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MEMORANDUM
.TO: . :
FR: ..
RE:
· cc:
.7~'
t
"
March 14, 1995 '
Carol and Laura
Chris Jennings.
",,: : ." .
'Managed.Care Memo and Health Care Polling Data
Gene', Bill, Jen,}eremy~ Tom'
I
:
.
.
,
·•.~L_-·
,,~', Attached is the. revised, managed care memo for the P~esident.:. I beli~¥!! it has
incorporated your changes-'aiid'suggesti()ns; but any further thought~: Bl,n be :easily integrated
into the memo .. (Our review ofmanagedcar.~·poli~y pptjonsJocy"qui:consideration should be'
completed by sometime nextweek}.
.
.., .
. ,
..
, Also for your information is ~0I1.1e recent pollingdata--ihatStan Greenberg has given'
out to the political folks in the White House. " [ have pulled out, the health care questions and"
· res~onses for ,your review.,
'
'
A bdef review of the informat'ion documents that health care -reform ,remains at or near
. the top of th~ public's legislative priorities. Arnedcans also consistently report that they not
on!y lose their appetite· f~r de!!':.itreduction when Medicare is thiown on th~Jabre for .
consideration, but that cuts in the Medicaid program: -- defined as the "health program for
the poor" -- 'produces a simihu result. 'More specifically, at least two thirds of those
surveyed respond negativdy to Medicare and Medicaid cuts being used fOf' deficit reduction.
.
.
'.
The polling data,clearly points ,out' the problem the Republicans will have when they
formally propose the level of Medicare and Medicaid cuts (over $200 billion over 5 years to
be roughly divided between the prograp:ts) that they are reportedly considering., [f we chpose
to criticize their proposals~ they will be extremely vulnerable to charges that they are
undermining the pr()grams and the people they serve. (This willpartieularly be the C&~~ when
the aging advocacy groups j()in in -:-- or start -- their own chorus of criticism.)
, '. The likely fig leaf the Republicanshope to stand on is·the public's growing familiarity
and comfort. with managed care (HMOs/PPOsietc). [f the Republicans can sell their approach
as provid~ng' greater, choice, with the ability to retain the option' of fee for service, they may'
have some chance of capturing the media elite, and" at least som~, of the public. The fact is,
however, that the'only way that managed care can produce the level of savings the
Republicans are discussing' is through limiting-choice of'affordable options. [n other words, it
appears that the Republicans ,need us' to providt;~ the cover they need to move in this area.
Conversely, we will need them to take the heat if we also decide to utilize MedicarelMedicaid
· savings for additional deficit reduction .. ' '
., .
�M~lfch 14, i995 '
MEMORANDUM FOR THE 'PRESIDENT ,
"
,··FROM:,
SUBJECT:
,
'.
, CAROL RASCO
LAURA TYSON'
Medicare Managed Care
As you know, the most recent HHS prbj~ctions for the, Medi~re' anel Medicaid baseline
between 1996 and 2000 were $94 billion,lower than the estimates in the August 1994
Midsession Review. Of this' $94 billion, $40 billion of the savings were for Medicare "
, , spending.
,,'
,
,
'
You me~tioned i n' your, March 3idpress confere~ce, that Medicare managed care contributed'
to this repuction in the ba~eline. ,Secretary Shaiala has made similar suggestions in the past,
although she now understarids tliat Medicare managed Care as currently structured is not
producing'savings in the program. The reduction in the HHS Medicare baseline was actually
the result of other fact()rs;including programmatit changes implemented during your
Administration that 'have improved efficiency and reduced fraud and abuse, and the lowering
of overall inflation in the economy:
'
,
BACKGROUND, ,
As currently designed, Medicare managed care aetually increases program spending. While
the industry argues persuasively that they are able,to reduce costs with managed care, it
appears'that the Federal Government ~s ,not shadng i~ these savings. Instead the savings
achieved by Medicare HMOs are largely passed along to beneficiaries in the form of Medigap
benefits, e.g., prescription drugs, hearing, vision, and/or retained by the plan, as higher
earnings/profits. The rea.son why Medicare doe~not' adequately share in the savings is due in,
large' part to ,two' characteristics of the current Medicare managed care ,program.
, First,' CBO and OMB no~ believethar Medi~rets current reimbursement for, HMOs is too'
high and' actually loses money on each beneficiary enrolled .. Medicare' 'now pays' participating
HMOs a capitated payment that is calculated at' 95 percent of the cost Of providing care to
fee-for-ser.vice beneficiaries in an area. At the time of the enactment of the Medicare HMO
law (TEFRA - 1972), there was too little experienc~ "i~ the' program to know what level of
'reimburSement was appropriate; The, 95 percent number was chosen to provide an incentive
for HMO participation in the' program w,hile CaptUring, some savings for Medicare, '
�ff ,~'
~
The current reimbursement formula 'does not adequately control· for the ·fact. that, 'on average"
people who enrol~ in HMOs are healthier (their costs if they had remai!led'in fee:...for-service
Medicare are often less than 95 percent of the average)·and subsequently Medieare overpays
the HMOs' for the cost of providing care-1o them. In' fact, CBO estimates that Medicare pays
5.7 percent more for beneficiaries in managed care than it would if they had remained in the .
fee-for-service sector. In regions where fee..:.;for-s~rvice costs are disproportionately higher
than managed care costs :.....:.. which could happen in' areas with very competitive managed care '
'markets-.- the'paymenLformula .ov:erpays HMOs: even. more.
"
..... >...
The second characteristic in the Medicare managed care program that ~ay increase costs is
the option for beneficiaries to disenroll'every 30 days .. There is anecdotal evidence indicating
that. beneficiaries disenrolLfrom an .. HMO and seek care in the fee-for~serviCe sector once. " .. '
.
....,
...the·y.get seriouslY"ilL The underlying theory behind managed care .. savings;·-however, ·is· that
.. ,capitatedpayments:provideincentivestokeep costs down.when enrollees become.sick. When-' .'-'
.. enrollees can 'leave managed care arrangements at the point when they' get .seriously -ill,:the ..:..:
· incentives:faced by the HMOs. to manage care effectively are minimized. Und~r. this.' "
,,'
-:scenario.. ffi(fnaged ~~reco~ld potentially flirt·her ·increase. Medicare costs:
'
: '
Many Republicans in. the Con~ess have suggested that significant savings can be achieved
through the utilization of managed care in the· Medicare program ... While they have' y~t to
~~lease details, proposals that could guarantee savings of the magnitude that :are being
discussed would restrict choice, particularly for lower income beneficiaries, It is therefore not
.surprising that elderly advocates are partieularly wary of proposals for capped vouchers that.
Republica~ analysts have been s~ggesting: The HMO industry aiso is not likely to'lead the
· charge toward initiating any. significant changes to the program since; for the reasons outlined
above, they are generally quite slltisfied with the current Medicare payment arrangement..
FUTURE ADMINISTRATION ACTIONS
'.~
We are c,onducting an intensive .review ·()f ma~aged care options to devdop an Administration
position on 'this issue. There is a strong commitment to' moving forWard on the managed care
front by OMB and HHS and the· Department has testified to this effect in recent weeks. In .
contrast to the approaches being advocated by some Republicans,' the managed care models-
s,±ch asa -.new .Medicare PPO modd--that have been referenced· in' Administration testimony
would increase the us~ of managed care by expanding the choice of plans available to .
beneficiaries. They would not, however, restrict beneficiaries' ability to replain in the fee..:..
:.. for-service',system: However,. without modifications' in the reimbursement methodology,
which would secure program savings at the~xpense of the plans' and/or beneficiaries' savings, ..
these alternatives would 'likely cost money -- -at le~st over the"short-term. Weare studying
..... thepolitica:l and policy feasibility/advisability of managed care options thatwoilld
significantly reduce the growth of Medicare spendirig;:
We are also soliciting input' from private sector managed Care firms..(such as FHP) and;we
believ.e this relationship has the potential to yield some interesting results. 'While any 'viable .
managed care proposal is unlikely generate significant Medicare savings- in the short term, we
· believe that movement toward managed care in the Medicare program has potential to
.
produce savings over the long term .. We will keep you apprised of the 'status of our workin
this area.
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Public Polling Update
on'
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Balanced Budget Amendment, Deficit Reduc,tion, Medicare and Medicaid
•
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. March, 1995
(provided 'by
.'
Gree~berg
Research)
~
�I'd like to read you a list of seven possible legislative priorities; Please teil me w~ich one or two you fee!
are the most important issues for Congress to address...an increase in the minimum ,wage. a balanced
budget amendment, a middle class tax cut. welfare reform. a revised crime bill, health, care reform. a
capital gains tax cut?
'
,
,. 18%
Increase minimum wage
·24
Ba!anced budget amendment
Middle class tax, cut
·28
, , Welfare reform
. 46
Revised crime bill
. ,21
,. Health car,e reform
". 29
Capital gains tax cut
. 8
·',3,
AILequally important (voL)
QUESTION NOTES: Adds to more than ,100% due to multiple responses
Do you favor or oppose a balanced budget
a~endment to'the u.s.
(United States)Con'stitution?
Favor
'·71%
,Oppqse
• 16
Depends (voL)
. 4
Not sure
'
9
Would you favor or oppose a balanced budget amend ment to the Constitution if thatwould require a
tWenty perc:ent cut in spending on entitlement programs such as ~re.Medicajd.' and vete.@ns
benefits?
Favor ,
Oppose
Depends (voL)
Not sure
28%
65
. 3'
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"
4
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Many Democrats say that Congress should have to explain which programs they inte,nd to cut before
voting on the balanced budget amendment. so people will understand theconseque'nces. Republicans
say that voting on the balanced budget a'mendment should come first, because without the ,?mendment. '
Congress won't 'really make the spending cuts that it should. Who do you agree with more on this
issue"':'the Democrats or the Republicans?
", , "
'"
,
, "
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, :
Democrats
·58%
Republicans
- 36
Both/neither (vol.) " . 3
. 3
Not sure
',",
POPULATION:, National adult
NUMBER OF PARTICIPANTS:, 1,003
INTERVIEW METHOD: Telephone
SURVEY SPONSOR: NBC News, Wall Street Journal
'BEGINNING DATE: January 14, 1995·
ENDING DATE: January 17, 1995
SOURCE DOCUMENT: NBC,NEWS, WALL STREET JOURNAL'
DATE OF RELEASE OF. SOURCE DOCUj'v1ENT: January 20. 19;35
ORGANIZATION: HART AND
RESEARCH COMPANIES
�Would' you favor or oppose a balanced budget ame.ndment to the, Constitution that wouid require the
federal government to balance its budget by the year.2002?
Favor
• 77% '.
, Oppose
- 15
Don't know INa answer
- 8
Suppose balancing the federal .budget required' c.uts in Social Security or Medicare-then wo~ld you
. favor a balanced Qudget amendment (that would require the federal government to balance the budget
.bY the year 2002), or'not?
Favor.
- 34%
Oppose
: 62
Don't know INa answer
4
POPULATION: National 'adult
NUMBER OF PARTICIPANTS: 4,943
IN-tERViEW METHOD: Telephone
QUESTION NOTES: Asked 'of those who favored a balance budget amendment (77%), .
BEGINNING DATE: January 10, 1995
ENDING DATE: January 20, 1995
SOURCE DOCUMENT CBS NEWS
DATE OF RELEASE OF SOURCE bOCUMENT:.January 23. 1995
ORGANIZATION: CBS NEWS
�,
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Do' you favor or oppose a ',balanced budget amendrn'ent to the U.S. '(United States) Constitution?
.
"
,
"
",
Favor
- 68%
Oppose
- 19
Depends (vol.)
- 3
Not sure
. - 10
Would you favor o~ oppose a balanced budgetam,endment to the C'onstitutio~ if that would require a
twenty percent cut on ~niitlement programs such' as, ~edicare, Medicaid, and vet~rans benefits?
.
Favor
- 33%
Oppose
- 61
Depends (vol.,)
- 3 '
Not sure
- 3
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.J
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I'd like to read you a list of seve'~ possible legisliHive priorities. Please tell me which one or tw~ you feel
are the 1\10st important issues for the next Congress to addr~~s .. ~ job'training programs, a balanced
budget amendment, a revised crime bill, welfare reform.-hl:Jalth care reform, a middl~ class tax cut, 'a .
school prayer amendment?
' , '. ' .'
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, ,,
.
Job training programs
- 21 %
Balanced budget amendment
- 28· ..
'Revised cri
ill '
~-'.,
- .37 "
.' - 31
.
Middle -c-:--Ia-s"'7-:-tax-c-u-:-t----~
s
School prayer .amendment
- 11
All equally important (vol.) . - 3
Not sure
1
QUESTION I~OTES: Adds to more than 100% due to multiple responses ..
1>3
"'POPULATION: 'National adult
NUMBER OF,PARTICIPANTS: 1,0'00, .
INTERVIEW ,METHOD: Teh3phone
SURVEY SPONSOR: 'NBC News. Wall.Street,Joumal
1994
BEGINNING DATE: December
ENDING DATE: December :13. 1994
. SOURCE DOCUMENT: NBC NEWS, WAlJ.. STREET JOURNAL
DATE OF RELEASE OF SOURCE DOCUMENT: DeCember 16.1994'
ORGANIZATION: HART AND TEETER RESEARCH "COMPANIES
10.
'
�1 ,
Would you,favor or oppose a balanced budget ame,ndment to the Constitution that would require'the
federal government to balance its budget bY,the year 2002?
'.
/
Favor
- 81% '
Oppose
' ,- 12
Don't know/No answer
- ,7
, Suppose balancing thef~deral bu,dget ~equired' 'cuts in .social Security-then would you favor a balanced
. budget amendment (to ,the Constitution that would .reqUire ,the'federal government to balance the budget
by the year 2002),o~·not?
'
',.
Favor
' ,: 37%
Oppose. '
- 60
Don't know INo answer
2
,
,
POPULATION: National adult
NUMBER OF PARTICIPANTS:, 1,147
INTERVIEW METHOD,: Telephone '
"',
,"
QUESTION NOTES: Second question asked
those who favor a balanced budget amendmef)t which
would require the budget be balanced by the year 2002 (81 %)
BEGINNING DATE:.Decemb,er 6, 1994 '
ENDIN~ DATE: December 9, 1994,
,
SOURCE DOCUMENT: CBS,NEWS, NEW YORK TIMES
DATE OF R~LEASE OF SOURCE DocuMENT: December 14, 1994
ORGANIZATION: CBS NEWS. NEW YORK TIMES
of
,
'.,
'"
�,
th~federal bUd9~t
'
tu~s Medicare"':the~ wo~ld
Suppose balancing
required
in
you favor a balanced '
budget amendmel1t. (to the Constitution that would require the'federa,J government,to balance the
budget'bythe year 2002). or.not?
'
','
,"
Favor
- 33%
Not favor
- 64
Don't know INa answer " - 2
,~
,
.
Suppose balancing the ,federal budget, req'uired cuts in spending on education-then would you favor a
, . balanced bLidget amendment (to the Constitution t,hat'Would require the federal government to bali:mce
the budget by'the year 2002). or not? '
'
, favor
Not favor
/
- 27%
- 73
Suppose balancing the federal budget required Increases in the amount you pay in'fec1eral income
tax--then would you favor a balanc'~d bu'dget amenqment (to the Constitution that would require the
federal government to balance the b~dget by the year 2002). or not?
'
Favor
·5·1%
- 47
Not favor
Don't know/No answer
2
POPULATiON: National adlllt'
NUMBER OF PARTICIPANTS: 1,147
'INTERVIEW METHOD: Teleph9ne
.
