Scvcntcenlh Street, NW, Washington, DC 20036, 202/331-5900, FAX: 202/331.2429
p
�FROM: SI ZER, C.
TQ:
2024567733
MAR 25- 1993 1:07PM «606 P. 03
|Ms. Clinton and Members of the Task Force on Healthcare Reform My name is Stephen Elmont. I am president of The Food Group, Ltd., in
Boston, ] also serve as Vice President of the National Restaurant Association.
Our industry is tremendously concerned about health care reform. For the past
few years, restaurateurs have struggled with double-digit inflation in health
care premium costs; with cancellations and denials of coverage; and with the
frightening prospect of a health-benefits mandate.
We are not engaging in hyperbole when we say that mandated employerprovided coverage or higher payroll taxes to pay for health benefits would
literally sound the death knell for thousands of restaurants - and discourage
thousands of other restaurants from ever opening up.
Our research indicates that COST is the major deterrent for restaurateurs who
want to buy health plans for their employees, as well as for those trying to
continue providing health benefits.
Since I know my time before you today is very limited, I'll focus on two areas:
First, the unique nature of foodservice businesses and their workforces; and
second, the specific reforms we endorse because we know they would mean
more coverage for more foodservice employees. We urge you to take these
into consideration as your task force deliberates.
Foodservice differs from other industries in several important respects:
•
FIRST, we are dominated by small businesses.
•
SECOND, our profit margins are extremely slim.
•
AND THIRD, we are labor-intensive - and our workforce looks
much different than many other workforces.
Today, foodservice employs nine million Americans. By 2005, that number will
climb to 12 million. Our typical employee is young, female and single; A live
at home with their parents. And our employees are more likely to work parttime. The combination of these characteristics means we are at once
tremendously affected by labor-cost increases and at the same time lackine
options for absorbing these cost increases.
3
�FROM:SIZER. C.
TO:
2024567739
MAR 25. 1993 1:08PM 8606 P.04
You have asked us to discuss the best ways to ensure that employees of small
businesses get health coverage.
We believe that the most essential clement of healthcare reform is cost
containment. We adamantly oppose employer mandates, price controls, and
global budgets. Instead, we support many of the concepts behind "managed
competition" which build on the strengths of our free-market system. Here are
the reforms we urge you to adopt:
•
ONE, we support pooling systems that would help small businesses and
uninsured individuals buy quality health insurance at affordable rates.
•
TWO, we support tax clxanges lo give all businesses a full tax deduction
for the cost of health insurance premiums, but limiting the employer tax
deduction and employee tax exclusion for excessive health coverage
costs.
•
THREE, we support reforms to the insurance market for small businesses,
so small business owners and employees are guaranteed insurance
coverage.
•
FOUR, we support federal pre-emption of costly state laws, such as those
requiring even basic benefit plans to include non-essential care and those
that put a damper on managed-care programs.
•
FIVE, we support reduction of paperwork by creating a uniform electronic
claims system that guarantees timely payments and curtails fraud.
•
AND FINALLY, we support reforms to medical-malpractice laws.
These recommendations are aimed at removing the barriers that prevent
businesses from providing health insurance to their employees.
Yet if legislation is adopted that mandates all employers provide health care
coverage for their employees, it would result in disaster for the nation's
foodservice operators, large and small.
�NATIONAL ASSOCIATION OF PRIVATE ENTERPRISE
MEMBERS:
NAPE has over 50,000 members n a t i o n w i d e .
REPRESENTS:
NAPE's members a r e p r i m a r i l y u n i n c o r p o r a t e d
mom-and-pop businesses w i t h fewer t h a n 10
employees.
TODAY'S SPEAKER:
NAPE has attempted t o t a k e a more low key
approach t o l e g i s l a t i v e i s s u e s , t h a n i t s
l a r g e r r i v a l s l i k e t h e NFIB. I t has r e c e n t l y
r a i s e d i t s p r o f i l e i n Washington and around
t h e c o u n t r y by h o l d i n g "speak o u t " town
meetings w i t h l o c a l and c o n g r e s s i o n a l
p o l i t i c i a n s on v a r i o u s s m a l l business i s s u e s .
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
PET ISSUES:
NAPE has avoided t a k i n g any p u b l i c p o s i t i o n
on h e a l t h r e f o r m u n t i l t h e y know more
details.
Non-specific
NAPE supports s t r o n g c o s t containment
measures, i n c l u d i n g g l o b a l b u d g e t i n g and
m a l p r a c t i c e r e f o r m . They s u p p o r t t h e 100
p e r c e n t d e d u c t i o n and any a d d i t i o n a l t a x
i n c e n t i v e s f o r s m a l l businesses.
Generally,
t h e y do n o t support mandates, b u t t h e y a r e
t a k i n g a w a i t and see a t t i t u d e t o see what
f i n a n c i a l support might be p r o v i d e d . NAPE
would l i k e t o c o n t i n u e t o p r o v i d e h e a l t h
i n s u r a n c e b e n e f i t s f o r i t s membership. Since
most o f t h e i r members have i n s u r a n c e
coverage, t h e y a r e concerned t h a t market
r e f o r m might a c t u a l l y r a i s e t h e c o s t o f
h e a l t h i n s u r a n c e coverage f o r i t s members.
They have n o t t a k e a p o s i t i o n on managed
c o m p e t i t i o n u n t i l t h e y know more d e t a i l s .
As a member o f t h e Small Business L e g i s l a t i v e
C o u n c i l , NAPE has p a r t i c i p a t e d i n a number o f
i n f o r m a l d i s c u s s i o n s w i t h t h e Task Force.
�HOT ISSUES:
NAPE's hot buttons are cost containment and
maintaining their a b i l i t y to provide health
insurance to i t s members.
�SMALL BUSINESS LEGISLATIVE COUNCIL
MEMBERS:
C o a l i t i o n o f 100 small business trade
associations
REPRESENTS:
The Council organizations represent a t l e a s t
1.6 m i l l i o n small businesses i n diverse
economic sectors (manufacturing, r e t a i l i n g ,
d i s t r i b u t i n g , p r o f e s s i o n a l and t e c h n i c a l
services,construction, t r a n s p o r t a t i o n and
agriculture).
TODAY'S SPEAKER:
Gary Frank Petty, Treasurer and member o f the
Board o f Directors (see b i o )
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Newsletter widely d i s t r i b u t e d ,
key congressional members.
Well l i k e d by
Their health care reform proposal does not
include an employer mandate, but have
signaled t h e i r w i l l i n g n e s s t o discuss i f the
cost issue i s adequately addressed and small
businesses are not unduly burdened.
They developed a reform proposal about two
years ago.
Establishment o f g l o b a l spending goals and
rate structures that r e f l e c t local
circumstances.
Recently released statement supportive o f
price controls.
Encourage c r e a t i o n o f v o l u n t a r y small
business "buying groups."
L i m i t s on employee tax exclusion f o r
employer-paid h e a l t h coverage.
Reform o f small group case market should
recognize importance o f a s s o c i a t i o n insurance
plans ( i n c l u d i n g MEWA's) as a means o f
p r o v i d i n g coverage and relevance o f workers
compensation as a l a r g e component o f t h e
h e a l t h care debate.
�POSITION ON
PLAN:
Noncommittal, but open.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
Transition.
HOT BUTTON ISSUES:
Cost c o n t r o l , employer mandate.
�NATIONAL CONGRESS OF AMERICAN INDIANS
MEMBERS:
144 member American I n d i a n t r i b e s and A l a s k a
N a t i v e governments
REPRESENTS:
N a t i o n ' s l a r g e s t and o l d e s t n a t i o n a l i n t e r t r i b a l o r g a n i z a t i o n r e p r e s e n t i n g t r i b e s i n 33
states.
TODAY'S SPEAKER:
M i c h a e l J. Anderson, E x e c u t i v e D i r e c t o r
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
PET
ISSUES:
HOT ISSUE:
Constituency
states
o f concern i n some w e s t e r n
Non-specific
Improve access t o h e a l t h c a r e f o r N a t i v e
Americans (over 50% n o t s e r v i c e d by t h e t h r e e
I n d i a n h e a l t h c a r e s e r v i c e systems) w h i l e
m a i n t a i n i n g consumer c h o i c e .
Possible
l i m i t a t i o n s o f managed c a r e t o s e r v i c e v e r y
poor and r u r a l areas n e c e s s i t a t e s t h e
c o o r d i n a t i o n between I n d i a n H e a l t h S e r v i c e
and l o c a l h e a l t h networks. S u b s i d i e s f o r
s m a l l employers. Improve a v a i l a b i l i t y o f
primary care p r o v i d e r s . B e n e f i t s should
i n c l u d e long-term c a r e and h e a l t h p r o m o t i o n
and disease p r e v e n t i o n .
Receptive t o A d m i n i s t r a t i o n p l a n .
Transition
Access t o h e a l t h care. A b i l i t y o f managed
c a r e t o meet needs o f poor r u r a l p o p u l a t i o n s .
P r e v e n t i o n ( p a r t i c u l a r l y substance abuse)
P r e s e r v i n g t r i b a l g o v e r n m e n t / l o c a l community
h e a l t h c a r e p r o v i s i o n o p t i o n s i n c l u d e d i n 638
progrms (want l e s s IHS d o m i n a t i o n )
( c u l t u r a l l y s e n s i t i v e and r e l e v a n t h e a l t h
care).
�Extended Page
1. 1
National Congress of American Indians
neetcnvi comtimi
QatMhUbo.
PlrM vtc« PmMmrt
Jotaph T. OoamW
Mom
Raeof « • « towatanr
Rachal jcwph
SMcfionv-PafuivMeno
W. RM AJtw\
AREA VICE PREWOSHTS
AbwdMd Area
Tarry Flddlar
Ohtyann* Rhrer Olowt
Albarquarqu* Araa
RayinsndO. Apodaea
rttota Dal Su/ PIMMO
Anateke Araa
Elmar Uanatawa
Sac A Fax
BIHIa«a * » • •
Earl Old Paraon
0lae*/Mt
Jwaaau Araa
Edward K. Thora»»
Vlnglt-HM*
Hlnaaapella Araa
Jatnaa Ciatferd
Fonet County Potrnmiom!
Maakogaa Araa
B. Diana Kallay
OMmkmo
Nerthaaalani Araa
J.C. Sanaca
Sanaca
Moaalx Aiaa
Mary Am Anions
Tohono O'edham
Pettlaad Araa
Bruea Wynna
Opoktne
Baoramaata Araa
Susan Uutsn
Yuro*
Sealhaaalam Araa
A. Bruea Jona*
Lumb»o
EXECUTIVE DMCCTOR
Mlohaal J. Andarton
Craalr
TESTIMONY OF THE NATIONAL CONGRESS OF AMERICAN INDIANS
BEFORE THE YiHTTE HOUSE HEALTH CARE TASK FORCE
MARCH29. 1993
Good morning. My name is Michad Anderson and I am tha Executive
Director of the National Congress of American Indians (NCAO. NCAI has a
membership base of over 120 American Indian and Alaska Native
governments. NCAI Is pleased to present our views on national health care
reform proposals being considered by the Clinton Administration.
In developing a national health care reform proposal, it is essential
that the Administration recognize the unique and constitutionally based
"government to government relationship" between the federal government
and this nation's 500 tribal sovereign Nations. Land was receded by these
Indian Nations (sometimes Hlegetily end forcibly) ip exchange for the
protection of the United States. Today, Indian Nations retain their own
forms of government determine wtfo is a tribal member, regulate tribe/
property, maintain the right to tax as we/i as other arias of tribal authority.
