Secretary SULLIVAN. Yes. That task force is headed by Constance Horner, our Under Secretary. She serves as chairman, and then Dr. Gail Wilensky is the vice chairman. So they would be points of contact there.

We would be happy to talk with you or members of your staff about some of the things that we are examining. Our plan is to have broad consultation, both with Members of the Congress, as well as with the private sector because I am committed to the idea that for us to have a plan that will make sense, we need to get the best information and as much information as we can.

And second, we have a job of education to do-educating the public, the business community, Members of the Congress, and other interested parties about the plans and what we get for what we invest. That has to be an essential part of it, so that we don't have a program that we go forward with that doesn't have broad understanding and support. So we would be happy to communicate with you on the things we are looking at.

Mr. BILBRAY. Thank you.

Chairman ROYBAL. Mr. James.

Mr. JAMES. Thank you so much for your testimony. It has been very enlightening in many of its aspects and thank you for commenting on the Pepper Commission report.

Along those same lines, I would like to ask you if you have an impression as to whether or not the $66.2 billion in this commission report includes the cost directly to business.

Secretary SULLIVAN. No, Mr. James, it is my understanding that that $66 billion is cost in Federal dollars and that the business costs are an additional $20 billion. Also. I have been advised that the $66 billion is a figure that some feel is really low. So while that is the published figure, we want to get more information on that as well as the cost to the private sector.

Mr. JAMES. I would think $20 billion was exceptionally low because by the 7th-this $66 billion is the Federal costs for the first year. But by the 7th year it is virtually business that is carrying the whole package for the medical insurance provision of it. Do you see any difference between-what bothers me, if we are costing business $20 to $50 billion, we know that will be passed on.

We know that it will also affect negatively incomes of employees to some extent. In other words, the compromise package will be that fewer people will be hired if business can't afford it, especially in the low income level, because in the moderate to low income level the proportion of the health care costs at $2 or $300 a month for their share of the group policy, is disproportionate to their income, wherein the higher income people won't be so negatively impacted.

A $15,000-$25,000 income person would be the area that business would look at to constrict, or to restrict from employment, because there is no difference in health care costs except based on one's age as to what their salary is. Whether they work for $1 or $5 a year, or $3 million a year, the health cost is the same. So it would appear that the lower income group would be most affected if it was a direct cost to business, understanding how business work.

Further, if you mandate this type of insurance, it will be passed on to the consumer and there again, the low income person is the

most directly affected in that they spend a much higher percentage of their income and have very low disposable income.

It may be a problem with some. They call it a regressive form of tax. Do you see any difference in this and a tax and the Federal Government doing it-that is a straight line tax. In the final analysis is there a difference?

Secretary SULLIVAN. Mr. James, certainly you have cited one of our real concerns, that indeed if the costs to the business community are too great that it could have very adverse effect on those businesses as well as on employment and on our national competitiveness-the cost of goods and services that are produced in comparison with the costs of those same goods and services from other countries. So clearly we are concerned about the impact of any recommendations on the business community. Again, that is one of the reasons that we want to wait until we can have a comprehensive overview, because in the health care system, everything is connected to everything else.

One of the things that I am concerned about is the disproportionately bad health status of our low income populations, and that is related to a number of specific things:

For example, one of the reasons I have been so active in my efforts to point out the adverse consequences of cigarette smoking is the fact that this is a number one cause of preventable death in our society. Cigarette smoking among blue collar workers and low income workers is much higher than among college graduates. I think among college graduates 15 percent smoke, while individuals who haven't finished high school, around 36 or 37 percent smoke. Mr. JAMES. Regardless of whether or not one dies at a premature age at some time or other and if you are in perfect health, even if you live to your early '90s, not only do you receive Social Security but someday you may need help, because of a medical problem unless you live to old age and die.

Regardless of preventive health measures, you are still going to need concern about health care. We have 33 million uninsured people now is what I heard estimated. Considering that group insurance policies per employee run probably in the neighborhood at least $2,000 per year, if through whatever resources that are available, based on our present health care costs and our health insurance premiums, it doesn't take a rocket scientist to compute that 33 million times $2,000 a year is $66 billion alone, just in health costs, no matter who pays for it. Two thousand dollars times 33 million is what, $66 billion, you add three zeros on to it.