QUESTION NOTES: Asked of those wh.o favor balanced budget amendment which would require th~
, budget be balanced by the year '2002 (81 %) "
,
BEGINNING DATE: December 6, 1994 ,
ENDING DATE: December 9. 1994
SOURCE·DOCUMENT:' CBS NEWS, NEW YORK TIMES
DATEOF RELEASE OF SQURCE'DOCUMENT: December 14, 1994'
ORGANIZATION: "CBS NEWS. NEW YORK TIMES
a
�Would you favor qr oppose a. balanced budget amendment that would require Congress to balance the
federal budget by the year 2002? .... .
.
.
Favor
. - 80%
Oppose.
- 12
Don't know Ino answer
- 8 .
If a balanced bud. get amendment were passed, to do you think ,Congress would be able to balance the
, federal budget by tile' year 2002. or don't you think Congress would be able to balance the budget by
then?
- 28%'
Will be able
Will not be able
63
Don'tknow/no answer
9
• y
POPULATION: National adult
NUMBER OF PARTICIPANTS: 1,120
. INTERVIEW METHOD: Telephone
BEGINNING DATE: November 27; 1994
'ENDING DATE: November 28. 1994
SOURCE DOCUMENT: CBS NEws
DATE 'OF RELEASE OF SOWRCE DOCUMENT: Novembe~ 29.1994,"
ORGANIZATlON: CBS NEWS
I'd like to read you al\st of six possible legislative priorities. Please tell mewhich one or two you fe~' are"
the most important is~ues for the next Congress to address... welfare reforrrl, health care reform, .' ,
'"
balanced. budget amendri1~nt to the const~ution, Congressional temn limits. a middle class tax cut. job
training progra'ms.
'
"
.
..
, Welfare reform .
-46%·
. ,
.
Health care reform
-.37
Balanced budget amendment
- 26
. Congressional term limits
- 8
Middle class tax cut
<29
.- 25 .
. Job training
All equally' important (vol, )
- 3 '
" '~\'1k (" <2..br tv'
,
"
~t~l;f- ~ ,\~~\~
~~\j >J.(\k ('<.,tn:ry
POPULATION: National,registered voters
NUMBER OF PARTICIPANTS: ,302
INTERVIEW METHOD:. Telephone
SURVEY SPONSOR: NBC News. Wall Street Journal
QUESTION NOTES: Adds to more than 100% due to multiple responses
BEGINNING DATE: November 9. 1994
ENDING DATE: November 9. 1994
.
SOURCE DOCUMENT: NBC NEW$. WALL STREET JOURNAL
DATE OF RELEASE OF SOURCE DOCUMENT: November 11. 1994 .
ORGANIZATION: HART AND TEETER RESEARCH .COMPANIES
..
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Idl-f !1~_
LYV~L»' VVl:Q'~,
0·12
A few questionsaoout priorities for President Clinton and the new Congress .next year.. ~. As I read
, from a list' tell me if you think the item thac I read. should be a priority: First... (READ ANP
ROT ATE) should this be a top priority, important but lo;.ver priority; not too important, or not·
'
.'
done?
Top
Prioritv
lmpcirtarit, ,
but lower
Priority
Not
Too
ImQortant
.
"
Not
Be
Done.
Don't
Know
..
a.
Stricter concrol of handguns
46
25
14
' 13
2=100
b.
Improving the job situation
64
27
5
2
,2=100
c.
Reforming health'care
'9
'7
3=100
d.
Cutting the capiral gains tax
27'
38
16
7
12=100
e.
Reducing crime
78
' 17
2
f.
Reformingthe welfare system .
66 .
~5
5
a
y
Reducing the budget deficit
65
26
5
h.
Reducing feder3J income taxes
f~r the middle class
.
53
32
9
3
3=100
Limiting the number of terms a
member of Congress c3.n s'erve
33
31
23
8
5=100
51
32.
8
'5
4=100
' 19
2=100
I.
J.
~(
Passing a constirutional ainendment
, requiring a balanced federal budget
27.) .
:0
4
2=100
,2
'2=100
3=100
,,'
k.
Passing a constirutional amendment
thac would allow prayer in public
schools
.
27
33
19
".
"1
3I
�~~t."
13. Here are some proposals memOOr.s of Congress have made. For, each
one, please tell ~e whether you think it ,should be the ~ priority for
Congress to pus within the ,first 100 'days, a.lll.9i1 priority, & .tow
priority, or ~ priority at all. First•••• Next, how high a priority
ahou~d conqress give to ••• {ROTATE}'
\\'?
.(IN":tERVn;wER, Na.rE: Ii' REsPOHD~' S.i\YS I:t:!:H, SHoatiD
PRlolUn_l
"'RO~
,
m
BE PASSED" .MARX AS
No
2::d.Qb:;i,,~
No
~
High
34
SO
12
2
"
2
Significant reduCtion in the
Feder!!.l budget .def:"ci t
.
n
Sl
13
3
:2
A 'Constitutional <IJl\endmGnt to
balance the budget
30
47
16
4
3
A cut in taxes for most
i\mQrican :axnilieg'
27
47
20
4
2
44 )
2i
5
2'
Tougher
anti-cr~e,
legislation
.Major reform ,in the. ,country's'
, health 'care system
1
~
i:Qr;;'2S
'\
~
\
\:
,
"~
~,
,Legislation to l.i:nit weifare
payments
26
44
24
'3
SiqnH1cant ciuts in spendinq
for Federal proqr~
22
45
26
S
:2
Legislation which ~ld &ll~
the President to veto indiV'idual
parts ot a' proposed spending or
tax·bill, rather than naving to
accept or veto t.b.a entire bill
2l
43
26
6
4
19,
36
34
8
3
19
' 33
33
14
1
IS .
36
33
7
9
An increase in defense
spending
12
30:
4S
11
2
Making it mora, difficult for
. ,.,omen t.o , get an abortion,
"
"13
21
40
23
3
l
A constit~tionalamen~nt
to limi.t ':..~e number of terms ,
members of congrea,S can serve
A
constitutional amendment
to allowV'Oluntary prayer
.
in schools
A cut in
~he
capital-gains
t.ax
~
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"
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(USA Today(Gallup poll
~2128-30(94
-~-
�';'
"
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,
Among the items Y'o'u. have said should ~eceive .. top .... priority with
Congress
~hich one do.you personally think is the'mo~t important one1
14.
')'
~0~·...:..1_1_____ o~r_r_e_f_orm
M,a_j_'
_c_ou-:n_t-:-ry~._a_h_e_a_l_t_h-:-.~ca_re_'_IJ_y_s_t.:. . -em
__i_n-:-t_h_e-:"
leq~slation
. Tou.ghu anti-crime
II
7.
SiQnificant reduction in' the?ederal budget. deficit
6
Legislation to limit· we,J.fare payments. .~ .
6
11.
6
.,
A cut in
i
COnstit':.1tional amenc1rn.i!n:t to balance the budget
taxes. .fot .most
Americans
·Legislation which would allow the President:. to veto
individual 'p~s of apropoaed spending or tax bill. rather
than having to accept or veto the entire. bill
5
~
,\
,
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,
"
'
A Cons·tit'.Jtional amendment. t:o allow .....oluntary prayer in
schools;;
5
4
. Significant cuts'in spendi.ng for Federal programs
4
. Mak!.ng it
"
more .di:!'!':'cuit
for women' to get.an abortion
.~
Constit'Utional amendment to limit the number of terms.
members of Congress can serve
11.
in
1
A.' cut
the ':apital-gains tax
.1
An ..i.ncrease .in defense
spen~ing
.No 'opinion
.-lQ.
100
15.
The .Republican leaders in Collg~88 have inadeseveral proposals to·
change the ~ay congress. operates. which they plan to bring to a vote on
the first day of the'newcongress. These change9 include reducing the
number Qf congressionaJ.· conim.i.ttees and statfand requiring all lDe@tings
':0 be made public.
DO' you t.'llnk these changes represent' ::aal refor:tla of
Congress, or are they ju~t a 'political gimmi.ck1
Represent real
37·
57,
ref?~
Just.. <1. politiCal. gimmick
-2.
No
opinion " .
100
'"
'1
CNN/USA..Today/Callup Poll
'.'
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12/28-30/94
-1,0':"·
�CBS NeWs Poil - November National Survey ',- N()vem~: i7-~ 1994)
~
.
Fagell
'~..:..;:..=-
.
. 24. Have you heard or read anything about
the Republican "Contract with America,"
which outlines proPosals 'the Republicans in
the u ~s. House of Representatives promise .
'to vote on in the first 100 days of. the new .
, . Congress. 'or haven't ,you ,heard or read
, anything aboufit?
I
. Have beard or read
Tot
Oct94B*'
.28 % 35 % 24 %
70
. 63
74
2
2
2
Have not
DKINA
~Varied wording:"
T ota! Respondents
00 • •
wouid work
25-%'
73
2
29 %
70
1
on if
. tbeywin a m.8jority in Congress this fall~
"
In the firSt 100 days of the new
Congress, ,do you think the Republicans will
keep their promiSe to vote on the propbsals
outlined in .theirContraCtwirh AmeriCa, or ..
don't you think they'll keep their promise?"
.25.
47 % 71 % 31 % 39 %
38
18"
53
43
15
11
16'
18
Will keep promise
wm not'- keep promise .
DKINA
of
:76.
With the Republicans in control both
the U.S. House of Representatives and the
U.S~ Senate, do you think your taXes will 'go
,'up, go down, .or stay, about the same?
.
.
42' % 22 % 58 %
2
'9
18 .
Up
. Down
Stay about the same
DKJNA
--'7
.,.
.
.~%
46
5
42
511
3
37
3.
6
4
27. Would you favor or appose a balanced
budget . amendment tha~ wouLd require .
. Congress to balance the fede~ budget by.
the year 2CXY.2?
'
. Favor
Oppose
DKINA.
80 % 85 % 76 % .
79 %
12
11
10
8
1114'
.t
'10
c~nducted in Nii!w Y~rJc State 9f29-f0r.U94; s.p94A W2.I
conducted 918-iU94; Aug94A wa3 conductM lf2J94; iul94C wu conduc:e(\ 71l4-i7/94: Apr94A was condl.l.Ctro 4121-2:3194;
J.a.094C was conducted 1I15-17l'i4; Jan94A wa3 conducted 1/3-5194; Feb9:3A W8.S coaduouxi 2/20-:21193; M.u8:2
conducted 3/11- tSI&2; AprSl wa& coQducted .4/Zl-2hJSl.
Trend Date:s: Oct94B was conducted. IOI29-111l194; NYS94A \lois
�,
'.1
',23. , (Of t...1.osewho support a ,.balanced budget' amendment) Would you support -t:,r
oppose a constitutional, amendJnentto •reqUire a balanced, fede,ral budget if
it meant raising your tederal income ,taxes?
Support
Oppose
No opinion
1/4/95
48
',49
2
,
Q.21/23 NET
Support aIOe.ndment if raise"federal income taxes
Oppose amendment if raise federal income taxes
tio opinion
'
"
-'
1/4/95
38"
55
7
24. Do you think- the president 'of the United- States should or"should not
have the auth'ority to veto individual itel!l.s in the federal budget,
something known as 'the line-item ve'to?
,
L
1/4/95
Yes, pre~identshould have ,the authority
tio, pres~dent should not have, the authority
N"o opinion ' .
.',
,
','
,,
'
•
"
, .1
•
•
64
31
5
' , '
25. ,Turning ,to another ,subject, the death penalty: Do you favor or ,appose
the death penalty for persQnsconvict:.ed a~'murder?
1/4/95 4/26/92* 12)18)82
74
,1.9
5
Favor
'Oppose
(Vol) It depends
No, opinion
'
" ,Word
'It
-
2
75,
-19'
5
-76
19
NA- ,
1
6
1/30/82
69 '
19
8
5/20/81
4
7J
20
5
3
oppose II adde.d to: question ' '
26. Dc you support or oPJ,JOSEl a reduction in the ,federal 'capital gains tax :- '
that ~,s, the tax on pro.f~ts from investments?
1/4/95
Support
Oppose
No opinion
10120/88,
52
44'
40
8
33,
23 '
27. Would you support or oppose, a l,aw' limiting wel£are' recipients to' a
'maximum of ~.oyears of benefits, atter which those who are able to .ark
would have to get a job or docbmmunity service?
,
,support
oppose
No opinion'
1/23/94'
1/4/95
91
,
'
,
"
89
a
, 8'
J
1
28. Do you favor or, OOoose an ,amendment to' t..'e (LS Const'itutiont..'at -...,ould
allow'organized prayer in the public schoal~?
:?avor
Oppose
No opinion
1/4/95
67
32
4/13/87
68
30
2,
or
on
29. Do you favor
opoose a l'imi t~
tIle'number of years a person could
,serve as a IT. S. Represfmtati:ve,inc:mgress?
,
,
. Favor
1/4/95
6/:?6/94
75 '
72
Oppose23
24
No, opinion
2
3
�•Af!:f!/vJP
aa,
11/14/93
4/9/92 :- ','
3/18/92 "
:3/11/92
10/21/91
17
21:
3
3
76
7'4,
21
'3
23,
~
74
24
24
3
16
73 '
10/14/90
LiLt /fS-
),
:30. Now on several 'of these issues I'mgoinq to ask ,you what kL~d of
priority it shoUld'qet in Congress. For each I, name l please tel~me whether
:rou think it/s absolutely critical to ,gat dona. as soon as possible l ,
Important but not, critical, notVlerj important or not important at all.
A.Health care 'reform
critical/important '(llET)
Absolutely critical
Import~nt but not critical
Not important (NET)
,
Not very important
Npt ~ortant at all
No opi~on
,
.~
1/4/95
~4,
45
39
, , 15
,
...
tf)
---
~.-'"
1'0
'5
,1
B,. CUtting the federal, budget deficit'
' .
<
"
1/4/95
93
55
39
5
3 "
2
1
critical/ important (NET)
, Absolutely critical
Important but not Critical "
Not important (NET)
Not very important·
Not important at all
No opinion
c. providin~ a. middle-cla..<is tax cut
Critical/important (NET)
Absolutely critical
'"
IlI1po~t but not 'critical
Not, important (NET) , '" , '
Not very important
" Not ~l?0rtant at <ill ,
No opl.n~on ' ,
'
i/4/95
~2
37, '
46
17
13
<\
1
D. Approving a constitutional ~endment to allow
organized prayer in puplic schools
1/4/95, .
critical/important (NET)
" Absolutely critica:l
60 '
"
Important but not 'critical
~ot import?nt (NET)
.
!lot very important
Not ~l?0rtantat,all
No op1n~on ,
.
22
]8
38 "
,- '19
19
'1
E: Approving a constitutional amendment requiring,a
balancedtederal budget
,..
"
'
. C:-itical/iJuportant (NET)
Absolutely critical
'
Ilnportant but ,not. critical
Not important (NET,)'
Not VQry important
1/4/95
35
41
45
13 ",
.7
. i
.
/1
\.
i.
•
�11.
As you ~nOH'. the President and theCongre.ss will be trying to cut
,
.. federal, programs; Ii order to reduce the budget defi cit. For.e3ch of the
. folla,.ring programs. please tell me whether you think. it is more .
importantta,reduce·the federal budget deficit. or more important to
grevent that program from being significantly cut .. First. (READ lSi
lTEM.RO!AiE); Second.: CREADANO ROTATE .RES! OF ITEMS) -- .
.'