Most recently, the unique relationship of the U.S. government to Indian
tribes and people was affirmed in the Indian Health Care Improvement Act
which declares that "it Is the policy of the United States to assure the
highest possible health status for Indians and urban Indians and to provide
all resources necessary to effect that policy.' (25 U.S. C. 1602(a)/
By recognizing this unique relationship between Indian Nations and
the United States, the new Administration, in developing health care reform,
can avoid inadvertently limiting or restricting health care benefits now
provided tp American Indians andfl^skan Natives. Such limits would occur
if American Indians were to become pert of a national heelth insurance plan
which reducedservices nowprovtyecf by the Indian Health Service end tribal
health care delivery systems.
\ j
To that end, all special authorities now provided for American Indian
and Alaska Native people's health services, i.e. the Snyder Act, the Indian
Health Ca^re Improvement Act (P.L. 194-437), the Indian Self-Determination
Act (P.L. 93*638), the Indian Health Amendments (P.L 102-673), the
Indian Wqterand Sanitation Facilities Construction Act (P.L. 66-121), end
others must be maintained through direct appropriations for Indian health
programs.
900 PemxBylvania Avenue S.E. * Washington, D.C. 29003 * (202) 546-9404 • Fax (202) 546-8741
�03/26/83
14.19
©2025463741
N . c . A . I . WASH.DC
21002
'2>
These authorities include many components of the comprehensive Indian
community based health service delivery systems which would not be provided by a
national basic benefit package. For example, health professional training for American
Indian and Alaska Natives, construction of Indian health facilities and sanitation facilities
for Indian homes and communities. These authorities also have been carefully designed
to meet the unique needs of Indian people and should continue to be emended as
necessary in order to meet the Federal goal of elevating Indian health status to the highest
possible level.
The question addressed today is "Given the need to control costs, how can we
ensure that people in the underserved areas have access to quality cere?" The enswer
for American Indians is to permit them the option to participate In nationally provided
health care options like insurance while retaining access to Indian health service/tribal
services. Currently, IHS or tribes operate 50 hospitals, 158 ambulatory health centers,
115 health stations and 172 Alaskan village clinics. Urban Indian organizations operate
34 health centers. IHS and tribally operated programs should be able to collect for
American Indian/Alaska Native people who have -other coverage who choose to use IHS
or tribally operated programs.
Moreover, the rlg/it of tribes to operate their own health care programs under P.L.
93-638 should be protected and tribes should be allowed to fully participate in other
financing structures created under health care reform. IHS and tribally operated health
care programs should be authorized to compete to offer services to non-Indians, but
should not be required to do so.
All services available through a national core benefit package should be
available to tribal members through Tribai/IHS programs. The Core Benefit Package
should include, at a minimum: Ambulatory/inpatient medical services, substance abuse
prevention/treatment, preventive health care, long-term care - home/Jnstitutlonal/y based,
referrals, patient educetion, screening and mental health. The Administration should
recognize that IHS/Tribai'providers are inadequately funded to fulfill the mission of the IHS
as set forth in existing federal law.
The minimum level of funding for IHS/Trfbal health care programs should be
equivalent to that which would be earned if all the core benefit services provided were
reimbursed on the payment scale negotiated by the HfPC for the region in which the
IHS/Tribal program operates.
Speciaf provision? should also be adopted to encourege Tribally operated Health
insurance Purchasing Cooperatives (HIPCs) for management of contract health services
and for urban Indians, in areas of high Americen Indian/Alaska Native concentration,
HtPC's should be required to give an advantage to Indian operated programs.
�03/28/93
14:20
©2025463741
01003
N . C . A . I . WASH.DC
|
.3.
.
•!
for other health care provVers.
while retaining the trust responstbMiesMWetfW'
^ n / a there ere meny,'i^Mebefore
Lat be recognize* that M * M f i J ^ ~ »
If any group of peop,, deserve ^ X ^
„ Americen Mien people. No '""'J^^Vnecks.
Peoples.
ft
the ege of 45, post-neonatel
Deeth Syndrome « emong
f 0
M
&
m
^
£ S E S X %
remove, from bom*,nJs
�10:10 --
PANEL TWO-BUSINESS-- TESTIMONY ENDS
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
�10:15 -
PANEL THREE-UNDERSERVED-- TESTIMONY BEGINS
Thank you to all the witnesses on panel two.
Now, we will hear from several groups representing underserved populations. We
asked this panel the following question: "Given the need to control costs, how can we ensure
that people in underserved areas have access to quality care?" Ourfirstwitness will be Larry
Naake [KNACK-EE], the Executive Director of the National Association of Counties.
�10:15--
PANEL THREE-UNDERSERVED-- TESTIMONY BEGINS
Thank you to all the witnesses on panel two.
Now, we will hear from several groups representing underserved populations. Our
first witness will be Larry Naake, the Executive Director of the National Association of
Counties.
�PANEL THREE: UNDERSERVED
Question Posed:
Given the need to control costs, how can we ensure that people in underserved areas
have access to quality care?
Groups:
National Association of County Organizations
Urban League
National Farmers Union
National Council of La Raza
National Congress of American Indians
Major issue concerns:
These groups are divided between rural, inner city, and two special categories - farm
workers and American Indians. All are extremely concerned about the ability of a
managed competition system to help them. They all share the point of view that genuine
universal access means more than being covered by insurance: it means having access to
high quality medical services in their area.
Talking points:
l.y
Our plan is being designed with the special needs of underserved populations in
mind.
2. ^
Having strong preventive services for low income people, especially children, will
be a major part of our plan.
�NATIONAL ASSOCIATION OF COUNTY ORGANIZATIONS ("NACo")
MEMBERS:
Over two-thirds o f the 3044 county
governments i n the United States belong t o
NACo, ranging i n size from Los Angeles County
(pop. 8 m i l l i o n ) t o Loving County, Texas
(pop. 100). The county governments
themselves are the actual members, and county
membership allows i t s elected and appointed
o f f i c i a l s t o p a r t i c i p a t e i n NACo.
REPRESENTS:
13,000 elected county o f f i c i a l s ; 2 m i l l i o n
county employees
DISTRIBUTION:
NACo has member counties i n 48 s t a t e s (none
i n Connecticut o r Rhode I s l a n d ) . There are
no member counties i n the U.S. t e r r i t o r i e s o r
possessions.
TODAY'S SPEAKER:
Larry Naake, Executive D i r e c t o r (see b i o )
SCOPE OF
INFLUENCE:
NACo i s the only n a t i o n a l r e p r e s e n t a t i v e o f
counties i n the U.S. and i t s member counties
w i l l be c r i t i c a l t o the implementation and
success o f a health care reform package.
APPROACH TO
REFORM:
Managed competition/HIPC model
SUMMARY OF
POSITION:
NACo supports the general managed c o m p e t i t i o n
framework o f managed care systems, w i t h an
emphasis on preventive and primary care;
f e d e r a l government should work w i t h s t a t e s
and counties t o develop purchasing
cooperatives; f e d e r a l government should
develop rates and b e n e f i t package t h a t
includes coverage f o r mental h e a l t h ,
substance abuse and long term care; f i n a n c i n g
should come from a n a t i o n a l t a x ; f e d e r a l
government should reduce a d m i n i s t r a t i v e costs
through s i m p l i f i c a t i o n . NACo opposes capping
f e d e r a l h e a l t h care e n t i t l e m e n t programs.
POSITION ON
PLAN:
Generally supportive, i n s o f a r as t h e p l a n
represents a comprehensive, u n i v e r s a l system
of coverage; reservations e x i s t , pending
disclosure o f the exact r o l e o f l o c a l
governments; usual concerns about managed
care working i n r u r a l / u r b a n underserved
areas.
�INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
NACo reps have met w i t h the Intergovernmental
A f f a i r s O f f i c e several times t o receive
b r i e f i n g s on the Task Force and t o discuss
NACo involvement i n the working groups; I r a
Magaziner addressed 200 - 300 NACo reps on
March 1; NACo's Health Policy Committee met
w i t h working group leaders and Judy Fader i n
the Indian Treaty Room on March 2; e i g h t NACo
reps have been added t o the working groups.
�NATIONAL ASSOCIATION OF COUNTIES
"Counties Care For America"
440 F i r s t S t r e e t ,
N . W. • W a s h i n g t o n , D. C. 2 0 0 0 1
•
202/393-6226
STATEMENT OF
LARRY E. NAAKE
ON BEHALF OF
THE NATIONAL ASSOCIATION OF COUNTIES (NACo)
BEFORE THE
PRESIDENT'S HEALTH CARE TASK FORCE
MARCH 29, 1993
WASHINGTON, DC
�MRS. CLINTON, MEMBERS OF THE TASK FORCE, I AM LARRY NAAKE,
EXECUTIVE DIRECTOR OF THE NATIONAL ASSOCIATION OF COUNTIES.
TODAY, COUNTY GOVERNMENTS ARE OFTEN THE SAFETY NET.
WE
PROVIDE CARE DIRECTLY AND PURCHASE SERVICES FROM THOSE NON-PROFIT
ENTITIES WILLING TO ACCEPT THE UNINSURED.
COUNTY OFFICIALS FACE
THE CHALLENGES OF DELIVERING AND FINANCING WHAT IS A PATCHWORK
LOCAL UNIVERSAL CARE SYSTEM.
BECAUSE OF THAT EXPERIENCE, WE HAVE
LONG CALLED FOR A NATIONAL UNIVERSAL CARE SYSTEM.
A FEW FACTS HIGHLIGHT OUR COMMITMENT TO THE UNINSURED:
o
COUNTIES ARE RESPONSIBLE FOR SPENDING OVER $3 0 BILLION A
YEAR ON HEALTH.
o
COUNTIES BEAR RESPONSIBILITY AS PROVIDERS OF LAST RESORT
IN THIRTY-SIX STATES.
O
COUNTIES OWN AND OPERATE 4,500 HEALTH FACILITIES,
INCLUDING 581 HOSPITALS.
o
COUNTIES PAY A PORTION OF THE NON-FEDERAL SHARE OF
MEDICAID IN OVER TWENTY STATES.
o
TEN PERCENT OF COUNTY HEALTH DEPARTMENTS ARE THE SOLE
PROVIDER FOR THE UNINSURED IN THEIR JURISDICTION.
OF
THESE, NEARLY TWO-THIRDS ARE IN RURAL AREAS.
o
COUNTY HEALTH DEPARTMENTS ARE THE LOCUS OF TRADITIONAL
PUBLIC HEALTH PROGRAMS, SUCH AS ENVIRONMENTAL HEALTH,
FOOD AND WATER SAFETY, AND DISEASE PREVENTION AND
CONTROL.
THESE ARE "STEALTH HEALTH" SERVICES THAT
PROTECT THE ENTIRE COMMUNITY BUT ARE NOT NOTICED UNLESS
THERE I S A BREAKDOWN IN THIS UNDERFUNDED INFRASTRUCTURE.
THESE FACTS HAVE BEEN GATHERED AND DISCUSSED AT THE SIX
REGIONAL HEARINGS WE HAVE HELD SO FAR.
I WILL NOW PUT THEM IN
�THE CONTEXT OF CONTROLLING COSTS AND SERVING THE UNDERSERVED
POPULATIONS.
I WILL COVER THE AREAS OF SERVICE DELIVERY AND
GOVERNANCE.
SERVICE DELIVERY
PRINCIPLE:
INVESTING I N A STRONG PUBLIC HEALTH
INFRASTRUCTURE WILL ULTIMATELY HELP TO CONTROL COSTS.
RECOMMENDATION:
A SPECIFIC PERCENTAGE OF TOTAL HEALTH
EXPENDITURES SHOULD BE SET ASIDE FOR PUBLIC HEALTH.
JUSTIFICATION:
PREVENTION, ASSESSMENT OF A COMMUNITY'S
HEALTH, POPULATION-BASED SERVICES AND OUTREACH TO THE UNDERSERVED
ARE KEY ELEMENTS OF PUBLIC HEALTH AND OFTEN PERFORMED BY NO OTHER
ENTITY.
THOSE SERVICES TYPICALLY FALL OUTSIDE AN ACCOUNTABLE
HEALTH PLAN BUT ARE NECESSARY TO PREVENT COSTLY ILLNESS THAT AN
AHP WOULD END UP TREATING.
THE COUNTY PUBLIC HEALTH
INFRASTRUCTURE EXISTS TO SUPPORT AHP DIRECT SERVICES.
PRINCIPLE:
THE PRIMARY CARE DELIVERY SYSTEM SHOULD BE AS
SIMPLE AND FLEXIBLE AS POSSIBLE AND DELIVERED I N THE MOST COST
EFFECTIVE MANNER.
RECOMMENDATION:
A REFORMED SYSTEM SHOULD ELIMINATE THE
CURRENT SERVICE PAYMENT INEQUITIES THAT ARE BASED ON THE TYPE OF
FACILITY PROVIDING CARE.
PROVIDERS.
THE FOCUS SHOULD BE ON SERVICES,
NOT
COUNTIES SHOULD RECEIVE THE SAME REIMBURSEMENT FROM
AHP'S AS FEDERALLY FUNDED FACILITIES.
JUSTIFICATION:
MANY COUNTY HEALTH DEPARTMENTS FORM A READY
INFRASTRUCTURE FOR PRIMARY CARE SERVICES, BUT ARE FINANCIALLY
UNABLE TO DO SO DUE TO EXISTING FEDERAL RULES.
PRINCIPLE:
INTEGRATING DIRECT PHYSICAL AND MENTAL HEALTH
SERVICES WITH SUPPORT SERVICES OUTSIDE OF HEALTH ASSISTS I N
PROVIDING ACCESS AND CONTROLS COSTS.
�RECOMMENDATION:
REFORM MUST ACKNOWLEDGE THE COORDINATING
AND SERVICE BROKERING ROLES OF COUNTY GOVERNMENTS.
JUSTIFICATION:
ELECTED COUNTY OFFICIALS ARE POLITICALLY
ACCOUNTABLE AND HAVE AN UNDERSTANDING OF THEIR COMMUNITIES'
NEEDS.
THEY ARE RESPONSIBLE FOR ADMINISTERING A NUMBER OF
EXISTING FEDERAL, STATE AND COUNTY PROGRAMS THAT COULD BE USED TO
ENABLE THE UNDERSERVED TO ACCESS THE SERVICES NEEDED.
HEALTH REFORM GOVERNANCE
PRINCIPLE:
TO CONTROL COSTS AND ENSURE ACCESS, THE
LOCATION AND MEMBERSHIP OF AN EFFECTIVE HIPC WILL REFLECT
GEOGRAPHIC AREAS AND PERSONS WHO UNDERSTAND THE REGION'S UNIQUE
DEMOGRAPHICS.
RECOMMENDATION:
INDIVIDUAL URBAN AND SUBURBAN COUNTY
GOVERNMENTS OF A SUFFICIENT POPULATION SIZE OR A CONSORTIA OF
THEM SHOULD BE ELIGIBLE TO BE DESIGNATED AS A HIPC.
LIKEWISE, A
REGIONAL GROUPING OF RURAL COUNTIES SHOULD ALSO BE ELIGIBLE, I F
DESIGNATION MEETS THE UNIQUE NEEDS OF THE AREA.
COUNTY OFFICIALS
MUST BE INCLUDED ON NATIONAL AND STATE GOVERNING BOARDS.
JUSTIFICATION:
AS REPRESENTATIVES OF THE LOCAL GOVERNMENT
MOST OFTEN RESPONSIBLE FOR HEALTH, COUNTY OFFICIALS HAVE A UNIQUE
PERSPECTIVE AND EXPERTISE.
THEY ARE ULTIMATELY ACCOUNTABLE TO
THEIR RESIDENTS FOR PUBLIC SERVICES AND UNDERSTAND THE BROADER
PUBLIC/PRIVATE LOCAL SYSTEMS ISSUES.
AS LOCAL GOVERNMENT
LEADERS, THEY WILL SHARE I N THE RESPONSIBILITY FOR THE H I P C S
SUCCESS.
EMPLOYERS AND CONSUMERS HAVE CLOSER ACCESS TO THEM THAN
STATE OR FEDERAL OFFICIALS.
ON BEHALF OF THE NATIONAL ASSOCIATION OF COUNTIES, THANK
YOU FOR INVITING ME TO TESTIFY.
�NATIONAL URBAN LEAGUE
MEMBERS:
C o n s t i t u e n t o r g a n i z a t i o n w i t h 113 a f f i l i a t e s
REPRESENTS:
Grassroots a f f i l i a t e s i n urban areas as a
c i v i l r i g h t s and advocacy b a s i s m a i n l y
focused on A f r i c a n - A m e r i c a n s .
TODAY'S SPEAKER:
Ann H i l l , D i r e c t o r o f Employment & Advocacy.
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
PET
ISSUES:
HOT BUTTON ISSUES:
Solid, credible organization annually
produces r e p o r t on t h e S t a t e o f B l a c k
America.
Flexible.
The Urban League s u p p o r t s t h e g o a l s o f h e a l t h
care r e f o r m t o p r o v i d e u n i v e r s a l coverage.
T h e i r p r i o r i t i e s a r e e n s u r i n g t h a t t h e most
v u l n e r a b l e , m i n o r i t i e s and t h e p o o r , a r e n o t
f u r t h e r disadvantaged by a new system.
Supportive o f p r o v i d i n g q u a l i t y h e a l t h care
t o a l l b u t concerned about u n i v e r s a l access.
T r a n s i t i o n , Maggie W i l l i a m s
AIDS, and "excess deaths" — t h e d i f f e r e n c e
between t h e a c t u a l number o f deaths among
b l a c k s and t h e number t h a t would have
o c c u r r e d i f b l a c k s had d i e d a t t h e same r a t e
f o r each age and sex as w h i t e s .
Medicaid b e n e f i t s t a x , which has
d i s p r o p o r t i o n a t e impact on poor; i n c r e a s i n g
age f o r Medicare e l i g i b i l i t y , w h i c h causes
A f r i c a n - A m e r i c a n (who d i e younger) t o
c o n t r i b u t e t o a system t h e y a r e l e s s l i k e l y
t o c o l l e c t from; and new system w h i c h may
h u r t h e a l t h c a r e p r o v i d e r s who a r e f r o m and
c a r e about t h e i r community o r w i l l p u t h e a l t h
c a r e workers, who a r e n o t c u l t u r a l l y
s e n s i t i v e i n t o communities.
�MAR 23 '53 16:11
FROM NAT. URBAN LEAGIE
TO 12323954198
PAGE.003/003
BIO
Anne D. H i l l , Director of Program Development for the National
urban League, Inc., has devoted years to the human service
f i e l d and use such experiences to develop and implement
effective programs that w i l l improve the quality of l i f e for
disadvantaged people, in general, and African Americaiis i n
particular.
Ms. H i l l also acts as spokesperson f o r the
National Urban League, Inc. i n the area of health programs,
she serves on a number of boards and committees including
Leadership Akron Alumni Association, NIDA African American
HIV/AIDS Planning Committee, NMAC Advisory Committee, American
Red Cross Advisory Committee, National Leadership Coalition
on AIDS and the Office of Minority Health Review Panel.
�RCV BY:
3-25-93 ; 5:S3PM
1 212 310 9219-
SOCIAL OFFICE!* 2
WHILE ACCESS IS UMITED
KB the nation tackles health cere reforn the uneven distribution ot heelth services must be aariouely addressed.
While
access ie limited tor all African American*, it is most
restrictive
tor those ot lover socio-economic statue who struggle daily vith
conditions such as poor housing, limited education, and leek ot job
opportunities.
In addition,
they face the daily ocourrence of
aubstance abuse, violence and other by-products
ot residing
in
urban areas.
The nation has created a stresstul
l i f e style
that
has devastating
consequences for the entire society.
Therefore,
there is no greater challenge than to improve the ailing health
care system for our most unhealthy citizen*. To truly close the
gap between the health status of black and white America, the
solutions
must be comprehensive, recognizing
all ot the
aforementioned
factors.
To specifically
ere as follows:
•
respond to the question,
our
recoamendetions
Partner vith community-based orfanisatlons
to
heelth services.
Such paxrtnerehips will assure
delivery
deliver
the
of health care in faailiar and tru*to<J
surroundings reducing the impact of extraneous
barriers
such as, transportation,
child care, etc.
Home services
by health professionals/para-protesslonels
should also be
considered for some
illnesses,
•
Con*uaor and provider input to planning and
especially
care,
In promoting
family-oriented,
evaluation,
community-based
•
A health education program which targets African Aoerlcan*
and the range of illnesses
most prevalent among this group
should be developed end delivered in a culturally
competent
manner. Such messages should consider beliefs
end
attitudes
of African Americans towards health care, as well
as their unique lifestyles
and
practices,
•
There is a critical
need to reinforce the behavior ot
providers to ensure that health care services are "user
friendly,"
Often those seeking health care do not return
because of the manner in which they are
treated,
•
Prevention programs aimed at substance abuse, AIDS, infant
mortality,
homicide, cancer, teen pregnancy,
hypertension,
etc, should be expanded. Such expansion will
greatly
reduce the need tor more costly treatment and
services.
�RCV BY:
3-25-93 ;
Silteu
1 2)2 310 9219-
SOCIAL OFFICE!.* 3
Page SVo
•
Local, state and federal governaent should be required
to
review practices
to reduce barriers,
A program should be
developed which ie accountable to the public - monitored by
local, state and federal governments for quality,
cost and
access.
One that assures primary core, geographic and
cultural distribution
ot providers ottering a proper mix ot
services in a system producing the fewest
duplications.
The program should foster consumer end provider
accountability
with respect to the use and abuse of health cere
resources,
special attention should be given to
for-profit
hospitals who provide minimal services to minority
patients,
• Insurance companies should be required to otter covereae to
high risk consumers at non discriminatory
rates.
This
would overcome the problems of fee-for-servlce
covereae by
encouraging the growth of health maintenance
organizations,
or H.M.O.'s,
•
H.M.O.'e should include a mix panel of competent
doctors
whose primary goals are to ensure the delivery of
quality
health services to all patients regardless
ot race and
economic standing.
Every effort should he made to
utilise
African American physicians in the development and continued provisions of services by H.M.O.'e
•
A shift of emphasis from treatment
rewarded,
•
The Department ot Health and Human Services should be
encouraged to convene a task force with
high-level
representation
from DOL, HUD, Education and the
Justice
Depekrtnents to develop comprehensive strategies
aimed at
reducing the health risk associated with each ot these
areas.
to prevention
must be
Limited eccess to high-quality
health cere translate
into
excess deaths tor African Americans, robbing children ot
parents,
communities of residents,
and the nation of its citizene.
it is
not
acceptable
for African Americaiifi to be at higher risk
ot
suffering
and dying from diseasee
ot which they are
not
biologically
predisposed.