,
Reduce Fed, '
,Sudget .
Pr!:!vent
'Significant
C.ut ; nProgrm
...
GeficH
'h
Medicare-- the. ''''~:
f~era 1 he:! 1th·",,"
,pr-vgram for.tl1e_.
\'1
elderly ..
Medicaid-'- the
federa 1 hea 1tl1:;:~:;:
program .for t::e
, poor
., ..,
.~c.
Sac1 a1 s,ecuri ty
d.
Defense sFendjng,
e
,
.il.D
Food stamps
'
,S.:L
.;:2.~
"3
\
.' t.A~
.'Lot::)
f. , Schoo L i unch:...p,r:,ogram
,
,
35
,
:S
,
~
~~
"3
Grants to cities ,to
put more pol1cEon
.;;2 ~ .
c....,~.
Aid to farmers
Y3
.. . 5"'"
'-\
S
Funding for the~.rts
'~l..
.::l.q
S
the streets "
Loans. to
co 11 ege:: . ,
students '.
F:.
l,oJe 1fa re
prOgrams ~:,:
in genera 1"
.
-.
t.....::;;.
?:J\
~£-
c..\
,
."
~c
'5"
--
.
,,'
.&
.
~.,
�,
., ..........'\ ... .
"
ID:202-395-6148
.
FEB 20'95
:
.. /
STATEMENT OF
.BRUCE VLADECK
ADMINISTRATOR
HEAlTH CARE FINANCING ADMINISTAATlON
BEFORE1liE
SUBCOMUrTTEE ON HEAlTH
COMMfTTEE ON WAYS AND Mf:ANS
U.S. HOUSE OF REPRESENTATIVl:S
FEBRUARV 10,1995
21:05 No.001 P.02
�ID:202-395-6148
FEB 20'95
21:06 No.OOl P.03
Mr. Ch81rman and .emDer. of 1he SuJKgnmtttee
I. am plelMd to be here today to begin a dialogue WIlt1 U11. SUboommittee
about the,curreAt state of the Medicare program and. more Importantly, about its
Mure. More than any other m&mbena oJ this Congress. the membere of this
subcommittee have Jong had an understanding of the complexttles of the Medicata
program and the vulnerable poputatiDn that we serve. and have contributed to maJor
improvements In the program Over the veara. MecIcar. Is a popular and 8uooeesful
program., I believe we need to work together to Improve on the prcgram'.IY008SS
and strengthen It for Its beneficiaries Mel the UPcpGyar'8 who eupPort It.
We in HCFA have been workr-g very hard to make the MadIc8re ,ptogram'.,
effective, affcrdabIe and ·customer fiiendty' program for bentfSdaries. At the Same
time. we have been working to Implement adminlstratlve and program improvements
, which maximize the effldena; and oost tffe=Jven,sa of the program. I want to begin
by reviewing some of our recent etfor18 arw:I SUCQ8SSeS and then provide you wtth an
overview Of our 8Iforts In the .rea Of managed. care, Finafiy. I wouk.1llke to "lieu..
lOme of our initiatives to Improve the administration of the Medicare program.
I. SUCOESSES
MedIClr8 is the world's largest health lnaurance program end by many
measures one of the most aucc:eSsful. It began in 1966 as 8 Federal health insurance
program for the eIdef1y and was expanded in 1972 to cover disabled persons and .
those with End Stag. Renal ctMase (ESRD). 'The Medicare program was estabfiShed
because our vulnerable populationa had dHftoulty obtaining private health Insurance
coversge.
Medicare Is adminIstered largely by private ccntradOr& unCl8r our IUperviIiOn•. In
1004, Mftdieare servec:.t almost 38 mllllo" paraona under Pats A and B of the ,progi'im.
Aged Medicare benefiolariea number 32 million, 3.8 minion are disab,led and 7t I:tXJ
have ESRD. Medicare has agreements with over as oon1raotor; to process .
beneficiary Claims. In FY '994, over 750 million clalma were processed ~ MedIoIt'e
. , ' paid more then 1159 blRton for mecicaI services. treatment and equlpmcmt.
,
' Today, we mafntak1 Madieara's commJtment toserv8 the most ·vulnerable.
M8d1cere Ie the wr;eat payor of 1he elderly's hoaJth 081" e~ns... A8 the
SubCcmmitt8e eXamines the Mur. of the Medicare program. I would urge you to
conlider the ~JoWIng Important facts abOut Medicar. benefia8lies.
o
RelaIIveIy few Medlcar.e beneficiaries can'be conlfdered flnancialty w.,1J..off.
Approximately 83 percent of program ,pending 'n 1992 w.. on bGhaff of those.
with incomes less than $25,(XX). (CHAAT 1)
o
Currenlfy• .20 percent Of 0Wt' btneficiaries are efther lieniora age as and Older,
.
�FEB 20'95
ID:202-395-6148
21:06 No.001 P.04
most 01 whom ar.e women, or paraona with disabilities Inoludlng End Stage
Renal Disease (CHART 2 ) . ·
.
g
ThIrd. per Qlplta·heaIth care spending for aged bBneflcllirles .Is 4 tfme& 1he
average fOr the under S5 population.
Medicare is successfully fuHiBIng Its mlasIon and beneftdarle8 continue to eXpress a
high degree of aatlsfadIon with the progr.n. MIllIo~1 of eIder1y WId dll8lt*Kl
Americans now have hGafth cere oovorego end • quolltY of life· that tnoy would
0Cherwiae lack. tho. to the Medicare program.
Innovltlvi Program AdmlnlltrlUon
Despite the alza of the M8dJcare program. we have maIntained • high lEWlI.at
consumer satisfaction with low administrative COlts, lela than two percent of .program
outlays. In contrast, private Insurance administrative ~nae. are about 25 .percer It in
1tnt amaJl group mark8t tiI1d about ftw percent In the large group market.
Medicare has been a pioneer In strearnilntng program adminiStration ancUs a
world leader In fOstering eJe~ claimS submission: Ninety percent of MecI1care'a
hospital and skilled nursing facUlty claims and 87 percent of its physician claims ara.
GUbmltted el8OIronIc&IIy. In contrast, 60 percent of Blue Oro';" hoepital. oIaiMsiltld 2Q
peroent of its pl?tBician claima are aItotronicaJty submitted. For oommerolaf 0III'1'iera,
the percentage 115 10 percent for alI dalms. {CHART 3)
,
We have focused attention on f8duolng the ~ burden on heafth care
.prcvlders. working closely with the heafth· care ccmmunity to eatabJlah a standard.
uniform netlonal Medioare oIaim form for. physioIans and ~r for hospitals, SkfDed
Nursing FacUJtIes (SNFs) and Hane Health Agehcies (HHAs). Many other ~rn
\De 111.58 fOrms, but attach addnk:Jnaf TOrma as well. ThesI. nowever, are U18' only
hospital and phyalcian claim forma that Medicare rGQuires.
DeclIne'" the
~edlcar.·BasaIln.
During U. Cfinton Administration, the pro~ 10rUlI average anAuaI·'" Of
growth for Medicare have deaeased. In the President's ~ 96 Budget, 1hI prOjected
*
annUlif average rata of growth for 1996 .. 2CKX) 1s.9.1.percent. In contrast,
manlh.
. .ago in the MId-8eetion Review, the .proJected annual ave. . . rate of growth for the
aame period
10.3 percent. The primary contrIbu1ion to.. lower Medicate
w-.
proJecUon& IcJ slQwer growth In Part 14. HOlpitaJ Inaurlilll08 expenditures. 1l18·decIIne In
prOjeCted Pan A··growtt results prim8rHy tern a decr.ase ·in-forecuted. hOlpilWccst
Inflation andslowlt growth in th8 ccmplexity of MecflC8r8 inpatient eases.
IL MANAClED CARE AND THE MEDICARE PROGRAM
2
.'
�ID:202-395-6l48
FEB 20'95
21:07 No.OOl P.05
Today, any discullion of the qUest'to enhanoe 008t effeothreneu, .. WIII~,_tha
accessibility of quality medical cae for: benefidarIes, must inclU!H managed care. We
. . c.unniltted 10 working wtth you to 1mpr0v8 WId ~'1he rnanaQed care chaices
available to our ~Ie& &0 that 1hey hive .... fuR range of mfiI1aged care capUons
, NitabIe to the genarallnsured population. The comerston8 of our polley ts lnfonned
ChoIce In.8· fair markatplace. in which beMflcIIrIIs have Y' and objective InfotmaIion
Md •• not disaimlnated against on the basil tI ralaUve need.
M~
care il not •
new c:cncept for the MtdIcare program.
SJnoe ..
Inception In 1sea.• portion 01 MedIcare blneflcIarIeI have rlOlivld care through
managed care arrangsmentR. Enrollment Is Incr8aslng. and we antIcIpata COIIliIIUIId
svong growth. newty·entftIed ben8ftdarte8, WhO are more:f8miIiar with managect
cere enter fle MedIcare program.
t
I
'';
Currently. 14 percent Of Medicare beneficianes'fiave' 80cetI to a managed care
plan and 9 percent of Medicare beneficlarlea have chosen to enroll 'n 8 rna!INIQ8d' care
. option. 1894 we. • year of hnpressive 'growth In Medicare managed care, we
exportencecI doUble digit Increases bo1h In plan enrollment and the numCor of, plans
per1IcIpatIng In "'program. Plan enrOllment Increased by 18 percent. We rt1N have
11 counties where 40 percent or more or our beneficiaries are enrolled In managed
care, an addttJonal 3:) ccuntlos with enrollment b8tw88n 30 and 40 percent, and mora
than 44 oourrti8C .with enrollment between 20. and 30 percent.
. ' .
,
, " MOrI lmpQrt8nt for futUre enrolment growth I, the number of contrect& witb
managed care pfens. In 1884,·the number or our MedIcare managed care plans
Increased by 20 percent. Many of theae new contraclS are ,in rega..a beyond ,thoSe
that tradltioMJly have had a strong Med1eara managed Cl!lre presence. In our
,
,PhKadeIphia regjQn, 1he number of CQI'1tr~ 1na'lJia.d from 6 'to 16.and In the Io8ton .
. reQlon contra IncrNeed frOm 4to 9. ...... ..
, .
,
AI we wCWtk,to extend and brOaden managed care options for Medlen
beneftcfarin. we·must be aware both of the practJcall1mitations of a rapld expatWIfon
of managed care in, Medica" and of past failures of overly eggressive effottIln ,both
, the Medlcere and Medicaid p-ogrems~ The movement to managed care cannot
owtpBce \he gapec;Ity of l1'l8I1iIgod QIte plans 10 8Of'V'O 18fge' numbera of now enrol. ."
p8r1icularty those ~ 1he expensive and special h8~h needs of the Medioere
'
population.
'
.
,
In addition. for Medlcare to benefit· tom 1he expansloo. Of managed oar't we
need to Impl'OYe',4he way Medioar. p8Y' managed oare piane. Managed oare
currently costs the Medicare program rather ~ achieving ·"Wlga. Our evaluations
hIV. suggested 'that MedJcare pays 5.7 percent mora for every enrollee In managed .
care tha"t would have been paid If 1he beneftciaty had stayed In fee·for-&8t'Vt08. 'The
reason for thl' II thai they attract the healthier members of 1he Medicare population
J
�.\
1D:202-395-6148
FES20'95
21:08 No.OOl P.06
whoM health cere QOSts are Iow.r. £ffot1a are underway to ImprOVe the aurrant
payment methodology 80 it doesn't act as a barrier to the expansion of managed
ewe. We haw iriitiated ..,eral researQh pro}lOC8 and demonstnJUons add...a thIS .
situation and we expect to hove preUmlnary results Ietor thf' YNf.
'0
.
1
I
•
Madicar.· beneflc!aries them. .·must de!8rmine the pace of 1hW ~
to managed cal't. The emphasis mull be on ctlg[gt. Managed car. Ytin succeed •
. managed care plene wo able to prove the value or 1hItIr products and as bellBftcIwln
reco;nI&e the benefit of tNt coordIn~ of CIn and caM management f\at high
quality .managed care plana can provide.
New Manag_
c.... 0pI0M
In adc:IiIiari to our efforts to· Improve current rneii&ged·.care optlons·....
MIdIcJr8. we WWlt to make avaBabkt to beneftdarles • new preferred provkler
or~ (PPO) option. This option has proven to be very popular In the
commerCIal mar1cst. and maPly of
8ccaaS to PPOs. We believe that Mec;Ioai'e
·benaficiariel IhovId have the same range of ohoIces. Under tne PPO option, 0CiI' .
objeCtive would" to aAow beneficiaries to choose to go to any physician at any: ,1Ime,
subject to htgh_ coet-ahIrIng.
""heM
In develop,lng a PPO ~ for MedfOarut W8 hope to learn from cur ~
with the M8dIcaIe SELECT ctemon8tration~Aa you know, Medicare SELECT was
designed to create'. hybrid of managed oare' and ~edigap·that tt W8$ hoped waufd
be ~fklial bo1h 10 beneflQiarie,8 and to Mec:JJcare. However r our expersenoe under
the demonstration has been hit while premiums for tradlttona1 Medlgap benefits 81'8
reduced.' Medicare does nat ahara In, the savIr1gs.
"
The
reason for this apparent anomaly. ;that the tower Medlgap premItmi h·
·MediGare KLECT pona are "ellerally the r..yll ur flUlfplh:Ih;JlSQ'JUI1~ ~
rather than 1he ~. manag~ Of cart or the efRCiency of the SeLECT netWorks•.
The balic problem with Medicare SELECT 11 that there are Rmited incentives for plana
to manage tMJ tQtaI costs. As 8 ,ellA. Medicare d088 not participate in afTi~,
and beneficiaries do not receive the. benefits of coordJnated:·care that they would .
reooIY. in' offiokWIl f'Ietworks. In. fact, If ptOPQeel, 10 IDIp8lld'SELECT ~ ·10
Part B servIcea
.enacted. Mecicare costs WOUld actually;·incr...., as .pihysiciai\s.
1nCreaSe utHizatJcfl to recoup their di$Qounts.
are
. A ~ Iuue with. Medicare' SELECT deals with the Idequacy of b8ne&ciary
patectlon. w. fNf atrongty
IMneftc:Jariea should not hav. to wor¥y about ...
quafty and ~ provisions of Ihelr Medicare choices. W.look forward to ~
Mh the Subcarnrnltl8e on tN. inportanl.i8sU'.
"'et
.
We also hci)pe to "tit . . to workWith'the SUbcOri'll'nlttee.ai the PPOoPtioM In .
-.,.------~
,_ _ _ r.', ,.......
�ID:202-395-6148
.
FEB 20'95
21:09 No.001 P.O?
. .
the months ahUd. In.adcItion, given the impending deadlina far expiration of the
.SELECT authorttV and the need to, examine the c:Sir"noc lStratian experience before 1he
program is eJCPltlCled. to l1li states, CongrRl may wIIh consider a 6 monch
extension of the demonstration for existing pIIna. 1NI WQuId allevkde the unoer18intY
for existing plana. and' provide time to make approprtete ChIngta to SELECT baaed
. on c8nonItratJon upII'I8nca.
.
=
~ry~uodon
, .
. I
. we need to do a better jOb t!f informing 'baneIic:iaria about the managed care
and Medigap ct"oIoeI thatara aV81lable. The cu""" lick mInformation in the faDe of
. 1UdI. variety, (I·ChOICes generates c:onfU8IOn WhIch .,.-ks :agaInst managed on
optIone. To ~d their c:hoIcea. beneficiaries hew to negotiate th~
.
dlfferen6es in benefit peckages, cost-sharing 1tndU'. and premium amounts.