Health is a right ot all Americana, this brief paper
suggests
several methods ot developing vital services
to those who often
tall through the cracks.
�THE FARMERS UNION
MEMBERS:
250,000 farm f a m i l i e s
REPRESENTS:
Rural farmers i n 26 states, a general
purpose n a t i o n a l farm o r g a n i z a t i o n
TODAY'S SPEAKERS:
Nancy Danielson,
Representative
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Legislative
Grass roots a t Federal, s t a t e and l o c a l
l e v e l , mobilizes q u i c k l y , and
i n f l u e n t i a l i n key a g r i c u l t u r e s t a t e s
Single payer
The Farmers Union supports s t a t e
f l e x i b i l i t y so the s t a t e s can adopt a
s i n g l e payor system.
Supports u n i v e r s a l coverage.
They support a plan t h a t meets t h e needs
of r u r a l America—access, choice and
quality.
The group recognizes t h a t they share the
President's o b j e c t i v e s and w i l l s e t
aside t h e i r ideology t o support t h e
President so long as t h e i r o b j e c t i v e s
are not abandoned.
POSITION ON
PLAN:
Supportive, wait and see
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
Public L i a i s o n and Members o f Task Group
PET ISSUE:
State f l e x i b i l i t y , r u r a l h e a l t h needs,
and b e n e f i t package
�National Farmers Union
Representative
Nancy F. Danielson
I am l i f e l o n g member of Farmers Union. For the past four
years I have worked as a l e g i s l a t i v e representative f o r NFU.
P r i o r t o coming t o Washington, I practiced law f o r 6 years,
i n c l u d i n g a 2 year term as D i s t r i c t Attorney f o r Chippewa County,
Wisconsin.
I grew up on a Wisconsin d a i r y farm. The issues I lobby on
f o r r u r a l America are the same issues my f r i e n d s and neighbors
confront each day.
My work f o r NFU has included t r a v e l i n g t o many o f our s t a t e s
and conducting l e g i s l a t i v e seminars and workshops on h e a l t h care.
�SENT BY:
! 3-26-93 ;10:20AM ! Natl Farmers UniorMYAT ECONOMIC COUNCIL'.* 2
TESTIMONY OF THE NATIONAL FARMERS UNION
PRESENTED TO THE HEALTH CARE TASK FORCE
3Y NANCY F. DANIELSON
MARCH 29, 1993
Outline of salient points
I.
II.
Who i s the National Farmers Union
Family farm organization, founded in 1902
Purpose: to promote the sustainability of the family farm
and rural community
Health Care P r i o r i t i e s of National Farmers Union
1) Universal coverage
2) Affordability
3) Cap on costs
4) Choice of doctor and hospital
5) Access i n rural areas
6) Preventive care
7) Long term care access
I I I . Need to maximize amount of service provided by dollars spent
Single payer system
Preventive care
IV. Challenges faced i n rural areas
Loss of rural physicians and hospitals
Average age of rural doctor - 60; d i f f i c u l t to r e c r u i t
Distances involved for emergency care
Inequitable Medicare reimbursement formula
V. Managed competition f a l l s short i n rural areas
ii T P P
makes i t d i f f i c u l t to support multiple
Aging population less suited to HMO economics
Proven alternatives necessary
S l n a
VI.
e
o
u l a t i 0 n
Solutions
Single payer system to provide comprehensive, universal
coverage
Tuition assistance i n exchange for working i n underserved
Incentives to "specialize" i n general practice
Increased use of nurse practitioners, with direct
reimbursement
Mobile health care c l i n i c s to a s s i s t i n preventive care
S?!!™?!f?
l!
P ? in-home
Paidcare
by the self-employed
Financial assistance
for
Make the deductible kick i n after the f i r s t x amount of
coverage, to encourage preventive services, but in a
judicious manner
tibl
1
y f
o
r
r e
i u i n s
�NATIONAL COUNCIL OF LA RAZA
MEMBERS:
Umbrella o r g a n i z a t i o n f o r 150 a f f i l i a t e d
H i s p a n i c Community-based o r g a n i z a t i o n s .
REPRESENTS:
Largest c o n s t i t u e n c y - b a s e d n a t i o n a l H i s p a n i c
o r g a n i z a t i o n which improves l i f e
o p p o r t u n i t i e s f o r H i s p a n i c Americans t h r o u g h
a p p l i e d r e s e a r c h , p o l i c y a n a l y s i s and
advocacy, c a p a c i t y b u i l d i n g a s s i s t a n c e f o r
community o r g a n i z a t i o n s , p u b l i c i n f o r m a t i o n
and s p e c i a l p r o j e c t s . T h e i r programs reach
over 2 m i l l i o n H i s p a n i c s a n n u a l l y .
TODAY'S SPEAKER:
Raul Y z a g u i r r e , P r e s i d e n t
SCOPE OF
INFLUENCE:
S t r o n g e s t i n CA, AZ, TX, I L , r e s p e c t e d on
data c o l l e c t e d
APPROACH TO
REFORM:
Favored s i n g l e payer.
SUMMARY OF
POSITION:
H e a l t h care r e f o r m must address demographic
and socioeconomic c o n d i t i o n s o f H i s p a n i c
Americans. Should reduce s t r u c t u r a l elements
and p o l i c i e s t h a t c r e a t e b a r r i e r s t o access
t o b o t h t h e p r i v a t e and p u b l i c i n s u r a n c e
systems f o r H i s p a n i c Americans. U n i v e r s a l
access i s key b u t s p e c i a l o u t r e a c h e f f o r t s
a r e necessary t o ensure r e a l access f o r t h i s
p o p u l a t i o n which o f t e n s h i e s away from
contact with o f f i c i a l o f f i c e s .
POSITION ON
PLAN:
Noncommittal
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
Transition
PET
ISSUES:
HOT BUTTON ISSUES:
U n i v e r s a l access, c u l t u r a l l y - o r i e n t e d
o u t r e a c h t o promote use o f s e r v i c e s
e s p e c i a l l y primary care, immigrant h e a l t h ,
community c l i n i c s , h e a l t h i n s u r a n c e r e d
l i n i n g . N a t i o n a l H e a l t h S e r v i c e Corps.
One s i z e f i t s a l l p l a n i n s e n s i t i v e c u l t u r a l
and socioeconomic d i f f e r e n c e s .
Concerned
about l a c k o f r e s e a r c h i n t o H i s p a n i c h e a l t h
issues.
�RCV BY:
N
C
L
R
•r
; 3-23-93 ; 9:28PM I
202 289 8173-»
SOCIAL OFFICE'.* 2
NATO
INAL COHNQI OF IARAZA
RAUL YZAGUIRRE
Raul Yzaguirre is one of the most widely recognized leaders in the Hispanic community. For
over 35 years, he has been among the chief national advocates for Hispanic Americans. Today, as
President of the National Council of La Raza, the largest national constituency-based Hispanic
organization, he continues his mission lo improve opportunities for Hispanic Americans.
A lifelong community activist, Mr. Yzaguirre was born in the Rio Grande Valley of South
Texas in 1939. He began his civil rights career at the age of 15, when he organized the American
G.l. Forum Juniors, an auxiliary of the American G.I. Forum, an Hispanic veterans organization.
After graduating from high school in 1958, Mr. Yzaguirre served four years in the U.S. Air
Force Medical Corps. In 1%4, he founded NOMAS, the National Organization for Mexican
American Services. A proposal he wrote for NOMAS helped sensitize the Ford Foundation to
Hispanic needs and led to the creation of what is now the National Council of La Raza.
In 1966 Mr. Yzaguirre received his B.S. from George Washington University, and became a
program analyst at the Migrant Division of the U.S. Office of Economic Opportunity (OEO). In
1969, Mr. Yzaguirre founded Interstate Research Associates (IRA), the first Mexican-American
research association, which he built into a multi-million dollar nonprofit consulting firm.
Since joining NCLR in 1974, Mr. Yzaguirre has helped it become the largest and most respected national Hispanic organization. He is a nationally recognized leader and expert in ihe
fields of civil rights, immigration, community development, and the socioeconomic stams of
Hispanic Americans.
Mr. Yzaguirre is currently serving as the Chairperson of the Independent Sector, a nonprofit
coalition of over 850 corporate, foundation, and voluntary organizations. He selves on the Board
of Directors of numerous organizations, including the Enterprise Foundation and the Hispanic
Association for Corporate Responsibility. In 1991, he was named by President Bush as a member
of the President's Advisory Commission on Educational Excellence for Hispanic Americans.
Mr. Yzaguirre has been honored on many occasions for his work. In 1979, he was the first
Hispanic to receive a Rockefeller Public Service Award for Outstanding Public Service from the
Trustees of Princeton University. He received the Common Cause Award lor Public Service in
1986. In 1989-90, he served as one of thefirstHispanic Fellows of the Institute of Politics, at the
John F. Kennedy School of Govununem at Harvard University. In 1993, Mr. Yzaguirre received
the Order of the Artec Eagle, the- highest honor given by the government of Mexico to non-citi
zens. He is also the recipient of the Martin Luther King, Jr. Medallion in recognition of his contribution to civil and human rights. He was first listed in Who's Who in America in 1980.
�RCV 3Y:
I 3-25-93 :12:37PM :
232 28S 8385-»
SOCIAL OFFICE!* 2
NCLR
NJilKMm'OLOFlAim
Statement of
The National Council of La Raza
on
ASSURING ACCESS TO QUALITY HEALTH CAKE
FOR THE UNDERSERVED
Presented to
The President's Health Care Task Force
by
RaiSl Yzaguirre
President
National Council of La Raza
810 First Street, N.E.
Suite 300
Washington, D.C. 20002
March 29, 1993
�RCV BY:
; 3-25-S3 ;i2:37PM !
202 289 8385-*
SOCIAL OFFICES* 3
I am Ratil Yzaguirre, President of the National Council of La Raza, the largest
constituency-based national Hispanic organization. I am here on behalf of NCLR and its
national network, which serves two million Hispanics each year. The question 1 have been
asked to address - How can we assure that the underserved have access to quality health
care, given the need to con^ol costs? - is at the very core of the health reform debate.
Health care reform has become a national imperative because a majority of Americans
now consider themselves to be underserved - or in danger of joining that category. The
challenge is to develop a health care system that satisfies the new underserved while at the
same time offering essential and equitable services to the traditionally underserved - and to
control costs at the same time.
Let me focus on the traditionally underserved. They are the uninsured, the working
poor and the working class, ihe unemployed, female-headed households, children, migrant
and seasonal farmworkers, the limited-English-proficient, and the homeless. They most often
live in inner cities or rural areas. Hispanics are overrepresented in all these groups.
The underserved are typically uninsured or underinsured. By every measure,
Hispanics are more likely to be without health insurance, public or private, than any other
major population group. This is true regardless of gender, age, or state of residency, and
irrespective of family, income, or employment status. In 1991, nearly one in three Hispanics
had no health insurance, compared to one in five Blacks and one in eight Whites.
Policy makers often assume that plans devised to address the needs of a particular
low-income population, such as inner-city Blacks or rural Whites, will equally serve all poor
people. There are many common factors. But different groups are underserved for
different reasons. Hispanics are often uninsured because they are the "working poor" — or
family members of the working poor. Because they work, they do not qualify for Medicaid,
but their low-wage jobs provide no health benefits.