Beyond 1hI' nMCd for tnformation, benefic:iaI1e8 nalao ~ feced with enrdIrnent
oerfods that vary by plan "'d. In the case of Medlgap, with health screenIng enct
unct.rwriting. BerKtficlar;e, who initially enrOl In a· managttd care plan 10_ their one
tim. option for open enrollment An ~edlgap.
'
We wgufd:'lfke to do 1V8~ possible to make managed care optlonl':very
. attraCtive to ~8. We think we can do a ~ar Job of helping them to
und.mand the
~88
of 1hese pI~.
.
Quality' and Ma~g.. car.
Today. managed care OrganlZ:atlons'proyiding services to Medicare and MedIcIIcI
beneficiaries .,..:reQulred to have Internal quality 888ellment and Improvement
programs to ldtw.dIfy ways to tmproV8 the delivery of health care _Men and the .
. ealth car•. Itself. We also requi~e Independent extemal. review of quality of care
h
c:ieliverod to our be~foa.
HCFA II ~In; In collabOration with the industry on along term dcrt of
develOping. single. 98t of measures that could ~ UMd by ·all payers to addreu the
·fuR range of a ~ pian's membershIp end performance.
. The first phaae 'of this effort centers on major performance measuren I8I'1t .proIIgts
underway In both: Medicare and Medicald. Theae are,designed to help us develop
me.urea that are focused on the special need. d our dlvarse populatiot\s:
In MedIcaId. we· are ~lng oolleQgrattvefy with NatIonal Committee for Quality
Assurance (NCCA). State Medk:ald agencaa, consumer advocates and managtd care
organizations to "dapt ~ ccmmercl~ ~'~ stete-of·the-art performance
meaeurwnent 1DaI HECIS (HeaM Plan Emptoyer caw and InfOrmatiOn set) to the
needs of the Medicaid progr.",.
•
-_._--,--
�.
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21:09 No.001 ~.08
FEB 20'95
ID:202-395-6148
.
'.
.
.
We Chose HI=OIS as the tampa.. for our U.cIloard Ift9rt for 88Y81'AII'888OnB!
a
HEDIS Ie viewed by most of the Ieading·state navJged care progr.n. • "....
·rapproprille mOdel ~ Medtoaid. Some __ . . already adoptirV HEOIS. W.
feel
. 0
~
II Important to prcMde acme naIonIIleIdnhIp.·
,
we wn to ~nate With the privatel8Cla and take advantage of the .
elgnlRolnt III'IeIytJoaI grCM.lndwork eIreIdy produaed by NCaA. 10 . ' to .rnllI*lnIIttrrnt,.
••
potential rapcrtJng burdens on ouf managed care plans. many of whIah . .
&dopang HEDIS~ .
.
.,-oaoh
In Medicare, we are begfnnlng to pIIQt test • new,. performance baSed .
to
Revfe\tl OrganlultJon (PRO) ~CIW of HMO. developed under contrlC.lt Wlln·!he .
Delmarva Foundeltion. These measures reftect 1ha apeoIaI haaIth needs· of an eIdIrty
end d&abIed ~n. for examplel in, management ot chronic condJtions. Thes8
measures wUI them be oon~ed In conjunctIon whh the broader HEOIS Iffcrt,
Paef
. ".yment/COm.,.uuve BIdding
AI5 I Cfi80IIlSsed &batie, concerns &boUt the payment methOdolOgy for rllk
contractors has been long standing. Currentty. we 'deterf11lne rate. on a ytlJ'ly blats,
and plans decide whether or not to enter Into • oontraat etaet. year ~ on the' ......
These rat••, callad the Adjusted AVerage Per Capita Coct (MPCe). are deYeIopeCI for
.each county and ,are based on feHor-llfViCe
In the area. County rates are tIeri
adjwsted for age., aox. InltnutJonal W1d MedicalQ SlaWI; no aaJuaunent 18 made far
haaJth SfatU8 per.. Plans have been eoncern8d with the adequacy, ItabIIty nI
eqUIty of the AAPCC. Earty on. when Ibecarna Admlnistratcr of HCFA, I 1rMttd· the
Industry to come up with alternatives to the AAPCC.. We still have no algnfficant
com
aItaTrativeI.
One ~ that has recentfy reoelved ~dsupport and attention from
IndUMry. acacJemIa and commerCl~ payers 18 that of 'competitive bidding.II ' ..
proponents of competJtive prk:ing models claJm that'the methodology will
In .
payments that more 80CUfately reflect the true costs of doing business. in·addItIon to
,.wIt
promoting .CJffidency ttvough greatoroompetitJon 8lt'1OI1Q hoalth plans.
, We V'tfnk 1b8t this is a pr~iSing idea, and we would like to test variants of ft ..
demonstrations In a· number of geographic araas. In ordar..,for the den10nlb atIcN to .
be uaefuf, we believe that «mpetitivi bidding should become the payment
methodology fOr aI1 Medloal'$ ",;".ged CIte ~ In the d..-nonvtratlon...... ".
always. beneIIcif.Iies wIJ &tiD'have the ability to choose to ~ In managed en.·pIn
We would be Imerested In watkin; wtth the SUbconunlll8e
·on ... R'tJCSture r:I a competitlv, bidding den'lonstratlOn.
or ...",..., in ......kK-eet'Vk;e.
t·
•
_-- __
~.-.-e
,_ _......, .._ _........
_.,,_.~_
',t
�10: 202,-395-6148
ill
FEB 20'95
21:10 No.OOl P.09
lMPROVID PAOQRAM MANAGEMENT
.
,
M~ ger, options 'while of growfng ImportIInoe to the admintantlonOf tne
MedIoare ~ .e not the whole aIory. W. ere aodvely working to improve
management throughout the program end to make continued Innovations In the fee.
for·aarvica ptOgtfarn.
CUtIomtt '8eMc:a lniIIaav_
,"
under IN 1 dtr1hip of Presidant Clinton. VIce President Gore and S8Ctetay
..
Shalela. we at HCFA have fDcused our effonI en making sure that our nearly 10
million bet18ftcIar1iII '(Medlcar. anj Medlcald) rec:eIV8 the h8IItn care 1hIy need ~
they need It. ihIa me&na1hat bonefk:I.-liI corrMt Itat In .. thal we do. HCFA has
undergone sIQnIflcant hternal and external changes 10 Insure that the .~ first"
phHoeophy beOOr'neI. rf8lftY. Throughout the agency. we are working to ,inprove .
communications with beneftcIarIes .. wha1har ,It be one-on«18 in persoo.. on4Ine .
ttIr'cu8h the computer. ov. 1he I8lephone, hough our numerous pubUcaUons or
.
tt'l'ough the
med~.
'
.
.
'
The naU'I Of tI"Ie MedIcare progrem is sUCh 1hat there are numerous other
people and organizallons Ihat have do.... contact whh bene1k:lar'l88 than HCFA. They
... also our cuatomel'1l and our partnere In providing heaJth care services .. .providers
such .. hoIpItabl. nursfng
home IieaIlh agendes. phy8lciGne and ,medfoaI
SUPPliers; contractora (carriere and Intermedtaries) that process and pay Medicare'
~••' WId, Peer Awn OrganizatIonS 1h8t assure the quaJity of health an .viCes.
hom.,
. We have QaIIeIoped 8 sat of c:ustorn8r ~.
~.
thai appfy 10 our'
Interactions with benefICiaries and our partners. Th_ atancJarda apply to ell or our
~, claims processing actMtiea. cUstomer satisfaction, consumer ChOIce,
, health 'GOrO queIitJ f.Ifld P-oQ'tlnl! Willi JIItratlgn. rror. "Xllmpl" we are working Wftn, our
CU8tornet'S to mal<e.our publiCations and notJcIIlUier to undel'lta1d: w
...
sim~ng Medicare claims admjnlstrltlon,80 that clalma dmarmlnatlons will be more,
ccnlatent. W. ar. placing • premiLm on ,measuring and improving oustomet'
88tlsf~ tht~h.1he use of survay&. fcQJ. groups andmNtlngs.
also,~
that the, need for Integ",,"; deDvery· systems wiRbecoma more
and more crttlQal . ' our population becomes Increasingly dIv9rse and ~d.r with mere
cI"IrcniO care neecda. In erdar to meet theaa needs. It Is cIur that HCFA must maintain
a ~ f~ with Its penners In the, provider communtty and assist ,them
We
to Improve their focu. on customer servioe. Several sudl inltSadvOi are 8II'eI8Cy
underway. HCFA Is examining all cj the Jonrrterm ave services provided ,by both
MecIcart and Medioatd ald IS considering ways 'that 1I1ese servk:es can be baUar
, CICOI"dII"MiIled wtth one anocher Wld With the acutB. care system. A similar ravIaw' of
nome helfth car. progrllTlf has also been undertaken.
.
'f
- - _ _ _.. ,_, - ' ' ' - _....._ , , _ - - ' . "w._,_ _ _....
'
�1D:202-395-6148
Fraud
FEB 20'95
21:11 No,OOl P,10
Mel Abu. .
8'I8I1ing • Ihe Office Of 1he AdmlnlltratOr -.d • every level Of HCFA, we nave
e.aparded and strengthened our efforts to root out fraud and abuse agail'l$tMedlcare
end Medloaid end to vtgoroUiIy pursue thole whO cotnmlt such Illegal ectMtIe8. W.
operate In a pat1nerIhip, not Qnty with the Departmri. Office of the lnapeotor
General, but with the Department of Justice, including 1hI FBI, state and loCal law
. enforc::ement agencies. and our contragtcQ. Ft.rther. H(iprA IIInorNlln;ty 8X8rct11ng
Its 8UIhorIty to ..spend paymenta to prOYid11'8 and .uppU.... when eYidenoe of fraud
8XIsts.
.
.
In ~. HCFA Is nMawing and ChangIng progratnl:wd pone. . . . tiM·
been found l110It vuil tel IbIe to IIbwIe. For uarnpie, In ~ to bitter rtQ'lttbr fraud
.-.cf abuae rtllMed to durable mcdcaJ equlpmett (DM&). HCFA has changfd"
procedures for claims processing.. Four carriers are now responsible for DME claims
prOO8S8lng rather than the previOut 33- cattJera, ••~ whloh proYided OME
suppIIn OpponUnltlellO lubmtcc&a1m8 to the carrier who8e payment policy WBI'1TXJ8t
liberal. The new system of using four regIOnal carrlera reduc;es the chance'for
fraudulent bAling because 8U~.must 8ubmlt cIaJrna 10th,·carrier In the re;bn
where hi benetiOIary. teaideI,
"n'Ie use of more sophisticated data proc:I8S8ing sylltema, auGh .. the· MTS
eyatem, that I diIcussed ealiler, further incra" the chance8 of detecting aberrant
pal1trns Nt migttt indicate abusive behavior.. The MTS SYstem wll greatfy improve
HCFA'I ability to lCI'eert Medicare -'clajms for errors and freud,
.
IV. CONCLUSION
. For thirty years, Medicare has been in.llning the nation·. eIderfy and· di8abIed,
we know 1t'Om QUI' fOCUS groups, JlI10 11I1nk you are 811 aware frOm .tnteracuons wnn
your constituents. that beneficiaries feel a certain ownership of the program. ThIs
faaIing is justified~ Through their "payroll ~ionI and thole of their ~. .,
during their wor1<Jni lives. and through their own prerhlum,payments, benet'fc1IrIeI In
fact contribute 70 percent of their -insurance coati. W. went to work wJIh )Ql1O ·make
r_ponlilbl8 ~ In planntng'lIl8 neXl steps for U1e MurBaf ltE MedICare
program.. We look iorward to WClrking with thilSubcxmmittee 88 we expand·choIces
available to benePciaries without compromising quality, eOc888 Dr value.
�.Electronic Submission of Claims
Medicare vs. Private Insurance
"
Percent EJectronic
H
t::1 '
120
I\.)
o
I\.)
100
J
<.N
1.0
80
U1
J
C1'
......
60
.b
00
40
20
o
~
~;
~0
~~~
.
""~
#~ ..
~(J
~
."
;t!J:-
~~'
.~
~JJ .
.tI'
.
eft
,~t::J.
.~
...(1'
<f'"...
.
~0
q;,G
((}Cl
~
(J)~'
(TJ
to
I\.)
o
1.0
U1 .
I\.)
I-"
I-"
1994
Sowce: t-CfAlBPO; Blue Cross Assx.
......
z
o
o
o
P78 HCFACHl2
I-"
-0
I-"
I-"
"
�...
!
I
,of
The Composition of the Medicare Population, 1992
Elderly. Disa~ed and EE.1D
t-I
t:::1
IV
65-74 Years 510/0
o
IV
I
VI
U)
U1
I
en
.a:::.
.......
00
<65
(Disabled & ESRO)
29%
85+ Years
f1
rrI
OJ
IV
0
U)
U1
IV
Total Bereeficiaries=35.6 Million
~
Source:. HCFAlBOtJIS
P78 HCFJ'.CHT4
......
......
IV
:z
0
0
0
......
"
......
IV
�¥
•
•
J
.
.
Share of Program Expenditures by Income
. Of Medicare Individuals or Couples. 1992
1-1
o
tv
o
tv
$15,000 or Under
I
VI
\D
Ul
I
6~
en
.....
b
oo
$15,ooJ to$25,OOO 21%
!I
IT1
t.p
$50.001 or "-4ore 3%
25,001 toJ $50.000 14%
tv
o
\D
Ul·
83% of Expenditures: AI.lual
Income of $25,000 or Less
tv
.....
.....
tv
Z
&aides 2..2% mit repomng j 1'1C01'De.
Afso Exdudes HMO enrolees (9%}.
Sc:Ju1:)e: HCFAJOACT
o
o
o
.....
\J
.....
VI
�:SENT BY:Xcrox Tclccopicr 7021
1- 6-95
7:54PM
HEALTH CARE REFORM· WHERE IS IT? .
OUESTION:
Where i5 the Adminlstr3tion'~ reform proposal?
budqet7 How will you pay tor it?
thr
will it be in
i
ANSWER:
~
The Pre5ident is committed to working in a bipartisan
t3shion to begin putting America on thG road to' health
security. AS he stated in his Decembar 27 letter to
Congre5eional leadership, he believoa that we should work
in A ctep-by~ctep manner to. achieve t.heso goalll. In the
meeting with bi-partisan leadorship on January 5th he
aqain urged Congr~ss to work t0gethar to Addrco~
Americana concerns about the 5ecurity of their hoalth
care. H. will work with Congress a8 Democrats and.
Ropublioane develop proposals.
The President remains firmly committed to providinq
insurance ooverage for every Amerioan and containing
health care cost for families, bu~ine8ses, and Federal,
State and local govGrnments.
He has made it very clear
that h. will NOT give up the right for healthl!leourity
andattordable health care.
.
[on health care in the budget:) The bUdqe~ is thQ
and he will announce it at thG appropriate time.
[A
copy. of the
Pre~ident I
PrQsidant'~
e letter is attached]
A - 15
January 6, 1995
�94567431:# 3
, r 7021 ; 1- 6-95
''\ ~ SENT BY:Xcrox TcicCOP1C
7 : 54PI-I
..