Critical considerations in assuring equitable and adequate health care for Hispanics and for many other underserved populations - include the following: universal coverage, an
adequate benefits package, and elimination of major non-financial barriers.
Universal coverage for all residents of this country ~ including the Island of Puerto
Rico - must be the goal of national health care reform, whatever the structure of our health
care system. NCLR is particularly concerned with how - and when ~ any proposed plan
would cover the working poor, female-headed households, children, and the undocumented.
We worry that cost considerations will delay the phase-in of some groups for years - and
that America's commitment to include them at all will disappear in the interim.
�RCV BY:
3-25-S3 ;12:38PM i
20£ 289 6385*
SCCIAL OFFICE!* 4
Let me say a few words about the undocumented. I do not want to focus inordinate
attention on this relatively small group rather than on the many times larger group of
underserved U.S. citizens and legal residents. However, there are several compelling
reasons why undocumented residents should be included in a "universal" health care system.
It isfirstand foremost a public health issue. Many families include both documented
and undocumented members. If a U.S.-bom child tests positive for tuberculosis, are we
going to deny testing or treatment to her undocumented mother? Denying immunization to
undocumented children or early diagnosis and treatment to their families can create serious
public health hazards for all Americans.
Cost factors are usually the major basis for excluding the undocumented. The data,
however, suggest that insuring the undocumented would cost somewhat less per family than
insuring the general population, since the undocumented are relatively young, with a very
high labor force participation rate.
Finally, in order to deny health coverage to the undocumented, we may end by
denying it to millions of citizens and legal residents whofitimmigrant stereotypes. We
simply cannot afford to ask health care providers to serve as immigration agents; they will
make too many mistakes. This is one lesson we have learned from employer sanctions.
Benefits packages are a second major concern. There must be a basic but
comprehensive package of benefits available for all. NCLR could support taxing
supplemental benefits in order to finance an adequate minimum benefits package. If we are
to have a two-tiered system, let us be sure that the lower tier provides for adequate health
care. The basic package must include primary and preventive services. Long-range cost
containment requires great improvements in immunizations, prenatal care, and early
diagnosis and treatment of acute and chronic diseases. We will have to pay now but we will
reduce costs later.
Non-financial barriers are also critically important. Some barriers to equal access
and high quality health care cannot be eliminated throughfinancereform. A national health
program must address the needs of all populations for culturally competent care - for
services delivered in an environment in which they feel comfortable.
Health reform must set in motion a plan for addressing the unequal distribution of
health care workers, especially physicians. More health care professionals must be attracted
to inner cities and rural areas. For example, in El Paso, Texas, only 30 of 800 physicians 4% - practice in the poorest part of the city, which houses one-third of the city's population.
There are only two federally funded community health centers in the entire county. NCLR
strongly supports the expansion of publicfinancingor loan forgiveness based on community
service by health care workers. The United States should consider a universal period of
"payback" community service -- as is a condition for physician licensing in many Latin
American countries.
�RCV BY:
; 3-25-93 ;i2:39PM ;
202 289 8385*
SOCIAL OFFICE!* 5
The lack of Hispanic or Spanish-speaking health care professionals is a serious
problem. Health reform must expand education and training programs and placement
opportunities for Hispanic health care workers at every level. NCLR encourages innovative
and appropriate use of foreign medical graduates, particularly from Latin America, to help
alleviate the great shortage of Spanish-proficient health professionals in areas where
Hispanics are concentrated.
Access also requires a health csre system which retains coverage regardless of
changes in employment status or state of residence. NCLR strongly recommends national
minimum standards and requirements to avoid major state-by-state differences in coverage or
benefits packages.
We are aware of the focus on managed competition, and are concerned that it may be
difficult to implement in some rural areas and inner cities. To guarantee access to health
services for residents of such areas, and to help assure culturally competent services, NCLR
urges alternative health delivery systems. We need to use and expand community and
migrant health centers. We need innovative outreach to assure that people get the services
they need.
Finally, there is the question of cost containment. In the long run, a major emphasis
on preventive health will save treatment costs; failure to make this investment immediately
dooms us to ever-increasing costs for years to come. Similarly, hospital costs for some
patients in their last weeks of life could be prevented by including coverage for at-home and
hospice care, so people could die in dignity. NCLR supports administrative simplicity,
particularly with regard to paperwork. We also believe that tort reform may help. Many
different approaches must be used together.
NCLR recognizes the immense challenge of crafting a health care system that can
address public needs and expectations within acceptable cost parameters. This can be
accomplished only if Americans accept fundamental changes in how this country delivers and
receives health care. For NCLR, the bottom line is universal coverage. Every U.S. resident
must be able to count on a reasonable minimum level of preventive and primary health care.
We look forwardtoworking with you to make this goal a reality.
�11:15-
PANEL THREE-UNDERSERVED- TESTIMONY ENDS
�NATIONAL CONGRESS OF AMERICAN INDIANS
MEMBERS:
144 member American I n d i a n t r i b e s and A l a s k a
N a t i v e governments
REPRESENTS:
N a t i o n ' s l a r g e s t and o l d e s t n a t i o n a l i n t e r t r i b a l o r g a n i z a t i o n r e p r e s e n t i n g t r i b e s i n 33
states.
TODAY'S SPEAKER:
M i c h a e l J. Anderson, E x e c u t i v e D i r e c t o r
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
PET
ISSUES:
HOT ISSUE:
Constituency
states
o f concern i n some w e s t e r n
Non-specific
Improve access t o h e a l t h c a r e f o r N a t i v e
Americans (over 50% n o t s e r v i c e d by t h e t h r e e
I n d i a n h e a l t h c a r e s e r v i c e systems) w h i l e
m a i n t a i n i n g consumer c h o i c e .
Possible
l i m i t a t i o n s o f managed c a r e t o s e r v i c e v e r y
poor and r u r a l areas n e c e s s i t a t e s t h e
c o o r d i n a t i o n between I n d i a n H e a l t h S e r v i c e
and l o c a l h e a l t h networks. S u b s i d i e s f o r
s m a l l employers. Improve a v a i l a b i l i t y o f
primary care providers. B e n e f i t s should
i n c l u d e long-term c a r e and h e a l t h p r o m o t i o n
and disease p r e v e n t i o n .
Receptive t o A d m i n i s t r a t i o n p l a n .
Transition
Access t o h e a l t h care. A b i l i t y o f managed
c a r e t o meet needs o f poor r u r a l p o p u l a t i o n s .
P r e v e n t i o n ( p a r t i c u l a r l y substance abuse)
P r e s e r v i n g t r i b a l g o v e r n m e n t / l o c a l community
h e a l t h c a r e p r o v i s i o n o p t i o n s i n c l u d e d i n 638
progrms (want l e s s IHS d o m i n a t i o n )
( c u l t u r a l l y s e n s i t i v e and r e l e v a n t h e a l t h
care).
�Extended Page
1. 1
National Congress of American Indians
Ert.lM4
m C t l T I V K COMIITTtB
PraaldMt
OalMhUbo* .
PlrM VlmPrMidmt
Jotaph T. aoomW
Raoardtaf ••aratory
Raehsl uoMph
BDothooe-PalLnm-Uono
TrMMirar
W. nan AIM
Jtnmtown SKMlun
MCA VICE PREWDBHTS
Abactfaan A T M
Twry FlWIaf
Obayannaflhraratoux
Atbarquarqua Araa
Raymond 0. Apedaea
ritofa Dal Su/ PuMWs
A«a««rfc»Araa
Elmar Manatawa
Sac A Pax
IIHlA«a Araa
Earl Old Paraon
aiaaftfeaf
Jaaaau Araa
Bdmrd K. Thonat
Mlnaaapolla Araa
Janaa Ciairfflrd
Pdrast County PotaMratoni.'
Maakogaa Araa
a Diana Kallay
Northaaatarn Araa
J.C. Sanaca
Phoaalx Araa
Mary Ann Anions
Tohono O'odhtin
Porttaad Araa
Bruaa Wynna
Spotan*
Saeraaiaata Araa
Buaan Uaitsn
yum*
Seattaaatarn Araa
A Bruoa Jenaa
Lumb»a
EXECUTIVE DMECTOR
Mlchaal j. Andaraon
Cntk
TESTIMONY OF THE NATIONAL CONGRESS OF AMERICAN INDIANS
BEFORE THE WHITE HOUSE HEALTH CARE TASK FORCE
MARCH 29, 1993
Good morning. My name is Michael Anderson and I am the Executive
Director of the National Congress of American Indians (NCAI). NCAI has a
membership base of over 120 American Indian and Alaska Native
governments. NCAI Is pleased to present our views on national health care
reform proposals being considered by the Clinton Administration.
In developing a national health care reform proposal, it is essential
that the Administration recognize the unique and constitutionally based
"government to government relationship" between the federal government
and this nation's 500 tribal sovereign Nations. Land was receded by these
Indian Nations (sometimes tllegdity and forcibly) in exchange for the
protection of the United States. Today, Indian Natlpns retain their own
forms of government, determine wtyo is a tribal member, regulate tribal
property, maintain the right to tax as well as other areas of tribal authority.
Most recently, the unique relationship of the U.S. government to Indian
tribes and people was affirmed in the Indian Health Care Improvement Act
which declares that "it Is the policy of the United States to assure the
highest possible health status for Indians and urban Indians and to provide
all resources necessary to effect that policy." (25 U.S.C. 1602(a))
By recognizing this unique relationship between Indian Nations and
the United States, the newAdmini$tration, in developing health care reform,
can avoid inadvertently limiting or restricting health care benefits now
provided tp American Indians and Alaskan Natives. Such limits would occur
if American Indians were to become part of a national health insurance plan
which reduced services now providetf by the Indian Hialth Service and tribal
health care delivery systems.
j
j
To that end, all special authorities now provided for American Indian
and Alaska Native people's health services, i.e. the Snyder Act, the Indian
Health Ca^re Improvement Act (P.L. 194-437), the Indian Self-Determinatlon
Act (P.L. 93*638), the Indian Health Amendments (P.L. 102-573), the
Indian Wqterand Sanitation Facilities Construction Act (P.L. 86-121), end
others must be maintained through \ direct appropriations for Indian health
programs,
'
900 Pennsylvania Avenue 8.E. • Washington, D.C. 20003 • (202) 546-8404 • Fax (202) 546-8741
�03/26,93
14:19
©2025463741
N . C . A . I . WASH.DC
©002
-277)650 authorities include many components of the comprehensive Indian
community based health service delivery systems which would not be provided by e
national basic benefit package. For example, health professional training for American
Indian and Alaska Natives, construction of Indian health facilities and sanitation facilities
for Indian homes and communities. These authorities also have been carefully designed
to meet the unique needs of Indian people end should continue to be amended as
necessary in order to meet the Federal goal of elevating Indian health status to the highest
possible level.
The question addressed today Is "Given the heed to control costs, how can we
ensure that people in the underserved areas have access to quality care?" The enswer
for American Indians is to permit them the option to participate In nationally provided
health care options like insurance while retaining access to Indian health service/tribal
services. Currently, IHS or tribes operate 50 hospitals, 158 ambulatory health centers,
115 health stations and 172 Alaskan village clinics. Urban Indian organizations operate
34 health centers. IHS and tribally operated programs should be able to collect for
American Indian/Alaska Native people who have other coverage who choose to use IHS
or tribally operated programs.
Moreover, theriglitof tribes to operate their own health care programs under P.L
93-638 should be protected and tribes should be allowed to fully participate in other
financing structures created under health care reform. IHS and tribally operated health
care programs should be authorized to compete to offer services to non-Indians, but
should not be required to do so.
All services available through a national core benefit package should be
available to tribal members through Tribal/IHS programs. The Core Benefit Package
should include, at a minimum: Ambulatory/inpatient medical services, substance abuse
prevention/treatment, preventive health care, long-term care - home/Institutionally based,
referrals, patient education, screening and mental health. The Administration should
recognize that IHS/Tribal providers are inadequately funded to fulfill the mission of the IHS
as set forth in existing federal law.
i
The minimum level of funding for IHS/Tribal health care programs should be
equivalent to that which would be earned if ail the core benefit services provided were
reimbursed on the payment scale negotiated by the HfPC for the region in which the
IHS/Tribal program operates.
Speciaf provision^ should also be adopted to encourage Tribally operated Health
Insurance Purchasing Cooperatives (HIPCs) for management of contract health services
and for urban Indians, in areas of high American Indian/Alaska Native concentration,
HIPCs should be required to give en advantage to Indian operated programs.
�.03/26/93
14:20
02025463741
121003
N . C . A . I . WASH.DC
-3I
: !
:
\
!
)
!
c.« reform f^posefe ^ J ^ g S !
!
'ESSkXS
E » »
for other health care providers.
while retelnlng the trust responsMties M"^*
^ .
» /Urfcsn to** «
r coera» f^e •» ^iT^Llfr^lllTSe
before the ege of 46, post-neohttal
must be recognized M ^
^ / ^ Z ^ ' n f o n t Death Syndrome is among
s w v f c e s
e
e
„ Amerila'nidian ^ Z ^ u ^ T n d X ^ a Z
Peop/es.
remdvel from bom^nds
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
�11:20--
PANEL FOUR-GENERAL HEALTH CARE PROVIDERS- TESTIMONY
BEGINS
Thank you panel three witnesses.
Now, we will listen to testimony from health care providers. We asked this panel:
"As front line providers of service, what is the best step we can take to control costs inside
the health care bureaucracy?" Ourfirstwitness will be Virginia Trotter Betts, President of
the American Nurses Association, and a former staff member of mine. I am especially happy
to see another Tennessean here today.
�PANEL FOUR: GENERAL PROVIDERS (I)
Question Posed:
As front-line providers of service, what is the best step we can take to control costs
inside the health-care bureaucracy?
Groups:
American Nurses Association
American Dental Association
American Academy of Physicians Assistants
American Chiropractic Association
National Association of Social Workers
American Psychological Association
Major issue concerns:
These are individual non-physician providers. They will have coverage concerns (dental,
chiropractic, mental health.) They also will be generally supportive of making medicine
less "physician centered".
Talking points:
1.
In order for our plan to be comprehensive, we know good mental health coverage
has to be part of the package.
We intend on emphasizing preventive care in our benefits package.
Where appropriate, we want to empower non-physician providers to provide more
of the care needed.
�AMERICAN NURSES ASSOCIATION
MEMBERS:
The ANA i s a p r o f e s s i o n a l a s s o c i a t i o n f o r nurses as
w e l l as t h e s t r o n g e s t l a b o r union f o r t h e n u r s i n g
profession.
REPRESENTS:
2.1 m i l l i o n r e g i s t e r e d nurses t h r o u g h i t s 53
c o n s t i t u e n t s t a t e and t e r r i t o r i a l a s s o c i a t i o n s and
i t s more than 200,000 members.
TODAY'S SPEAKERS:
Virginia Trotter Betts,
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
President
E f f e c t i v e l o b b y i s t on n u r s i n g i s s u e s , s t r o n g grass
r o o t s e f f o r t s a t b o t h t h e F e d e r a l and s t a t e l e v e l s ,
and a b i l i t y t o m o b i l i z e q u i c k l y , f o r e f r o n t on
p o l i t i c a l and l e g i s l a t i v e i s s u e s .
Very s u p p o r t i v e
The ANA supports h e a l t h c a r e system t h a t assures
access, q u a l i t y and s e r v i c e s a t a f f o r d a b l e c o s t .
The f i n a n c i n g mechanisms must be employer based w i t h
minimal co-payments. The b e n e f i t package must
p r o v i d e p r e v e n t i o n , h e a l t h s c r e e n i n g , extended and
l o n g term care, and mental h e a l t h b e n e f i t s .
Nurses want t o be "empowered." B e l i e v e t h e y need t o
be p r o t e c t e d i n managed c o m p e t i t i o n system.
POSITION ON
PLAN:
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
PET
ISSUES:
Likely
Mrs. C l i n t o n , A l e x i s Herman, O f f i c e o f P u b l i c
Liaison
Access, w e l l n e s s and c a r e , empowerment
�RCV BY:
I 3-Z3-93 ;i2:27PM ;
1 202 554 2262 •»
SOCIAL OFFICEi«_3_
American Nurses Association
600 Maryland Avenue SW, Suite 100 West, Washinqton, DC 20024-2571
202-554-4444 • Fax: 202.554-2262
Virginia TroLLer Betts. JD. MSN, RN
President
Barbara K. Redman. PhD. RN, FAAN
Ex&Culiut: Dinclor
For more informaiion contact:
Communications Department, 202/55^-4444 Ext. 247
Virginia Trotter Betts, JD, MSN, RN
President of the American Nurses Association
Virginia Trotter Betts is currently serving a two-year term as president of the American
Nurses Association (ANA), the nation's leading professional organization representing the major
health care, practice, and work place issues of the nation's 2 million registered nurses. Mrs. Betts is
a nurse attorney on sabbatical from her position as a senior research fellow at the Vanderbiit Institute
for Public Policy Studies while she serves in her position as president of ANA. She is the president
and CEO of HealthFutures, a health and nursing consulting fim specializing in utilizing nurses to
address the complex issues inherent in the health care delivery system, and she is the past president of
the Tennessee Nurses Association.
Mrs. Betts has served in a wide variety of national leadership roles in ANA and in nursing.
She is a member of the National Coalition on Health Care Reform and is a member of the Tricouncil
for Nursing. She chaired the ANA Legislative Committee, served as a trustee of the ANA Political
Action Committee, and served as the board liaison to the HIV Task Force. At Vanderbiit she is
involved in research on policy issues on Medicaid. Her areas of expertise include: health policy,
health care law, mental health, nursing education, reproductive health, health care reform, tort
reform, and liability and medical malpractice.
In her 20 year career as a professional nurse, Mrs. Betts has worked as a staff nurse, a
clinical specialist in psychiatric mental health nursing, an administrator, a researcher, a policy analyst,
a nurse attorney, a consultanr, and an entrepreneur. She is the author of more than 50 articles on
nursing, health care, and health law and has given hundreds of presentations and speeches across the
country.
Mrs. Betts received her BSN from the University of Tennessee, her MSNfromVanderbiit
University, her JD from Nashville School of Law, and she has completed Postdoctoral Studies in
Health Policy at the Institute of Medicine at the National Academy of Sciences as a Robert Wood
Johnson Health Policy Fellow.
A native of Sevierville, Tennessee, Mrs. Betts now resides in Nashville, Tennessee with her
husband and: two daughters. She maintains offices in Washington, DC, and Nashville.
The US Member of the International Council of Nurses
ANA - An Equal Opportunity Enployer
�Extended Page 1.1
American Nurses Association
600 Maryland Avenue SW. Suite 100 West, Washington, OC 20024-2571
202-554-4444 • Fax: 202-554-2262
Virginia Trotter Bens. JD, MSN, RM
Prvidtnt
Barbara K. Redman, PhD, RN, FAAM
Excculioe Director
American Nurses Association
Testimony
Health Care Task Force, March 29 Public Hearing
Question: "Asfront-lineproviders of service, what is the best step we con take to control costs
inside the health-care bureaucracy?"
The American Nurses Association believes that the single best cost savings measure is to move away
from the expensive "medical model" of illness care that now exists in this country. Organized
nursing believes that the high costs of physician-centered, hospital-oriented acute care can be greatly
reduced through a new emphasis on primary health care delivered in community-based settings that
are accessible to everyone. By community settings we mean delivery of an array of health services in
schools, work sites, day care centers, and community clinics, as well as home-based care, thus
limiting the utilization of specialists, hospitals, and expensive technologyforacute care intervention
only at the most appropriate time.
If we facilitate primary health care delivery, which includes prevention, early diagnosis,
uncomplicated illness treatment, and self care and wellness education, we can reduce our overall
health care costs while significantly improving our personal and national health at the same time.
Every dollar spent on preventive care will eliminate four dollars in subsequent acute care
expenditures.
Current public policy encourages both consumers and providers to postpone early care and/or to seek
acute care services in hospitals and emergency rooms using high-tech treatment A lack of activist
public health and primary health care delivery has taken its toll in many ways, such as overburdened
emergency rooms, unnecessary morbidity and mortalityfrompreventable or manageable diseases,
high infantimortality rates, and the world's most expensive medical care services. In our country we
spend 90 percent of our health resources on acute care and only ten percent on prevention and
primary ca^e.
We must reform the U.S. delivery systems for a consumer-centered community-focused model. In
order to restructure the delivery systemforuniversal access to primary care, a cost-effective mix of
health providers must be available to deliver that care.
MORE...
The US Member of the International Council of Nurses
�03/25 '93
18:28
O l 202 554 2262
AM NURSES ASSOC
1 2 1 0 0 2
ANA Testimony/2...
This can only be achieved by removing the anti-competitive biimers that prevent non-physician
providers, including professional nurses,fromworking within their full scope of practice.
Currently, 70 percent of physicians are specialists, not generalists, resulting in a serious shortage of
primary care physicians. Professional nurses functioning in an advanced practice role are ready to
deliver primary care and can do so as competently as physicians and at a 40 percent savings - yet
their availability is compromised by current public policy.
Among the anti-competitive barriers that need to be removed are:
unnecessary practice act restrictions,
overregulation of non-physician providers,
unnecessary limitations on prescriptive authority,
and removal of the very significant barriers to reimbursemeat in both public
and private programs.
There is a growing awareness worldwide that health care workers other than physicians are able to
provide quality care at a lower cost, that hospitals using sophisticated technology are not the only
places where consumers can receive quality care, and that the medical model is not necessarily the
appropriate,foundationfor a heal* care delivery system. Remodeling the U.S. delivery system
toward health is essential to controlled cost and is abundantly congruent with increasing access and
enhancing quality outcomes.
�AMERICAN DENTAL ASSOCIATION
MEMBERS:
Members o f t h e ADA a r e represented i n e v e r y
community across t h e U n i t e d S t a t e s .
REPRESENTS:
The American Dental A s s o c i a t i o n (ADA) r e p r e s e n t s a
t o t a l o f 139,620 d e n t i s t s , w i t h 73% o f U.S. d e n t i s t s
members o f t h e ADA.
TODAY'S SPEAKER:
Dr. Jack H a r r i s , P r e s i d e n t
SCOPE OF
INFLUENCE:
Grass r o o t s , a c t i v e , s t r o n g advocacy
APPROACH TO
REFORM:
Non-committed
SUMMARY OF
POSITION:
The p r i m a r y c r i t e r i a f o r t h e ADA i s u n i v e r s a l access
and i n c l u s i o n o f d e n t a l b e n e f i t s i n t h e c o r e
package. T h e i r f i n a n c i a l package i s employer based,
p r o v i d e s coverage f o r i n d i g e n t s , s m a l l employer
r e l i e f t h r o u g h HIPCS and r i s k r e i n s u r a n c e p o o l s , and
co-payments. The ADA i s f o r t h e p r o t e c t i o n o f a l l
w o r k i n g people from f i n a n c i a l r u i n as a r e s u l t o f
i l l n e s s , e d u c a t i o n s e r v i c e s and access t o p r e v e n t i v e
dental services f o r c h i l d r e n .