TH.~
wHITE HOtlSE
.....ItUI'fQtClN
,
u'l&r Nevt t
ve .~Qu14 ftot achievo ~~I~.Da •• a agreement 'on A nl&l~n
1"1titt!~e ll'~ year, thc~o ~4n ~e,li~tlc d~iig~oemon~
that ~••till fael,t~1 onQrmo~! prohlem. of incre.g1n~ health
ar., c:o.l:a 4nd. 4Gcrudn,g ClQvulge. WI naeC! to eoaf:cnt these
)
roblema en 1 eipartiaan ~&.i. ano .d~~e~~ the 1neecur1ties that
00 ftlAny ARluiclnS 1\lv, abcti: cheir t1nlth en..
:t 1111 ,.,d\;Lng
~~le
re:crm
~
,0
AU.rata ro.y,ltt'cmg de81ra
tOlrlCr);
with
Y0\l,
11:1
thU ra~:..rc!.
~cnw~tt'c1 to provi4ing insuranc:t ccvuagefcZ'
an4'eoneain1ns b.&l~n care COle. :cr tami11a~,
U81ftlaaa., &ad r~Qe~.l. Stat., .~d lo~&l ~.rnme"ta. In ~ho
poeming e•• ,~cn of Coftgrl•• , WI can 'nd anou14 work togQ~h.r to
aXI chA fi~.t .tep. tcvarc! aehiev1ng ;h.'e goall. we cln pa••
e;1.alat1cn l!hat. i!leluc!t. ",... ~re. coo aw.... tM 1.1ntdrne" 1n
he in.~~an~e mi~kGt, matt ecvera;. mo~8 aftordlbl~ !O~ yo~);ins
k remain
firmly
av.~ ~er1Q~
.1I\1n quallty &ao 1:!!i,iencY in thl
ano Meci1clid pre~r~, &no t~Q~~' the loa~-~'rm pod.4al
'
.
am111eland ehil4reZlo,
ed1e&~.
.£i~lt.
• leek forward ~o t&lk1ng w1tn you ift tho ~pooming WeekA
o~t a bipa.t184n .{tort to 4el1vo. health oape ?fc~ to the
"ice pUblic. U1UIlry &nd I .eno ou but wishua for .. Uti
d. ha.ppy hol1d.J.y U"Oft.
I'
',inc.nl.y,
~'C~'L-~
\'
\
1h. Honor~le
ijou••
'----
Nawe
Qln,~i~h,
o~ RAp~esantat1v.a
If&lh1n~Qn.o.c. , 20$15
�94561431:# 4
, ~
~
!
SENT
By:~crox
..
TclccOplcr
1021: 1- 6-95
1:55PM
HEALTH CARE REFORM - EXPANDING COVERAGE
.You say you want to expand coveraSQ. How will you pay tor it?
Would you support Medioare cute to pay fOr coverage
expansions? particularly .for children?
~
The Administration remains committed to expanding
coveraqe for all Americanll, including children. As you
may remember, when we sent up our bill last year we
provided run4inq to pay for it -- we want to work this
year to oontinuo to search for solutions aDd .e will al.o
VI-At to ahare .:lll the t.spous1bllity of idtUltityiftl1the
r ••ouzae.to pay for it.
As far as Medicare outs are concorned, let me reitorate
what the President has Gaid
he will not support the
use of any new Medicare savings outside the context of
health oare reform.
~
Once we all have a better $en~e of what kind of coverage
expansions we are discussing and what other options might
be there tor tund1ng then we all can digcUQ~ which
options may be the m05t suitable.
FOLLOW-UP QUESTION:
Will the President insist on univQrsal coverage?
~
II'
The President is committQd to providing 1nQurance
coverage for every ~erican and containing ·health care
costs for families, businesses, and Federal, State, and
local governments. He believes that we ehould work
together with Congress to take the firat steps toward
aohieving these qoals.
'together we 'can work to pass legislation that 1ncludQs
measures to address the unfairness in the ineuranc8
market, make coverage more affordable tor working
families and children,· assure quality and e!!1c1&ncy in
the Medicare and Medicaid programs, and r.duce the 10ng
term Federal d$ficit.
.
A - 16
,
January 6, 1995
�·\ ~ SENT BY:Xcrox Tclccopicr 7021
1~ 6-85
7:55PM
84567.4 31 : # 5
LONG TERl\-J CARE • T.AX CREDIT
QUESTION:
The President has 8aid noth1nq lately aboutlons-term care.
Would you 8upportthe tax credit tor carlq1vera wo propose in
the contr~ct? [or--have you abandoned your so-called
commitment to long-term care?)
ANSWER:
..
~
Thi. AClminietrat10n continues to support alllsillltance to
states to develop home-and-community-cAro ~ystema that
help people with substantial ~isabilities, req3rdless of
ago or condition; strengthen families' ability to c~re
tor disabled family Ulemb8rsl ~d allow atatoQ the
flexibili'ty to tailor servioes to their pattlcu13r naedc.
we are delighted that .the Contract too r~coqnizes the
importance Of addressins our citizens' long-term care
needGi. We lihar. the Contract's interest in .xtending
preferred tax treatment to long-term carQ insurance. But
we feel 5tronqly that insurance should inclUde
. information and be marketed in ways that helpaenior5
understand tho benefits and limitations of insuranco
policies.'
.
(It Mrs. Johnson or another member shouldaek about
requirements for insurance policy, answer should
be: We'll be happy to work with you.)
~pecific
~.
We too ahare the Contract's concern about helping
caraq1vers. However, we believe the propoaed tax credits
lUay not be 'the best 'Jay to targot limitlid rGiBOUrCes 'to
oaresivers end their chronically 111 family lllo.mberl5. Wlil
th1nx a bettor lpproach to helping these Americans would
be through grants to Stateg for ~ervice5 tailored to
oommunity needs.
(swn.mary of lonq ter:m care propo15al5 within the contract With
America is attached]
A - l7
January 6, 1995
�94567431:# 6
. 7Q21
".' SENT BY:Xcrox TclccOplcr
i- 6-95
7:56PM
i~
P!uy1IiW:
nere are two propoala tor add.re&'stna loftl term care Deed.a:
•
•
A s"OO a year refundable taX crcd/., for taXPayers who haw :l patQllt or &ralll1parent with a
dlsaoillty living with them 111 their AO=el IDd
A IIIO<1lficat1on of the tu code to pcrm.lt t'avo11ble tax tre&tmcIlt for privlIIO 10112 term ea:t ..
~ pCCllliums.nd
expe!ld.iturlS.
The retwuiablc t.u crc4It Is probltlDlUot
•
The credit Is ll.%l:lltcd to wG w:payon who have ~ par=£ or &nndparent living with them. It ' .
provideS no Wlstanee to older people: livllJi Ilene. to the milIlona of IpOUles WhO 110W care
for a dia&blcd wife or husband, or to the ;&ropv", of disabled chUdren aDd. young adWI.S. :
•
The benefit Is roo small to provide ~ assistance to the fatDilla or old.er peOple with
slgnltic:a.tlt d.babUltloa. who are srruasliDg to· cue for thcl.r loved ones without lIDy help.
The Adml.D1straUoQ c:ontiDues to ad'oeate ror I
pSded by tht toUowtu, prtadpla;;
.•
•
DCW
lODg term care proara= or grants to states wbleb Is
Pcoplo with .ieDifiant disabillu03 IDd their !mllics lbDuld receive 10115 tc:nIl
bIMId on Ihclr nccll /lot on tbcIr aae or ci:lMit!O/l.·
,
C&rC
assiJtance
TQ c:ompltQlC!U aDd I~eo. the Wonnall:aI'O givinl I)'stem we l'.Uust tltl4 wayl to make
wi community long term care aenrlcosav&llable ill every Stale and eomr%lWllty in dW
country: To maP lhia happen we must work in par'ttUIf1hlp with govetnDlOll( II allleve1s aut!
heIDI
wllh me private ~ot and voluntlQ)' &X01lp&,
'.
Public funding fot 10111 term em aIlowd be hlghly Gulblo 110 th&L ,lata and COmtl'lunltles c:aA
tailor !he 4eai&n of th!lr .ervica d.cUvcry I)'au:ml to their UlIique nteda 8AQ ~tanCOII,
Printc louatn c:ar"8liLNruee proposal Dads ImPl"OVfmfllltt
•
. Th1s proposal iI.vary aJmilar to the ad.ml:datraLloc', proposal, We IUpPOrt the IltJfId for
"
nuwtvcr, ..~ bc:J••" t.1:.e:. ~ ~~ pcu \[~ or J;4:.±oi p:!;.;:,e !,,;:.,t 1tr'Q ~e lJj,ltiIiI.llCC
favorable tu ttea1t!ICnt lathe .l4bliahmcDl of SOIIlll m!Jl1murn ~t protcc;tiQtlS ,
taX
Clarifications 10 thal private lOIil termc:.ate inl1.ltaIlce aM prlv&Ull~ !CrIll care ~
cau be dedw::u:d WIder the tI.X code hi the aamcrway tlW medical ~ c;.&ll be dcductcc1.
�9456H31:# 7·
. '<:' SENT BY:Xerox
Telecopi~..r' 7021
1- 6-95
7:56PM
ERISA - PREEMPTION
As you know, 8tate~ are limitad in their ability to pursue
health t:-aform because of ERISA preemption. What i8 your
position on giving states greater tlexlbill~y over employers?
•
states have taken a leading role in health care reform.
They should be encouraged to continue their efforts to
incr.iue coverage. and contain health· CClra COQts. At the
8ame time, ERISA has permitted laros employera to develop
innovative health programs, free from sta~e mandated·
benefits and anti-managed. care law".
•
We are currently evaluating options on the bast ~ay to
proceed in th1s·arQa. We look forward to working with
you on this important issue.
A - 15
January 6, 1995
�94567431:# S
'I;'
SENT BY'Xerox Tc I ccopier 7021
WAIVERS .. MEDICARE SELECT
t.
He.dicdra Select has been succeSsful in l'D.i!lny S'tates. I t
~bout to expira.
would you ~upport not only ita extension but
its expansion to all 50 St~.tes on a permanent r~th.r than a
demonstration b~sig'
'ANSWER;
~
While wo believe that the SELECT damonstration has baen
successful on 4 number of fronts I we believe that boforo
the proqram ia mado per~anent and expi!lnded to all SO
ati!ltee that we should laarn from our oxperionc::e unda,r the
demonstration dnd maXe ~ number of program changes.
We should ba assured that SELECT plans are actively
mana9in9 care and that bonofic::iaries have tho $~me
level of assurance as to the quality ot care and,
access to care that they receive under the other
Medicare ~4n4ged care options.
Por oxamplewhile Medicare SELECT plans are required
to havQ procedures tor evaluating quality and takin9
corrsct1vA actions, th&re is no atter tho ti!lct
determination throu9h Qite visits that the 'plan has
tolloved tham or that they are effective. While we
'roquire that other Medicare managed care plans have
'active quality improvement committees that collect,
analyaeQ and aot on ~ata there iQ no such
requirement for Medioare SELECT.plans.
We look forward to working with the Congree8 to learn the
lQseon from the SELECT'demonstration and to make an
improved SELECT option availahle on a permanent basis in
ail states.
~
In OBRA 90 , Congress authorized a 3-y••r demonstration in
15 atataB tor the sale of a hybrid managed care/Medicare
product oall Medicare AEL!C~. Unlike other Medigap
policies vhich pay benefits vithout regard to where
servic::e5 are providad, Medicare SELECT polioies may limit
benefits to services provided through tha plana'
preterred provider networks.
The demon~tration woul~ have expired in December 1994,
but it was extended for 6 months in the Sooial Seourity
Act Amendments ot 1994, signed into law on October 31,
1994.
1;. - ,19
,january a, 1995
�...
9456H31:# 9
. : SENT BY:Xcrox Tclccopicr 7021
Many mellLbers of Congress support: making
it a permanent,
nationwide proqram; such a provision ~as included in
lIaveral health care reform proposals. However,
congressman 'Stark oppo~ed it. The 6-month extension was
• oompromise to buy additional time to decidQ what to do .
about a program with strong supporter5 and detractors.
A - 19.1
January
(i,
199~
�B4567431 :#10
"
SENT By:Xcrox Tclccopicr 7021 : 1- 6-B5 : 7:58P~ :
WAIVERS - SAVING MEDICAID MONEY?
What are you doing to save money in Medioaid?
~
To da~e, nearly e million Medicaid beneficiaries are
enrolled in managed care plans, which is approxima~ely a
40 peroent increase in enrollment over ~h9 past yellr.
Since, January 1993, HerA has approved SO state
applioation. to establish Medicaid managed care programs
and 18 more appiicat10ns are under rQv1e~. Through the
8~ansion of managod care, savinga will be aChieved
t.hrough et'.ticient program manaqement, foous on primary
and preventiveoare and effective case management. of
Medica1d henefioiaries.
As more st.ates apply and are approved for waivers, HCFA
has Sf:J.t a hudget neutrality cap tor thetive-year lifo of
tho project. This means thet states must stiok to their
projected bUdget and the rederal budqet i5 protectGd from
any unanticipated increases over ~he lifo of the,waivQr.
The end re5ult is savings for the state and the federal
governm.nt if the waiver is managed efficientlY.
A -
20
January 6, 1995
�•
'. SENT BY:Xcrox Tc Iccopicr 7021 : 1- 6-95 ;, 7: 56PM :
..
94567431:#11
MANAGED CARE AND SENIORS
Would you support moving seniora into managed care programs?
Isn't that the· best way to promote efficiency in the Medicare
proqram?
[CONVERSELY" you could. l:le,askAd: How do we protect 5eniora
and other consumers from being forced. into managed care, which
may not be in their best interosts?]
,ANSWER:
II>
This Administration has alwe.ys supported choice. There
is no question that managed oare is 'Workinqto keep costs
down while keeping consumers happy and healthy. Sut
While I support man~qed o~re, I also strongly beliQve
that consumers, 1ncludinq seniors, need to have the
choice as to whether or not to jotn a managed care
proqram.
'
As affective aa managed care can be, it is not for
everyone. As Chairman Archer said to me in October 1993
when I teetitied betore this Committee, thetreedom to
choose one's health care providers,is a "very, very
special ~reasure to AmericanQ today,ll, I could not agree
moro, and giving Americans'of all aqas the ability to
choose their health plan guarantees ,that choice.
11>'
seniors are increasingly
of It per month.
choosln~
A - 21
managed care at a rate
J'i'1nuary 6, 1995
�·
94561431:#12
.
SENT BY:Xcrox Tclccopicr ?021
MANAGED CARE AND l\fEDICARE
What is th. current statue of. manaqed care programs under
Medicare? What specifiC things can We do to promote managed
oare in the Medica.re program?
)
~
As of September 1994, nine percent of oar Me~icarQ
benoficiaries wore enrolled in managed care, which 18 an
increase ot l~ percent over the prevIous year. More
importantly, the number ot plana with Medicare contracts
increased by 2~ peroont. 50 clearly, thie is a' qrowing
asp.ct of tho Medicare prcgram.
There are many ways, either throuqh legislation or
r~9Ulation, which wa can expand and improve Modioare
manaqe~ carQ programs, inCluding:
Our prosent payment mothodology needs to ba improved
and updated, the Department is currently examining
the possibility ot using .a competltiv; bidding
process ~~ establish payment rates.
We believe that Medicare SELECT is a promising· new
option, and would like to work with you to find way~
to expand that program.
.
We nQed to do a. better job educatinq Medicare
benefioiariea about managed care. Current choices
between managed careoptione And Medigap can be
oontusing, .and we'd 11):e t.o move to an annual open
enrollment prOCQse to make these choices more
understandable.