The ADA b e l i e v e s d e n t a l s e r v i c e s a r e n o t a c o s t
problem. I f t h e r e i s n o t a problem, d o n ' t change
us.
POSITION ON
PLAN:
Wait and see
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
T r a n s i t i o n , Work Group Members, OPL
PET ISSUES:
I n c l u s i o n o f d e n t a l s e r v i c e s i n t h e b e n e f i t s package
�MPlR-23-1993
16=12
FROM PDPEXDIROFFICE
TO
912024586241
P.02
Biography of
Jack II. Harris, DDS
Dr. Jack ll. Harris DDS, who lives in PearlancJ, Texas and
practices periodontics in Houston, i s president of the American
Dental Association.
Dr. Harris served for six years as the ADA'S rifteenth
District Trustee, representing member dentists throughout Texas.
His numerous other past positions with the ADA include serving on
the Quality Assuxunue Committee and a committee to develop policy
on HIV infection.
A 1961 graduate of the University of Texas Dental Branch at
Houston, Dr. Harris practiced general dentistry for four years
before beginning his periodontic practice.
Dr. Harris served as president of the Texas Dental
Association in l y s i .
The Texas Academy of General Dentistry
named him Dentist of the Year in 1980, and the Pearland/Hobby
Chamber of Commerce named him 1991 Outstanding Citizen.
Dr. Harris' distinguished career has also included serving
as a member of the Texas House of Representatives since 1985.
As
a state representative he has served on a wide range of
committees and task forces, including the Committee on Public
health. Natural Resources, and Environmental Affairs and the
Governor's TasX Force on Health care.
Dr. Harris and his wife, Mary Ellen, have a son and two
grandchiIdren.
/
# *
REV. 11-13-92 DC
�RCV BY!
; 3-25-93 ; SMIPH !
31 2 440 2600-»
SOCIAL OFFICE!# 2
"AS FRONT LINE PROVIDERS OF SERVICE, WHAT IS THE BEST STEP WE CAN
TAKE TO CONTROL COSTS INSIDE THE HEALTH CARE BUREAUCRACY?"
Response by Jack H. H a r r i s , DDS
President, American Dental Association
I n order t o c o n t r o l costs w i t h i n the h e a l t h care
bureaucracy, i t i s necessary t o b u i l d s p e c i f i c checks and
balances i n t o the system.
The o r a l h e a l t h care d e l i v e r y system
i n the United States provides an example.
Four basic p r i n c i p l e s — preventive measures,
a c c o u n t a b i l i t y , competition, and p a t i e n t involvement i n decisions
and outcomes — work together t o keep o r a l h e a l t h care costs
under c o n t r o l .
How e f f e c t i v e i s t h i s system?
The Health Care Financing A d m i n i s t r a t i o n p r o j e c t s t h a t the
r a t e o f growth i n d e n t a l expenditures from now through the year
2000 w i l l be one t h i r d lower than the r a t e of growth i n t o t a l
h e a l t h care expenditures.
The growth i n dental expenditures w i l l
average 6 percent per year, compared t o 9.5 percent f o r h o s p i t a l
expenditures and almost 11 percent f o r p h y s i c i a n s e r v i c e s .
The f i r s t of the four cornerstones
of dentistry's system for
controlling costs i s preventive measures.
In addition to
preventive treatments i n the dental office, t h i s measure includes
making patients aware of personal habits that promote o r a l
health.
The d e n t a l p r o f e s s i o n encourages employers t o emphasize
p r e v e n t i v e care i n t h e i r d e n t a l plans by covering 100 percent o f
the cost f o r d i a g n o s t i c and preventive care — r o u t i n e o r a l
exams, t e e t h c l e a n i n g , a p p l i c a t i o n of f l u o r i d e and s e a l a n t s , and
�RCV BY:
I 3-25-93 ! 3:i2PM ;
Dr.
312 440 2800^
SOCIAL OFFICER 3
Harris — page 2
other treatments designed to stop dental diseases before they
start.
We acknowledge that the scope of dental practice does not
routinely include the catastrophic i l l n e s s e s that are within the
scope of other health care providers,
i t i s clear, however, that
an effective system to control overall health care costs must
encourage patient education and other preventive measures that
w i l l reduce the incidence of these catastrophic i l l n e s s e s .
The principle of accountability, which i s sharply focused in
oral health care delivery through mechanisms such as third-party
review, combines with the basic American p r i n c i p l e of competition
to further control costs.
F i n a l l y , the practice of dentistry i n the United States i s
characterized by a high degree of patient participation i n
decisions and outcomes.
This patient involvement i n decisions
about treatment for more complex oral conditions and diseases i s
a major factor in controlling costs.
Costs are more l i k e l y to be
driven up when none of the r e s p o n s i b i l i t y r e s t s with patients and
treatment i s dictated solely by coverage
The American Dental Association believes that applying some
of the p r i n c i p l e s from dentistry's system to our nation's o v e r a l l
health care delivery system can be an important element i n
controlling costs.
DC32593
�AMERICAN ACADEMY OF PHYSICIAN ASSISTANTS
MEMBERS:
22,000 p r a c t i c i n g physician a s s i s t a n t s and 3600
students e n r o l l e d i n the country's 55 accredited
physician assistants programs.
REPRESENTS:
Academy chapters located i n a l l 50 s t a t e s . Members
provide medical treatment f o r 150 m i l l i o n p a t i e n t
v i s i t s per year.
TODAY'S SPEAKER:
Ann Elderkin, President-Elect
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Sway i n r u r a l s e t t i n g s where Physician Assistants
are more o f t e n u t i l i z e d .
Increased u t i l i z a t i o n o f physicians a s s i s t a n t s and
other non-physicians.
Want h e a l t h care reform t o provide i n c e n t i v e s f o r
increased use o f physicians a s s i s t a n t s (PAs):
recognize PAs and other non-physicians as authorized
providers under new system, encouraging s t a t e s t o
enact more f l e x i b l e laws and r e g u l a t i o n s f o r PAs,
t r a n s f e r Medicare GME d o l l a r s from r e s i d e n t t r a i n i n g
t o support the t r a i n i n g o f non-physicians, provide
appropriate reimbursement f o r PAs i n a l l s e t t i n g s .
Also support basic b e n e f i t package, u n i v e r s a l
access, cost c o n t r o l s should focus on prevention o f
inappropriate cost s h i f t i n g , e l i m i n a t i o n o f excess
bureaucracy, malpractice reform.
POSITION ON
PLAN:
Supportive, i f workforce issues addressed.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
Transition
HOT BUTTON ISSUES:
Licensure, empowerment, reimbursement issues
�American Academy of Physician Assistants
Representative
Ann
L. Elderkin,
PA-C
President-Elect
Ann L. E l d e r k i n , PA-C, i s the president-elect of the American
Academy of Physician Assistants. Since 1980 Ms. E l d e r k i n has
been d i r e c t o r of the health department f o r the c i t y of
Somerville, Massachusetts. Previously, she was a senior analyst
f o r the Massachusetts Senate Committee on Health Care. A 1980
graduate of Yale U n i v e r s i t y PA program, Ms. Elderkin has worked
i n i n t e r n a l medicine, CT surgery, and f a m i l y p r a c t i c e and has s i x
years experience w i t h the Harvard Community Health Plan.
�03-25/93
12:37
© 7 0 3 684 1924
A.A.P.A.
11002/005
AMERICAN ACADEMY OF PHYSICIAN ASSISTANTS
950 NORTH WASHINOTCK STRB^T • AUXANDRU, V.KCINIA 22314 • (703) 836-2272
Testimony
of
The American Academy of Physician Assistants
Before
The Health Care Task Force
Presented By
Ann Elderkin, PA-C
President-Elect
March 29, 1993
Washington, DC
�03/25/93
12:38
© 7 0 3 684 1924
A.A.P.A.
121003/005
Mrs. Clinton and members of the Task Force. On behalf of the
American Academy of Physician Assistants and the 22,000
practicing PAs we represent, I want to thank you for this historic
opportunity to present our views on national health care reform and
the specific steps our nation can take to control health care costs.
Physician assistants (PAs) practice medicine with supervision by
licensed physicians. We provide a range of medical services that
would otherwise be provided by physicians.
We believe that increased utilization of physician assistants and
other nonphysicians such as nurse practitioners can help control
escalating health care costs.
It has been well documented that PAs,
working in conjunction with their physician supervisors, can provide
greater access to cost-effective health care than a system that
relies solely on physicians.
The federal government has been using this approach for many years
and today, is the single largest employer of PAs.
The VA, for
example, employs over 1,000 PAs. Why? Because under the VA
system, the largest capitated health care delivery system in the
United States, PAs are viewed as essential. A recent study of the
VA system by the Institute of Medicine documented that the
productivity of physicians in VA hospitals with PAs was more than
double the productivity of physicians in VA hospitals without PAs.
This type of staffing arrangement can result in significant near
term cost-savings.
These savings can then be used to either reduce
the overall cost of health care or pay for expanded services.
If appropriately factored into a new national workforce policy,
increased utilization of PAs and other nonphysicians can also result
in significant long-term societal savings as well.
Last year, for example, the federal government, through the Medicare
program alone, spent approximately $4.4 billion dollars to support
86,000 physicians in hospital based residency programs.
The
average annual societal cost per resident: $51,200. The
overwhelming majority of these physicians will pursue careers in
highly technical specialty or subspecialty areas of medicine.
By contrast, the federal government spent less than $5 million last
year to support 2,000 physician assistant students in training. The
American Academy of Physician Assistants
1
�03/25/93
12:38
© 7 0 3 684 1924
A.A.P.A.
average societal cost per PA student: $2,500. At least 50% of these
students are expected to choose primary care medicine.
Common sense would dictate that you increase support for the
profession that costs less to train and produces more primary care
providers. Unfortunately, we do just the opposite. Is it any wonder
therefore, that what this has produced is a workforce that looks like
an inverted pyramid with few generalists at the bottom and a large
number of specialists at the top.
In recognition of this the Physician Payment Review Commission
recently recommended the phased elimination of nearly 11,000
residency slots. We believe some of the money saved as a result of
eliminating these residency slots should be invested in training
more PAs.
Eliminating 11,000 residency slots would result in an annual savings
to the federal government of over $560 million by 1996.
Recognizing that a significant portion of this money would still have
to be paid to hospitals to meet service delivery needs, a
conservative estimate would result in an annual net savings to the
government in the neighborhood of $150 million.
If we took 5
percent of the annual savings - $7.5 million - and invested that in
PA education, we could more than double the number of PA graduates
and replace residents with PAs, improve physician productivity, and
still realize significant savings to the system.
We are not suggesting that we don't need physicians.
We do.
Properly trained and educated physicians are and will be the most
important ingredient to maintaining a high quality health care
delivery system. We are, however, suggesting that we do not need as
many new physicians as we may have thought.
If we are going to truly reform the system and do it in a way that
will reduce health care costs, without reducing quality, then we
must consider new ways of delivering that health care.
Enacting polices that seek to achieve these two goals will not only
improve access to health care, but accomplish this in a way that
reduces both near-term and long-term costs. The specific policy
American Academy cf Physician Assistants
©004/005
�03/25/93
12:39
© 7 0 3 6*4 1924
A.A.P.A.