A - 22
January 6, 1995
�,
.,
84567431:#13
'
702 1 : 1- 6-95 : 7:59PM
SENT BY:Xcrox Tclccopicr
MEDICAID ENTITLEMENTtnLOCl\, GRANTS?
Should Medicaid be an ent1tlQmcnt'?
about m4kinq Medicaid a block, grant?
Why
What 0.0 you think
ANSWER:
~
We are committed to protecting thepopulationssrvQd by
Medicaid, While working with states to promote cost
containment and tlexib1lity within Med1caid ' s current
entitlement ~pproach. That approach ae5ure5
states that tederal matching funds Will be availablu
to pay for the health,care. needs of thGir VUlnerable
cititens,so that. they do not llear these coste on
their own;
providers that they ~ill be paid for care to
vulnerable populat10ns~ so that they do .not ~ave to
shirt these cos~s to other payQrQ; and
low income children, pe.ople with diaabilitie.s and
other VUlnerable populations 8CCe.S~ to health oare,
80 that they do not have to go without needed
service.
A -
23
January 6, 1995
�94561431 ;#14
.• " SENT BY:Xerox Te Iccopicr 7021
1- 6-95 : 7:59PM
MEDISAVE PROPOSAL
.QJlESTION:
What i. the adminis~ration'e position on
introduced by chairman Archer?
.
•
~h9
Medisav8 proposal
We support many of ~ho ~oala that underlie MSAe -- we
wan~~o encourage families ~o save moro ana we want to
make the health inaurance market more competitive.
However, we have looked at a number of MSA proposals, and
we are concerned that they could cause serioue problems
in the in.urance market because they mOVe away from the
concepts of pooling ot risk and shared responsibility.
Unlo8G we are careful, we could undercut many of the
insurance market reforms that states have enacted.
'rhese propolials could cauas premiums to increase for many
Americans.
The combination of an MSA and a l'1igh
deductible insurance plane will b~ much more attractive
to younger and healthier families than it is to older or
less healthy·oneal. This would load to adversQ selection
-- premiums for young and healthy people that are ~illlnq
to enroll in high deductible plans will tall, whilo
pramiume for everyone else will ri~G. Ri5k adjustment
oan help some, but they ~re impreCise and would not
eliminate effects or selection.
I know that these propoGllh also raise serious questiomi
related to Administrative comploxity, budget neutrality
and tax equity. 'rheee issues are better addresses by tl'1e
Tre~~ury Department.
A -
24
January 6, 1995
�01,56H3' :#,5
,
'
, r 102'
" ." NT 13Y:xcrox Tc\ccoptC
SE ;-.
~C-22-19i4 . 1S:B2
"i!Iy\lU
,_ 6-05 ; 8:00P~ :
tlQSTAl< tU.l C'I'
,
IQJ OOS
'492 5i2 f1?64
P . es--e6
)
Mcdlc::al Sa'fblp A.ccaDUU
N&~
'Qru;luslpos,
•
Medial Savin,s AccaIUI%S (MSA,s) are po1ltblly appel&&.
•
MSAs may have In adV!t'lt ef!'= OD tha btalib ~ mubL . M a ~.
premiums Of the lUi healthy \\IOuld rise,. ~ pr=tums of ~ hc.althy 1l'out4
faU. '
•
liealth ,.rorm proposals by Dole, Chifco, !.ru:be1. Samctum. and Gcpbatdt
Includ. variants of Medical SlVL=gS, Mcl'll2cra (MSAI). "l'hco, J3lW:1 A4m.b\i.stn.tiO'l1
worked \IIi~h several membtrs of C~SlIO'tlUds'developi.q'lI.D MSA ,proposal.
Miny Rtpubli~ and. loma Democrat!! u.yor WSAl. n. Health Seeurlty Al;t
did nor inelu~, MSAs. but 1M propostl IpProvc:d. by'the Wa)J Ill4 Moaris
Committee did.
"
,•
MSA prcponls allow wtpayers to 1'11C:C t'wld. in lipcQal t:U.-prefmcd atCOUl11.
Funds from MSAs that are used tor IPCdftc6 mc4i.c:&l purposes arc ugt \Ue4,
'while runes 'used rer other purposes mlY or may =at be mxed ~ upon thI·
. proposal.
"
or
•
.The iftt:nt an MSA i.S to ;nc:ouraac employers e.ci employoeS to JWirdt Cram
"cnmprchcnslvc" health insurua te -tat.l.SU'Oph1c- PI~5 tha.t have b.lchet c;oa .
payments and deduc1iblu. thereby livia: employeec tn lnceD1ive to reduce
unnecenary mel1ical CUI.
.'
•
In glnerll~ MSAs 1:01.116 provld'e & mechanism for tIX-prefe1l:'Ot1 Avina for healthy
individuals ....hlle Qluslns pret!\iwns tor lKi hetlthy 1n~vidUals to risl, Advtnc
s.:lc:t:tlon m1Y, r"ult 111 huhh)' and upper i.r.II;ome lndMdllli.ls jolu1ng MSA.t,
k:1"ln~ less heahhy and lower income. iD4lY1duals in tht more cornPrcMus1ve Pee·
F('r..Scrvic\: plw and HMO pl,..al. A'i a rtWlt. ~remluml of tbt leA bWth)"
~I.·"uld riM. whil, 'I'Cmi~lTLs at the heAlthy would fall. 'Ib1s idod or refCC'lll woyld
.unutrminl tommunit)'-t'&tin,. RisK-adjusters Illd taXq cwld be dcvbed to ~uco
the~ efT,'l'. However. Nk adjuster1 a.rc impr=d.se: 'would be dif1l.eult to do
~~>n"eelly~
:tnt.! wO\lld be lIiowcd lS'ldrolni,rtr&tivdy bun1ensortlc.
�94567431:#16
:Xcrox Tclccopicr 7021
199~
.\
1- 6-95 : 8:00PM:
lSlill2
•
~~2 '2::1 8'78.4
P . ~/0G
IR3 Tp')( P!l....ICY
MSAs would
~\lg:
inluranca prenUutl'l.S
tar pal11ciplJ1.DI but expose them to
1a.r&er out-or·poekct costa. Some individuals who un~pa:tcdl)' bt".eOrne _
flnd thel'r\stlvw.s shon of f'wIdsta cover tl'Ielt medical ~sc:a.
mlY
•
A lbnd study of heaJth inlunnc:e. condud!d in ah~ 1910's, IUJPItl mat if an
individual switches ~m , pllll with & 5200 deductihle to a. plan with a 52,000
dmu.ctible thu IndMdlJll '!"Ould, reduce !a1'Jl bealth oxpcndlw.ra by 10 pcr.e1\t.
Tcm pc:rce.nt t, In upper' boun4. Bcca1& mete would be no av!:lgs for
nonpcnidpuus and, for rhoce who I~td\ tram COlt eiftctivc In(Os to MSAS,
IIlre,ltt savinls \ItOuId probahly b. mud! tower tNn 10 ptrcecLt.. daplnding
upon palti~patiQn. (Soma people outsido the AdmirUnntion lI\&y boUM that
cost SAvin,s loR ,realer than 10 pcn:cnt. but lOme ,pa.rtic!PUlta in the NEe
meedn: btUcve ",vines ue close to zero.)
•
Greater p:uti=ipat.ion in caculmphle plans wowd rtduCe costs icm.awhat.
Howev.: thm art bcu.er ""'.YS to eneouZ1gG rM usc of QWU'Ophle pb.Da, Th'-SO
lneludt: (1) ,t.u. QPS on, co-pa.yments ind dcducdblca; or (2) expanded
dedUCtibility or medic:&l coxpcnscss. Other health in'~cc market retorm& mi,bt
also be (1esilned to encourlic l:a~trOphle plans or cost containmant: However,
c:ost containment will rdU be dimc:ult to obtain.
'
•
fo~, thoy should be c:arefully dc:signed to red~
.tfe:u. Diffetlnt ),{SA 4c.sicnl tc:aC1 to d..i.ffe.ront mqnitudO$ of ct!ecu.
, O~i,n (catu.res, to be coaafdBrCd indlldc: (1) lim.lts on ccl\uibutiolUi (l) tax
. treatment of caminc! in the funds; (3) Urnh! on and taX trea.tmeat of withdnwals
for n.onmcdic.eJ purposes: and ('> tigh1cninl tho definition of medleal wtUlclr&Wil.s~
"The limits ilia othor dcslgn fe:a.tUrel sb,?uld depend to some extent on OUlct MSA
desicn featurc.s Sl.ldl as risk l.Ojuston.
•
rf MSA proposals 10
adY~K
I
.-.
e
5
2
&
�THr. SECRETARY OF HEALTH AND I-iUMAN
SER\I!C£~
WAS",,,,CTC,.'1.0.<:' ?0201
March 7,1995
The Honorable Bill Archer
Chairman, Committee on Ways and Means
House of Representatives
Washington! D.C • . 20515
I"
Dear Mr. Chairman:
This letter expresses the Administration's views on H.R. 483, as
reported by the Subcommittee on Health. H.R. 483 would make' the
'Medicare SELECT demonstratio'n program permanent and extend it ~o'
'all 'States.
Our experience with the Medicare SELECT demonstration should be
part of the effort to improve current and future managed care
choice~ under Medicare.
We have previously made' available the
case study portion of the Medicare SELECT 'evaluation. Other
pieces of the evaluation arestil! in process; these include a
survey of SELECT .plan enrollee satisfaction and an analysis of
SELECT enrollee utilization experience. Preliminary results will
not be available until the later part of this summer. We believe
that Congress would benefit from a review of the full evaluation
results before beginning the deliberations on Medicare SELECT as
a permanent program.
The case study portion of the Medicare SELECT ev~luation has
already raised a number of questions about· the Medicare SELECT
demonstration. As managed care options under Medicare are
expanded, we want to ensure that our beneficiaries are guaranteed.
choice and appropriate consumer protections. In addition, many
of the SELECT plans consist solely of discounting arrangements to
hospitals. We would be concerned if the discounting arrangements
under Medicare SELECT were to be expanded to Medicare
Supplementary Insurance (part B) services. Discounting
a~rangements, particularly for part B services, may spur
providers to compensate for lost revenues through increased
service volume. Consequently, we are concerned that such an
expansion would lead to increased utilization of part B services,
rather than contripute to the efficiency of the Medicare program
through managed care. We 'Would therefore oppose such a·change.
�."
Page 2 - The Honorable Bill Archer
Gi~en that the Medicare SELECT demonstration is under ,an expiring
authority with an impending deadline, the Administration supports
a temporary extension of, the 15-State demonstration.' Such an
extension would provide sufficient time to examine what we have
learned from the demonstration and to make needed changes to
SELECT based on our findings.
We are committed to working with the Congress to improve and
extend the available choices to Medicare beneficiaries so that
.they have the full range of managed care options enjoyed by the.
general insured population.
We are ,advised by the Office of Management and Budget that there
is no' objection to the presentation of this report from the
standpoint of the Administr~ti
�Extendinq cur'rent Mldicare Policies
o
The President t s FY 1996~'budget proposes. to extend four
current law Medicare provisions.
+
o
These extenders are provisions that are in effect now but
are scheduled to expire unless they are extended.
+
o
f
1n
th~
Inclusion ot these extender provisions in the budget
will lower the projected FY96 outlays by $140 million,
and the to~~l FY96 through FY2000 outlays by $9.8 bill.
We are concerned that new Medicare cuts outside of
health care reform will impose new costs on
beneficiaries and/or reduce provider payments inducing
them to refuse to taka Medicare beneficiaries, both
without providing additional health· security to those
on Medicare.
'
The President's budget uses the savings from the Medicare
extenders for deficit reduction and explicitly not ,to
finance the president's middle-class tax cut~
+
a
s~ike
The President does not intend to propose any new Medicare
savings proposals outside the context. of health care reform.
+
o
without extension, there will be an upward
Medicare spending baseline.
These extenders do help reduce Medicare spending. But they
are not new Medicare cutSt rather these are policies that
are currently part of .the Medicare program.
+
o
The budget contains DQ new Medicare savings proposals.
The Administration's proposed tax cuts of $63.3 billion
from 1996 - 2000 are financed by $80.5 billion in
reductions to discretionary programs. In addition,
$26.2 billion in savings from the second phase of
reinventing government, $37.4 billion from mandatory
programs, as well as other,initiatives will produce
another $80.6 billion in deficit savings over the next
five years.
Specifically, the extenders cover:
'+
+
Medicare Secondary'payor protections which allow the
Medicare program to collect payments from primary
insurance sources. These expire after FY 1998.
A provision that maintains the Part B premium at 25
percent qf program costs.
This expires after 1998.
�. ·,.
)~
,
page 2
extending current Medicare policies
DRAFT
+
A provision that makGs permanent the savings from a
two-year temporary freeze on payments for skilled
nursing facilities (just like all other freezes in
Medicare have worked). This"··expires:' after FY95.
+
A similar provision 'with rGga~d to home health
services.
\
'J
�:ources of Funds
i\'lcdic~re
Receipt Proposab
Illdin'rt Errect.,
Mcdicare
Oil
Herl'i"t,
S~\'ings
i\lcdicaid 11511 Frce?e
Medic~id
Offset
Uses of Funds
Kids Prol(r:lm (133'10 - 241J';I-,) +
Temporarily Uncrnplo\'cd (100% - 240%)
6.7,81
FQHC
Expaf1.~ion
Erfect
Oil
!'vledicare/i\ledicaid
l.oflg-Il'rm CaI'(' Progral11
Long-term Ca re Ta,
ell" ngl'S
Self-employed T:1.' Decluclinn Phased to 100%
.~\
',·1
\
. WHI
I !.3
12.0
12.8
I ~.6
1451
36.7
5,J
5.5
5.9
6.1
6.5
7 I
19.8
6Jl
68[
5.1
57
5.6
6.1
'u,
02
0.2
0.2
02
0.2
02
n.1
0.1
O.l
0.2
02
0.2
u
1.5
J .6
1.6
1.7
IR
0.2
0.5
OJ>
O.X
0.')
1.0
0.5
0.9
I.~
20
2.2
2.4
00
6.8
9.4
10.0
00
0.0
0.0
0.0
3R
JO
5.2
4.2
101
0.0
0.2
0.2
n.2
III
00
01
aI
121
o.n
0.0
111
0.0
I dl
0.5
Subsidies for Kids (net or ki,h ill TU Program)
Subsidics ror Tcnl(lorarily Unemploycd F~rniljes 91
Puhlic ""-altl! Se~\'ic"'FQIIC Expallsjoll
10.6
0.0
16.9
50.7
50.1
021
1.0
2.0
0.2
OJI
O.S
1.5
I.S
1.9
2.01
6.2
15,4
1.1
1.2
1.4
1.)1
30
92
2.7
30
1.2
3.51
7.5
22.3
7.7
�·s
DRAFT
Footnotes for Package Three - No Tobacco Tax
I estimates are preliminary. Totals may not add due to rounding.
Ie both Sources and Uses of Funds appear in this table as positive numbers, in the budget, Medicare and Medicaid savings would
be indicated in negative numbers as reductions in outlays .
. Similarly, the cost of the self-employed tax deduction would be indicated in negative numbers as a revenue loss. Increased receipts
would be shown in positive numbers.
Administrative costs have not been estimated.
II
21
Includes income-related Part B premium and extension of HI tax to all state and local employees. Includes effects on Part B
. take up and utilization of services. Estimates from HCFA:iOACT and Treasury.
Indirect effects on receipts of the kids subsidy. Subsidies for unemployed cause a negligible effect on receipts under standard
assumptions. Includes on-budget effects only. Estimates from Treasury.