©005/005
recommendations we would make to achieve these goals include:
1. Recognize PAs and other nonphysicians as authorized
providers of health care under the new system.
2 Encourage states to enact more flexible laws and
regulations regarding supervision and scope of practice
for PAs.
3. Transfer Medicare GME dollars from resident training to
support the training of nonphysicians.
4. Amend existing federal health programs, including Medicare,
(to the extent they exist under a new national health
program) to provide reimbursement for PAs in all settings.
In the written comments we have provided, I go into greater detail
on each of these proposals.
As you set about the task of creating a new health care delivery
system, we ask that you make PAs full participants in the new
system.
For the past 25 years, we have been trying to get
reimbursement policies changed so that PAs are recognized
providers under public and private programs. There is little use m
training a PA to practice with urban or rural underserved
populations if the principal programs that pay for medical services
rendered to these patients do not recognize physician assistants as
covered providers.
I would be happy to respond to any questions you might have.
Amsrican Academy of Physician Assistants
�AMERICAN CHIROPRACTIC ASSOCIATION
*
MEMBERS:
22,000 d o c t o r s o f c h i r o p r a c y (DCs) and s t u d e n t s a t
the accredited c h i r o p r a c t i c colleges.
REPRESENTS:
The Nation's 45,000 c h i r o p r a c t o r s s e r v e o v e r 19
m i l l i o n p a t i e n t s a n n u a l l y and a r e l i c e n s e d as
p r i m a r y care i n f i f t y s t a t e s .
The purpose o f t h e ACA i s t o seek t o advance and
p r o t e c t t h e p a t i e n t ' s access t o c h i r o p r a c t i c
s e r v i c e s and promote t h e d r u g - f r e e , n o n - s u r g i c a l
care d o c t o r s o f c h i r o p r a c t i c p r o v i d e - - a h e a l i n g a r t .
TODAY'S SPEAKERS:
SCOPE OF
INFLUENCE:
APPROACH TO
REFORM:
SUMMARY OF
POSITION:
Reeve Askew, Member Board o f Governors
F a i r l y e f f e c t i v e g r a s s r o o t s network. I m p o r t a n t i n
c e r t a i n s t a t e s (e.g. Iowa, New Hampshire)
O v e r a l l f l e x i b l e , b u t c h i r o p r a c t i c must be covered.
C h i r o p r a c t i c services included i n t h e basic core
b e n e f i t s package. Encourage use o f c h i r o p r a c t o r s as
p r i m a r y c a r e p r o v i d e r s , and gatekeepers under
managed c a r e p l a n s .
The p r o f e s s i o n i s w i l l i n g t o p l a y a s u p p o r t i v e r o l e
i n t h e promotion o f t h e a d m i n i s t r a t i o n ' s h e a l t h care
p l a n i f t h e y f e e l i t i s i n good p u b l i c p o l i c y .
POSITION ON
PLAN:
Wait and see.
INTERACTION W/
TASK FORCE AND
WORKING GROUPS:
OPL, working
group.
�03/26/93
14:43
© 7 0 3 243 2593
AMER CHIRP ASSO.
©002/005
AMERICAN CHIROPRACTIC ASSOCIATION
1707 Clarendon Boulevard, Arlington, Virginia 22209
TESTIMONY OF THE
AMERICAN CHlROPRACnC ASSOCIATION
BEFORE THE
PRESIDENTS TASK FORCE ON
NATIONAL HEALTH CARE REFORM
PRESENTED BY
REEVE ASKEW, D.C
AMERICAN CHIROPRACTIC ASSOCIATION
BOARD OF GOVERNORS
GEORGE WASHINGTON UNIVERSITY
SMITH CENTER
WASHINGTON, D.C.
MARCH 29, 1993
(703) 276-88(>0
�03.26'93
14:44
© 7 0 3 243 2593
AMER CHIRO ASSO.
©003/005
Good morning. I am Dr. Reeve Askew, a member of the American Chiropractic
Association's Board of Governors and a practicing doctor of chiropractic (DCs) in Easton,
Maryland. On behalf of the ACA's 22,000 members, I would like to thank you for this
opportunity to address the Task Force. The ACA welcomes the opportunity to work with
you toward systemic reforms that will guarantee access to affordable health care for all
Americans. For years the ACA has supported universal health care for all Americans
regardless of their income, controls on overall health care spending and guarantees of
consumer freedom of choice in the selection of licensed health care providers. America's
45,000 doctors of chiropractic (DCs) are anxious to help tackle the problems that have
left far too many Americans exposed to the great physical and economic risks associated
with their inability to obtain appropriate health care services.
You have asked me to address the issue of how I, as a "front-line" provider of care,
would suggest controlling health care costs. Many ways of controlling costs have been
suggested. Unfortunately, many of these can only be accomplished by sacrificing some
degree of health care access and quality. For instance, some view limits on the scope
of a standard benefits package as one way to reduce costs. However, such a proposal
may put at risk those with special health care needs such as the disabled. In addition,
a strictly limited benefits package might erect barriers to the millions of Americans who
choose to receive their care from licensed alternative providers such as chiropractors.
Dearly, this would reduce access to health care services at a time when we can least
afford it.
Unfortunately, this is often the case with health care policies - they can "cause as much
as they cure." I certainly don't claim to have answers that will avoid unintended
consequences. But, I do feel that my suggestions can help hold down costs without
unacceptable compromises in health care access or quality.
EXPAND ACCESS TO NON-MD HEALTH CARE PROVIDERS
Everyone agrees that expanded access to primary care is essential However, the failure
of medicine to provide an adequate supply of primary providers is well documented. In
order to fill this gap, policies must focus on expanding access to non-MD providers such
as chiropractori, nurse practitioners and others. Today, these providers are meeting the
primary care needs of millions of Americans and have done so for years. Nearly 19
million Americans received health services from a D.C in 1990 and, according to one
survey, 85% of employers provide coverage for chiropractic care.
Unfortunately, non-MD providers are often overlooked by policymakers simply as
"specialists." While it is certainly true thai chiropractors specialize in the treatment of
musculoskeletal conditions - especially back pain, which is one of mankind's most serious
maladies - they also perform a range of high quality primary care services. DCs are
trained, licensed and obligated under state law to diagnose any and all health conditions.
In satisfying this task, they use the standard procedures common to all providers, such
as physical examination, laboratory tests and x-rays. The federal government takes
advantage of these services by authorizing DCs to perform them under the federal
workers compensation act and under the federal highway administration.
�03/26/93
14:44
© 7 0 3 243 2593
AMER CHIRO ASSO.
121004/005
Non-MD health professionals also help reduce costs by providing care at significantly
lower costs. Over the years, many studies have proven the cost effectiveness of
chiropractic care for treatment of back and neck ailments. This fact was best
summarized in a study recently published in the Journal of American Health Policy which
stated that for similar conditions, "chiropractic users tend to have substantially lower, total
health care cost" than do users of other modes of care.
If we are to control costs, we must channel more Americans to primary care providers.
Primary care identifies health problems early, before they become complicated and
expensive to treat. It is preventative, emphasizing healthy life-style and nutritional habits.
And it keeps people out of the expensive institutional settings. These are all attributes
of the practice of chiropractic and other non-MD health professions. I think the Task
Force would be remiss if it did not take aggressive measures to ensure that Americans
enjoyed expanded access to all primary care providers especially non-MD providers.
FREEDOM OF CHOICE
Of course, suggestions to increase access to alternative providers begs the question: how?
First and foremost, government pohcies should provide an iron-clad guarantee that
patients will have thefreedomto choose their health care provider. Freedom of choice
is fundamental to this country's traditions and should not be undermined in our health
care system In fact, a majority of the States have enacted health provider freedom-ofchoice laws in recognition of the need to provide this guarantee. Forty-one states have
freedom-of-choice laws guaranteeing access to doctors of chiropractic and many others
ensure access to podiatrists, optometrists, psychologists and other licensed providers.
It is important to stress thatfreedom-of-choicelaws do not "mandate" coverage of new
services - rather they merely expand the pool of providers eligible to render covered
care. Such laws simply provide that for treatment of any condition covered under a
health plan, patients have the right to choose any provider licensed to treat that
condition or provide that service. In so doing, these laws expand the pool of providers
without adding new services or costs. The ACA would strongly recommend that any
national health reform proposal include a guarantee of provider freedom-of-choice.
Other ways to control costs include:
INTEGRATED HEALTH SYSTEMS
Alone, non-MD providers may not be qualified to treat all conditions presented to them.
But this is no reason to dismiss the idea of utilizing them to a greater degree. In
instances when a condition is beyond the scope of a provider's expertise, it is the
professional and moral obligation of the provider to refer the patient. This is certainly
how DCs practice. According to ACA's annual survey, DCs refer nearly 20% of their
patients to MDs and other health providers.
To help provide a single point of access to a full range of primary care, federal policies
should encourage the creation of integrated health systems staffed by providers of all
disciplines. This would provide consumers with access to the full range of necessary
primary and preventative health care services at one location.
�03/26/93
14:43
© 7 0 3 243 2593
AMER CHIRO ASSO.
©005/005
FEDERAL HEALTH MANPOWER PROGRAMS
Existing programs like the National Health Service Corps (NHSC) should be fully funded
and expanded to include all licensed health providers as eligible participants. These
programs encourage the practice of primary health care by offering scholarships and
repaying student loans in return for commitments to practice in medically underserved
areas. Chiropractic and other non-MD professions need to be made fully eligible for
these programs.
In addition, non-MD professional teaching institutions should be encouraged and assisted
in obtaining federal grants for primary care research. Students attending these
institutions should be made eligible for the fiill range of federal educational loans. It
is unfortunate that this is not now the case, but we remain hopeful that these policies
will change under this Administration.
OUTCOMES ASSESSMENT RESEARCH
The government should continue its work through the Agency for Health Care Policy
& Research (AHCPR) to determine the best treatments for common illnesses. With
two DCs serving as advisors, the chiropractic profession is currently participating in an
AHCPR effort to determine the most appropriate treatment for low back pain. ACA
encourages the Administration to continue this trend by calling on the expertise of all
health care disciplines as outcomes research continues. With so many millions of
American consumers utilizing their services, it is obvious that these professions have
much to offer in the area of outcomes research.
MALPRACTICE REFORM
We are all familiar with the costs associated with the practice of "defensive medicine."
In an attempt to avoid liability, too many health providers feel compelled to order extra
tests and services - practices which drive costs higher,. The chiropractic profession is
justifiably proud of its record of quality and safety - a mere 1.8% of a DCs practice cost
goes towards malpractice insurance coverage. Still, ACA realizes the current medical
liability system needs substantial reform and is working toward reforms as a member of
the National Medical Liability Reform Coalition. We would encourage the task force
to take a close look at the coalition's proposals.
CONCLUSION
If we are to expand access to health care coverage to everyone in this country, health
costs must be controlled. The ACA believes that this can be achieved in part by
expanding access to alternative providers, guaranteeing patients the freedom to choose
them and expanding federal health manpower and research programs so that all licensed
health care disciplines have access to them.
I thank you for the opportunity to share my views.
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Administrative Material on Constituency Groups and Ethics Working Groups – Folder 1
Creator
An entity primarily responsible for making the resource
Task Force on National Health Care
White House Health Care Task Force
Charlotte Hayes
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 2
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 15
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2006/2006-0885-F-2.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12093114" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
2/6/2015
Source
A related resource from which the described resource is derived
42-t-12093114-20060885F-Seg2-015-001-2015
12093114