Estimates from HCFA/OACT.
41
Includes 25% behavioral offset. Estimate from HCFA/OACT.
51
Medicaid offset reflects savings to Medicaid as a result of Part B savings. Estimates from HCF A/OACT.
61
These estimates assume some employer or employee dropping of insurance,
revenues.
71
Also assumes that kids and families with access to employer contributions of 50% or more arc ineligible 1'01' subsidies.
Assumes 100% ESI takeup for unemployed program. Assumes durational effects on health insurance subsidies.
February IX. 1995 (.1:40pm)
""
ch would
jn small, increased tax
~'
�\:.
DRAFT
8/
Assumes that unemployed compensation is included in income determinations for the unemployed program. Eligibility for
subsidies based on monthly cash income. Basing eligihility on annual cash income would reduce costs and coverage.
Subsidies to unemployed individuals will have an indirect effect on.the unemployment insurance (UI) program. Such an
indirect effect is estimated to increase the cost of the UI program by approximately $2 billion over five years'and $3 billion
over ten years (net of offsetting UI reccipts).
10/
Estimnle from HI-IS/PHS.
111
Estimate from HCFA/OACT.
12/
Grant program to states to expand home & community-based services for disabled individuals. Estimate from HHS/ ASPE.
3/
] 4/
Includes !ong-'term care insurance tax incentives, personal assistance services tax credits, and accelerated death benefit
changes. Estimates from Treasury.
Five and ten year totals include $0.5 billion cost for self-employed tax deduction in FY 1995. Assumes that self-employed
must provide health coverage to their employees in order to claim a deduction in excess of 25%. Phase-in: 25% in 1994/95;
50% in] 996; 75% in 1997; and 100% in 1998 and thereafter.
Five and ten year totals
8, 199:\ (I AOPll1l
ude $0.5 billion cost for self-employed tax .deduction in FY 1995.
\
�. ":,
DRAFT
Possible Sources and Uses of Funds - Package One (Phased-in Tobacco Tax)
.
J
\ 11)
Fi,cal Ycars. Il illions of Dollars
lUrces of
II
0.0
0.0
39
54
5.4
54
5.:1
5.:1
6'1
(,.R
671
20.2
50.8
,\edicarc Receipt Propos:"s
21
0.0
1.4
2.7
2.(,
2.6
2.<)
1.2
3.5
.1~
:L2
,1.61
11.3
31.4
odin.'d Efft'c.:t.... on i{t,t'l'ipts
11
(j,n
(lO
0.1
0.2
0.2
0.2
0.2
0,2
0.2
0.2
02
0.7
1.9
27.1
115.9
8.9
35.9
0.0
0.5
36.7
100.8
Oh:H"f(l
Tax (pha.'.:t'd-lo)
1
2351
\iedicnre Savings
41
0,0
0,8
4.0
5.4
7.3
9.7
125/
14'.8
17.5
203
\Iedicaid [)SII Freeze
51
0.0
0.6
1.1
1.7
2.4
), I
3&
. 4.6
5.4
6.2
.\ledicnid Offset
61
0,0
0.0
0.0
0.0
0.0
0.0
0.1
0,1
0.1
0.1
7;8,91
0.0
0.0
6.8
9.4
10.0
10.6
11.3
12eO
12.8
. l3.6
Subsidies for Kids (net of kids in TU Program)
Subsidies for Temporarily Unemployed Families 101
00
0.0
0.0
0.0
3.8
3.0
5.2
4.2
5.3
4.6
5.5
5.1
5.7
5.6
5.9
6.1
6.1
66
6.5
7.1
68
7.7 1
19.8
16.9
I II
0.0
0.2
0.2
02
0.2
0.2
0.2
0.2
0.2
0,2
0.21
1.0
'·121
0.0
0.1
0.1
0,1
0.1
0.1
0.2
0.2
0.2
0.2
0.31
0.5
III
0.0
GO
1.5
1.5
16
16
1.7
1.8
1.8
1.9
141
0.0
0.2
0.5
0.6
O.S
0.9
10
1.1
1.2
1,4
1.5
3.0
151
0.5
0.5
0.9
1.4
2.0
2.2
2.4
2.7
3.0
32
3.51
7.5
:~l
)ses of Funds
Kids Program (133%·240%) +
Temporarily Unemployed C100%. 240%)
Public Heallh ScrvicclFQHC Expansion
FQHC Expansion Effect on i\!cdicarcfMedicaid
Lon~·terlll.Cat'e
Program
LO!ll(-lerm Care. Tax Change.,
Sclf-eTT1plo~'cd
\
T:1,\ Deduction Phased
10
100%
14.5,
20/
6.2
�DRAFT
Footnotes for Package One - Phnsed-in Tobacco Tax
I estimates arc preliminary. Totals may not add. due to rounding ..
ile both Sources and Uses of Funds appear in this table as positive numbers, in the budget, Medicare
be indicated in negative numbers as reductions in outlays.
Medicaid savings would
Similarly, the cost of the self-employed tax deduction would be indicated in negative numbers as a revenue loss. Increased receipts
would be shown in positive numbers.
Administrative costs have not been estimated.
'1/
Increases by $0.49 per pack from today's $0.24 level. Specifically, on 1/1/97 increased to $0.60 and to $0.73 on 111/2003.
Estimate from Treasury.
21
Includes income-related Part B premium and extension of HI tax to all state and local employees. Includes effects on Part B
takeup and utilization of services. I Estimates from fICF NOACT imd Treasury.
31
Indirect effects on receipts of the kids subsidy. Subsidies for unemploy'ed cause a negligible effect on receipts under standard
assumptions. Includes on-budget effects only. Estimates from Treasury.
41
Estimates from HCFA/OACT.
51
Includes 25% b.chavioral offset. Estimate from HCFA/OACT.
61
Medicaid offset reflects savings to Medicaid as a result of Part B savings. Estimates from HCF A/OAeT.
71
These estimates assume some employer or employee dropping of insurance, which would result in small, increased tax
revenues.
Fehru"rv 18.1995 (1:40pm)
"
.
'"'
t)
�-,:
families with access to employer contributi-ons of.50%'or more are ineligible for subsidies.
for unerpployed program. Assllmes durational effects on health insurance subsidies.
8/
Also assumes that
Assumes 100% ESI
9/
Assumes that unemployed compensation is included in income determinations for unemployed program. Eligibility for kids'
subsidies based on monthly cash income. Basing eligibility on annual cash income would reduce costs and coverage.
Subsidies to unemployed individuals will have an indirect effect on the unemployment insurance CUI) program. Such an
indirect cfICct is estimated to increase the cost of the Ul program by approximately $2 billion over five years
$3 billion
, over ten years (net of offsetting Ul receipts).
III
Estimate
12/
Estimate from HCF AIOACT.
HHs/PHS.
Grant program to states to expand home & community-based services
disabled individuals. Estimate from HHSIASPE.
'\
141
lSI
16/
Includes long-term care insurance tax incentives, personal assistance services tax credits, and accelerated death benefit
changes .. Estimates from Treasury.
Five and ten year totals include $0.5 billion cost for self-employed tax deduction in FY 1995. Assumes that self-employed
must provide health coverage to their employees. in order toclaim a deduction in excess of 25%. Phase-in: 25% in 1994/95;
. 50% in 1996; 75% in 1997; and 100% in 1998 and thereafter.
Five and ten year totals include $0.5 billion cost for self-employed tax deduction in FY 1995.
rcb,unl}' IS. 1995 (IAOpm)
_
.....
�HEALTH CARE REFORM
"Our families will never be secure, our businesses will never be strong, and
our government will· never again be fully solvent until we tackLe the heaLth care
crisis." [President Clinton, Joint Session of Congress, 2/17/93]
THE CLINTON ADMINISTRATION CONTINUES TO FIGHT FOR.REAL HEALTH
CARE REFORM.
•
As you know, last year the Clinton Administration fought hard for health care reform.
While we could not reach agreement on legislation, there can be little disagreement.
that the problems remain. Nearly forty million Americans have no health insurance
and millions more are just one pink slip or illness away from losing it. Eighty-four
percent of the uninsured in 1993 were in working families, and more that 55 percent
lived in families headed by full-time workers. And while health care costs have
begun to slow down, they are continuing to rise at three times the rate of inflation.
•
As the President said in his State Of the Union address and in his December letter to
the Congressional Leadership, we remain firmly committed to guaranteeing health
security to all Ainericans and to containing health care costs for families, businesses
and Federal, state and local governments.
•
The President believes that we should take a step-by-'-step approach. This year, we
can take the first steps. The Congress can and should:
•
•
Make coverage affordable for and available to children.
•
Help workers who lose their jobs keep their health insurance ..
•
Level the playing field for the self-employed by giving them the same tax
treatment as other businesses.
•
•
Reform the insurance market -- so that people don't lose their insurance when
they lose their job or change jobs or family member falls ill, and so that
small businesses can afford to buy insurance for their workers.
Help families provide long-term care for a sick parent or a disabled child.
a
Because their constituents are demanding action, some Republicans.have begun to
respond to the President's challenge by coming forward with proposals and bills. We
look forward to working with them to take the first steps this year.
.
�THE CLINTON ADMINISTRATION IS FIGHTING BACK TO PROTECT HEALTH
CARE FOR MOTHERS, CHILDREN,THE .DISABLED AND AGED AMERICANS.
•
Unfortunately, for too many Republicans in Congress, "health reform" has turned into
the code word for slashing Medicare and Medicaid to pay for tax cuts for the wealthy.
Republicans in the House and the Senate have talked about cutting both Medicare and
Medicaid by hundreds of billions of dollars.
•
•
,•
Republicans have signaled their intention to cut Medicare by about $300 billion
between now and 2002.
Republicans have suggested cutting Federal Medicaid spending by at least $180
to $190 billion between now and 2002.
It's not hard to figure DUt what that means for the doctors and hospitals who treat
patients receiving benefits under these programs, and for the patients themselves.
G
•
.•
It means dropping coverage or shrinking benefits for mothers and children on
Medicaid. Or it means asking States to pick up the tab to preserve the
Medicaid program, and in doing so, forcing them to raise taxes or sla,sh
spending for services like education and public safety.
•
•
It means shifting a staggering financial burden to elderly and disabled Medicare
benefiCiaries. Or to small businesses and families who will pay higher
premiums and fees if these programs are slashed without overall reform.
It means significant cuts in payments to hospitals, physicians and other
providers.
The President presented a responsible budget to Congress -- a budget that made tough
choices to get our rising deficit under control, but a budget that protected hard
working Americans and investments in our children. Now it is Congress' turn to act.
To detail where they will get the cuts they need to pay for their tax cuts for the
wealthy. To step forward with their plan for deficit reduction.
The President has consistently said that we cannot get a hold of the deficit without
passing meaningful health Teform. Over the next five years alone, ,almost 40 percent
of the growth in total Federal spending will come from rising costs in Federal health
care programs. We must contain costs in these programs. But we must do it as we
reform oUf 'health care system as a whole -- not by arbitrarily cutting programs. that
serve the most vulnerable Americans.
March 6, 1995
Staff Contact: Jennifer Klein (6-2:S9~)
�DRAFT March 7, 1995
FAWELL (DR 995 AND DR 996)
Strengths
J.
Expands access to health coverage, primarily in those states that have not yet
implemented incremental insurance reforms.
• .
•
•
Eliminates pre-existing condition exclusions for those changing coverage
(e:g., when changing jobs), and limits exclusions for those newly purchasing
insurance. These rules would apply to all plans, including self-insured
plans. Due to ER ISA, states have only been able to limit exclusions for
insured plans (generally offered by smaller employers).
Requires health .plans to guarantee access to and renewal of coverage.
This provision applies both to small busiri.esses (those with 50 or fewer
employees) and individuals.
,.
Preempts state anti-managed care laws.
Weaknesses
•
Preempts all state health insurance laws that are .inconsistent with the· bill.
•
•
Preempts state mandated benefits laws without establ.ishing a national
minimum or standardized benefits package.
•
•
States that have gone further in guaranteeing access to coverage or moving
towards community rating would have to scale back reform. States could
choose to continue to enforce insurance laws, but would have no discretion
over the content of the laws.
Appears to preempt state premium taxes for health insurance, reducing
state revenues.
. Continues to permit wide variations in premiums across small businesses and
individuals. Provisions are similar to the NAIC's model law, which many states
have enacted (though some states have gone further).
•
Small business premiums cou Id vary due to age bya factor of 4 to 1
(potentially phased down in the future to three to one). Variations due to
age f~.r individual purchasers (e.g., the self-employed) would be unlimited.
•
Small busmess premiums could vary due to claims experience by a factor
or 1.5 to 1 (potentially phased down in the future. Premiums for individual
�DRAFT March 7,1995
purchasers could vary due to claims experience by a factor of 2 to I All of
the major Republican bills last Congress prohibited experience rating.
•
Health plans could vary premiums by size of business for differences in
administrative costs (up to 15% higher for the smallest businesses).
•
Insurers could establish separate classes of business (based, for example, on .
how coverage is marketed), and charge different premiums across these
classes.
•
Permits assOciations of small employers and individuals to obtain coverage
through self..:insured or insured arrangements outside of the c~mmunity risk pool.
The bill establishes reserve requirements for self-insured associations, but these
requirements are inadequate given the amount of risk mvolved. This provision
would preempt state efforts to restrict or regulate these arrangements.
•
Establishes medical savings accounts, which could further segment healthy and
sick individuals into separate risk pools. (Note that the tax treatment of medical
savings accounts is ·under the jurisdiction o'f the Ways and Means' Committee.)
�MEMORANDUM
TO:
FR:
RE:
cc:
Political Strategy Group
Chris J.ennings
ShortlLong-Range Health care Challenges
Carol Rasco, Pat Griffin, Janet Murgia
March 3, 1995
Attached is a one-month calendar that outlines. some immediate (predominantly)
. legislative even"ts, which will refocus ~ttention on the health care issue. Understandably
enough, it starts with yesterday's balanced budget vote and the attention it focuses on health
care entitlements (Medicare & Medicaid), the deficit, and our position on health reform;
Background on Politics of Health Care and the Budget
The President has consistently said we cannot get a hold of the deficit without
enacting meaningful health reform. As such, we oppose "Medicare cuts outside the context of
health reform.
II,
.
Until we make a more specific statement on the health reform issue, the
Administration will be pressed extremely hard by Republicans and the elite media to provide
oUr'definition of health reform, with speCifics on how much --if any -- deficit reduction
such reform entails. Moreover, a number of very visible Democrats on the Hill (e.g.,
Ranking Budget House/Senate Chairmen Sabo/Exon), responding to this prpssure, will almost
certainly produce their own deficit reduction proposals. There is little doubt that these visible
Democrats' proposals will contain significant MediCare and Medicaid cuts.
"
The Administration's current position is that we stand firm on challenging the
Republicans to produce their budget BEFORE we engage in talking about any specific health
reform package that the Adininistration might support. (This is consistent with the President's
position of not wanting to "push a health reform proposal down the Republicans' throats and
inviting them to work with him to jointly produce a "meaningful" health reform proposal).
Although everyone within the Administration understands and supports our position, the
outside pressures will make it very difficult to implement and will require enormous
discipline.
�Sbort-Term Stra,tegy Recommendation
During the pre-Republican budget resolution mark-up period, we need to continue to
coordinate any necessary responses with the President's health policy development team
chaired by Carol Rasco and Laura Tyson .. As the calenda~ illustrates, the.Republicans are'
already startingJo hold hearings and mark~ups on health bills .. Leon,:George, Pat, Harold,
Erskine, Alice,G~ne,<Bill, the primarf health care j~risdiction Department Secretaries and
others are represented in this work group and, so far, our clearance and policy position
prpcesshasworked quite well.
'..
In addition, we must understand the importance of being better prepared to define our
health care reforn;t/deficit reduction position. Even if we can avoid being specific for now; it
become almpst impossible to not further expand oil our current position after the
Republican budget resolution mark-up. There is no question that the longer we remain silent
on this issue, the more vulnerable we become to criticism that we are being fiscally
irresponsible and playing politics with the health care and deficit reduction issue.
will
Similar to our short, short-term strategy, the DPC/NEC working group needs to
, continue to be the focal point of our political/policy deliberations around a specific health
policy position. We must ensure, however, that its work is running at a parallel and
consistent track to the stragegy being discussed in the political and budget groups that are
now being formed within the White House.
I
?'
�HEALTH CARE
RUBIN_SOOPD
MARCH 1995
Secretary Shalalo testWies
• Senate Approps
Subcommittee(AGy Dr,
full House Approps
- Balanced Budget I/Ote
deteated 6!>-35
test~ies
SubCommittee
Shalala test~ies
House App,ops
Sull<:ommitteeiOr, Lee testWies
. .. Health Professions Senate
LoborlHRlDr, Lee testffies
- Ways&Means H,R483 marl<
upIMedicare Select&Medicare
Extenders for tax package
- GOP ATTACKING OEMS
FOR NO HEALTH
ENTT11.EMENT CUTS TO
REDUCE DEFICIT
Committee hearings on health
,etorm: the problem
Committee hearings on health
reform: the solution
• Possible POTUS release 01
FDA Regulatory RetolTl1s?
- House Approps
Sull<:ommittee(AGY Or,
Kessler, FDA testWies
Shalala testWies
- House Approps
Subcommittees/Or, Chavez,
SMlHSA testWie.
- House Appmps
SubcommitteeiOr Sumaya,
HRSA testifies
- House Approps
SubcommitteeiOr, Graus.
AHCPR testWies
FDA Regulaltlry Reforms?
- GOP ATTACKING OEMS
FOR NO HEALTH
ENTITlEMENT CUTS TO
REDUCE DEFICIT
------+-----------
FY'96 Budget
ATT4(""1o(11IoJr.:
OEMS
GOP ATTACKING OEMS
FOR NO HEALTH '.'
ENTT11.EMENT CUTS TO
REDUCE DEFICIT
Today(3(lII99511:06.)
Onlime(R) Copyrighl CampbeU Services. loe. 1991. 1994
�,,'
EFFECTS OF CAPPING IVIEDICAID
,
0
Medicaid is a safety net for mothers and children, the elderly and people with
disabilities.
>-
Republicans have proposed to cut federal Medicaid funding by at least $180 to ,
$190 billion between now and 2002 -- a 24% cut in 2002 alone.
>-
Medicaid spending per person is already projected to grow at a slower rate than
private health spending. So, with a cut this large, people win suffer.
•
If you want to protect mothers and children, you would have to:
o
Drop coverage for as many as 3 million elderly and people with
disabilities, or
o
Eliminate benefits like home health, hospice, Medicare premium
and cost sharing assistance, dental, drugs, and personal care
services _.- and, by 2005:, begin to limit nursing home services. "
,
•
,
If you want to protect the elderly and people with disabilities, you would
have to:
0
o
Drop coverage for as many as 16 million mothers and children,
or
o
Eliminate all inpatient hospital, outpatient, and physician service$
for mothers and children -- and still not have enough savings to
offset the loss of federal funds.
States could, of course, decide to increase their spending 'by more than $180
billion. But that would mean a 33% increase in state Medicaid spending in
2002 alone, and would force states to raise taxes or sl~sh spending for seIVices
like education and public safety.
In other words, there are no easy choices when you have to cut $180 to $190
billion out of a health care program for mothers ;and children, the elderly and
people with disabilities.
�EFFECTS OF CAPPING MEDICARE
)0-
>-
Medicare is the primary health care program for 32 million elderly and 4 million
disabled Americans.
. Republicans have proposed to cut Medicare funding by at least $150 billion
between now and 2000 -- a .20% cut in 2000 alone ..
\
>-Medicare spending per person is already projected to grow at roughly the same
rate as private sector health spending. So with a cut this large, both beneficiaries
and providers will be forced to shoulder huge burdens.
•
If all the savings come from providers, in 2002 alone a 25 pereent
reduction in Medicare payments to hospitals, physicians and all other
providers would be needed. This would cause serious financial distress to
the nation's medical system, which would still bear the growing burden of
uncompensated care. Many providers could no longer· afford to see
Medicar~ patients. Those that do, would have to shift costs to businesses.
•
If providers are protected, a staggering financial burden would be shifted to
elderly and disabled beneficiaries. 111 2002, beneficiaries would have to
pay $3,640 more for Medicare, a 290% increase over the premiums they
pay today.
�01124195
16:12
ft
~004
. ·1
.. '
,
j
(
DT-STATE OF TBE UNION
BEAL'IH CAllE TALKING POINTS
WJuJt ,... wUllletllth t.'an! p'll;ol ill tits ~brB :llltIW
As he stated in hi8 December 21. 19941et.ter to the C0l1IH8Ii0J1~ Leaciership. tae
President rema.ille firmly committed. to guar8.Dte~r hlait}, inaurA:t1M for every
Americ:all atad to containing health care costa to: f&iznillu,· busineMes and FederaL
State and local ~ve:mDleD.tB, While'we didn't succeed last year. that doa..,'t me81l
tile problem of Wlaflordable health ca.re ud alack 1ha81th I8curity have
cliaappeared. lor millio=a of working families. The Americ:aD people still want ud
lleed health C8.1'8 nfona, and we owe it to them to ~B that it happell8 thi.. year.
Doell tNJ Plvsitlsnl "..,.. NI'Driu.ce ItsrillA care jlqialG&bII
'
The Pre.ai.d.ent wuta tlWl CODifIes to work together to take the :5.ret steps towarde
univeraa1 eoverap. He feell that we Qhould 'be able to pasa meaeuree we 8.P'et all:
reforming the unf'Jlim"8A in tn.e ;nilurance market. =akini coverale ava:ilable for
chndren and people who loas their job., and e!li~1 the quality and efliciencyof
the Medicare Gel Medicaid ~rorrama. The Preside~t iataftd. to work with
CongnN Lo' aea that thee goals are achieved. He h;aa made it very clear that lte
will not &i:ve up the Gght lor health security and affordable health c:are.
Has ,he Presitlt:1II ret,.atetl on unive,.,al 0XIe;.q,e tdllr. the .tc.D8 he I.Gltl oed
flRllgltt,
1'bJ1 :Preaitlent haa not backed. away from his oom~l!lent toprovicio Americans
With 1'611 heiltli CAre security. By Nilizing the goa!l.s laid out tonight in a step-by
step apprOAC'.h, ArntlMca will be Oil the rosa to achieVins univ8Hal coverage..
The Presid.enL will aG.mel that issue when he releases his budget.
Did t1Iie 1Tu~ draw 0 line In the Band on MedJcure'
The President will ftot allow Medicare to be cut 'in Order to pay far ta c~t8 tor 1J1e
wealthy. TAe PrefJideAt has aoneistently aaid that he oppose. new 'Medicare (;:1.1tll '
outaida the c:ontezt of health Gare reform.
,
I
I
't
I
I
I
, -....•..r --:..... ~~~--·."""--"""":--
-_,,"-_0,'"
I
l
�01/03/95
IaJ 002
13;05
"·w
('
.
THE WHITt Hotr!\£
27, 1994.
hile we 'could. not achieve broad-based agreement on a health
cform initiaeive last year, there can be little disagreement
hat we still face the enormous problems of; increasing heal~h
are c;:esta and decrea.sing coverage. We need to confront these
roblQms'on a hipartisan basis and. ad.Qreas .the inseQur1ties that
00 many Arl'Ier1c:ans' have a.bout their healt:haare.
I am writing
o reiterate my streng des,ire to work wich you in
thi~
regard..
remain f1rmlY'committed to providing insurance coverage for
very American and. c:ontain.ing health. care: cose.s for fa.rnilies, .
UIiI ina
anc:l 'clI:iCIIZ'al, , S~at:.e, and local g'Qvsrmnencs. In the
i
i iiii.,,
pc:oming session of Congress,
WI!!
can and should. wo:;k eogether to
ake the fi:ret steps toward ac::hievins these gea.l~. We c;an pass·
.g~liIlation that· 1ncluc:les measures to address the unfairness in .
ho 1nsurancc markee, make coverage more
afforda~le
tor
wor~ins
..mil!e. andch11dren, aesure qu.al,i ty and efficieney in .t.he·
edieare and Medicaid program.. a.nd red.uee the long-t.erm Federal '
ef1e1t.
e look forward to- talking with you in the upcoming weeks
boue a bipartisan effort to deliver healch care re!crm to the '
e.1can pu~l~c. Hi~lary and I send our boet ~iehee for a safe
nd happy ho11~ay season:
ineoroly,.
he Honorable Richard A. Gephardt
Quae of Representatives
&shington, D.~. 20515
�01/03/95
~003
13:05
., .
.
.
. ._ . ··_·t·······- _.- ._--"--'-.' '.._.
.
TK~
IDa~~mber
'KnITl HOlTSE
27, 1994
I
I
loa.lil!'
,
Newt:
I
~ile we c=~ld no~ &chieve brcad.baaed agreement on & health
!reform initiative laar:.yea::, there ean ~CI lit:t::le disagreement
that we still fac~ the enO~OUg problema of increaaing health
.
are costs an4 decreasing coveraqe. we nee4 to confront ~hese
roblems on a bipartisan basis and address the insecurities. 'that
00 many Amliricans have about their health earl!.
I am writing
.
o reiterate my strong des.ire to work with. YOU in t.his regard..
i
remain firmly committed to providing insuranee c~vQrage for
vary American and containing health care cost.1 tor families.
\.Iainesees, and Federal. State, a.nd 100a1 governm.ents. In tho
peoming session of Congress, we can and should work togethgr to
aka the first steps toward achieving-these goals, We can pass
eg1elation that includeD measures to address the unfairness in
hI! ins~rance market, make coverage more affordable fo~ working
amiliea and children, aS8ur. ~&11ty and efficiency in the
e4icare and Medicaid programs, ·and tedu.ce the long.:.t:erm Pederal
efleit.
.
.
,e look forward ~o talking with you in ~he upcoming ~eek~
about a bipa;rtit1an effo:-t to deliver health care reform to t.he
American publio~ R111a~ and I ~end ou.r best wishes for a sate
_nd happy h011day .• eason.
I
·$inc.r~iy •
~-C~~·
I.
I
!
h.e Honoroi.ble. NevtGing't'ich
ouae of Rep~esentatives
.
a8h.1ng~on. D.C.
20515
..
�Q1/03/95
IgJ004
13:05
.
....
.
l
''rUE WHtTE HOUSE
I ecember
"'ASHtNOTON
27, 1994
,
ear
t
aoo;
"
,
hila wa ~Quld not aohieve broad-baeed agreement On a health
e~orm '1nltlative lalt year, thet'e can be little disagreem.ent
, Fhat we still fa~e the enormOI.1&1 prol;;leme of int:reasing health
are costs and decreasing ooverage. We need to confront these
roblems on a bipar~i8an basis and address the insecurities eAat
00 many Americans have about their health care.
Iamwrit.ing
o re.it.er='~Q my strong desire 1:0 work with you in ebia ,regard. '
f
remain fi4mly committed to provid1ng insurance cov~rage,ror
very American and ~ontaining heal~h cars coste for families,
us1neaaes, and ~ederal, scate, an~ local governments. In the
pcoming ee•• ion of CQng~8ss, we can and'should wo.k toge~her to
axe the first at.pa tawara aohieving these goals. We can pass {
eg1s1at1on that 1ncl~des measureS'CQ address the unfairness in
~e insurance marke~, make cQve~age more affordable for wOrking
amilies and ehildrQn, assure quality and effioienoy in the
edicareand. Medicaid programs" and reduee t.h.C!!I ·lortg-toerTTI F'eoe"f:at 1
~
, <leficit.
I
e lOQk forward.
to~alkingwith
you in the upcoming wPoeks
bout a bipartisan cffQrt to deliver healt:hcare l:efcrm to I:he
m@rican public. Hillary and I 8end our best wish.es for a safe
nd happy holiday
1neerely.
,
season.
'
AE~'~
\'
he Honorable Robert Dolo
nited State. Senat8
Washington. D.C.
20510
�01/03/95
•
141 005
13:~6
, ..
•
l. •
THE WHITlt HOOSE
WASHl'Nn'H'l N
oecember
27, t994
Dear Tom:
h1l@ we ceul~ net ac:hieve :t:".t'oe.d.-oased agreement' Ona health
form initiative last year, there ca.n be little ~1Bagreement
hat. ....e still face the enormous problems of 1nere.u1·ng health.
are costD and decreaeins coverage. We need to confront. these
rcblems on a bipart1aaft ~aaiQ and address the. insec~rities t~at
00 many Americans have about their health care.
l am writing
o re1t@rate my st.r~ng desire to work v!th you in this regard.
remain firmly comm1tted to prov1ding insurance coveraga tor
very Ame~1ean and cQn~a1ning he.lth car~ coate for families,
ue1ne5ses, and Federal, State, and loc~l governmenta. In ~he
pcoming session of Congress, ~e.~an and should work together. to
~k~· t.h. first atGpa ~oward achievini t~c.e goals.
We, can pa~a
eg191atiQn that inclUdes measurea to address the unfa~rneee ~n
he ins'U..ra.ncQ market, make COVel"age
affordable tor working'
am1liea an.d. children,aaaure qualiey and e££ic:toeney j"n the
cdica~e and Medi~a1d pro;rams, and reduce the long-term Federal.
e£icit.
.
c look forward to talking. with you in the upcoming w@Qks
ut a bipartisan effort to deliver health care reform co the
merican public. Hillary and I send. our beet wishes for 5 safe
nd happy hc11day season.
more
I
,
he Yonorable Taomas A. Daschle
ited States senate
aehiZ19ton, D.C. 20510
.
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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
Carol Rasco - Issues Series
Creator
An entity primarily responsible for making the resource
Domestic Policy Council
Carol Rasco
Issues Series
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="http://clinton.presidentiallibraries.us/items/show/36305" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/7763322" target="_blank">National Archives Catalog Description</a>
Identifier
An unambiguous reference to the resource within a given context
2010-0198-S Segment 2
Description
An account of the resource
Carol Rasco's Issues Series collection consists of records relating to affirmative action, health care and reform, Medicare/Medicaid, immigration, disability, children, families and seniors, education, welfare reform, Middle Class Bill of Rights, and state and local economic issues. This collection consists of memos, letters, reports, schedules, itineraries, talking points, copies of legislation, and organizational material such as flyers and pamphlets.
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
Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
92 folders in 7 boxes
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
Health Care [1]
Creator
An entity primarily responsible for making the resource
Domestic Policy Council
Carol Rasco
Issues Series
Identifier
An unambiguous reference to the resource within a given context
2010-0198-S Segment 2
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 123
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2010/2010-0198-S-IssuePapers.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/7763322" 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
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Publisher
An entity responsible for making the resource available
Clinton Presidential Library & Museum
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
12/4/2013
Source
A related resource from which the described resource is derived
2010-0198-Sb-health-care-1