In the business I had before coming to Congress, with 16 employees, I think at one point health insurance premiums for employees and their families were $33,000. They went up 50 percent, and we were constantly faced with the problem of shopping for health care costs for the firm and it became not just 17 percent a year, but it became a task, a task that even the healthiest business has problems with.

So considering that Canada and maybe Norway, have about 8.5 percent of their GNP spent on health costs and we, in spite of the fact that we have 33 million insured, have 13 percent of our GNP spent on health care costs, I am surprised that there are not other

recommendations in the Pepper Commission addressing that disparity, what is the answer as far as that is concerned.

So I hope the administration would look at all aspects of the spectrum because we cannot continue, in my mind, to tolerate this kind of uninsured numbers, and with the increase of 17 percent a year, I see businesses dropping their insurance more and more and more, and whether you mandate it or tax the people to pay for insurance, I see it as a tremendous problem unless we address the entire system. Not just for the elderly either, we have got to address it for the uninsured. So I don't see it as simple as a mandate that may only offer a short term solution, we have to investigate all possible avenues.

Secretary SULLIVAN. I fully agree with that, Congressman James. Indeed, we have to take a comprehensive view with the goal of providing access but also restraining costs.

I maintain that one of the factors in our high costs is the way we spend our dollars. The fact that a number of other countries spend less than we do and yet the health status of their citizens is equal to or superior to that of our citizens means that simply spending dollars alone without evaluating how and for what we are spending them is not a good answer by itself.

Mr. JAMES. But in fairness to our system, we have to look at the problems created by access and rationing of health care. I see it as a very perplexing problem that we must address, and I hope we find some of the answers as soon as possible.

Thank you so much for your testimony. I think I have used up my time and I yield back whatever time is left.

Chairman ROYBAL. Mr. Blaz?

Mr. BLAZ. Thank you, Mr. Chairman. Dr. Sullivan, first let me start by saying that I was particularly intrigued by your statement on page 8 of your testimony. Let me quote a part of it because it has to do with my question. To give an idea of your deep commitment to improving service delivery to the vulnerable elderly, I want to mention a measure, the SSA initiative or SSI outreach program. You go on to explain what a major effort there is to reach, through an extensive outreach program, those who are especially deserving.

One of my most serious laments in this Congress is that SSI is not extended to my people in the Territory of Guam. It is a very befuddling decision on the part of someone not to do that, for just north of us by about a hundred miles, the people of the Northern Marinas who became citizens of the United States 30 years after we did, are eligible for SSI benefits.

I am given all sorts of reasons as to why Guam is excluded, but perhaps it would help those who work for you to first understand the plight of my people.

In my community, the elderly are venerated-everywhere, but I think much more so in the community on the fringes of Asia. It is a very serious and a very traditional cultural aspect of life there, so that when the elderly are in the home they usually mean the family home, not a home away from home.

So consequently I think that our expenditures with respect to Federal funding is probably much lower because we don't have the same kinds of requirements as others have. So we consider then

that SSI is something that we think we should be entitled to, and we have been requesting it for some time! But unbelievably, sir, in a written, formal statement responding to why my people are not eligible for SSI, your department stated that it would be culturally disruptive if SSI were extended to Guam.

Now, I thought about that word innumerable times and I find it almost affronting if not downright despicable to say that somehow the people on the edges of the republic will be culturally disrupted. Somehow the people in Appalachia who may need SSI are not culturally disrupted, so I was compelled during a meeting to say that cultural disruption is when an enemy force like the Japanese occupies an American territory called Guam and stays for 3 years-that was culturally disruptive.

Cultural disruption is during the Korean War when my people sustained more injuries, KIA and WIA, than any community its size, and seeing 71 names on the wall as a result of the Vietnam War surpassing all of America in terms of KIA and WIA.

While I do not challenge the desire of the Department to do certain things, there are some people apparently who don't seem to understand that an insensitive statement like that is extremely unacceptable to people like myself and for any American.

So my purpose is just to call your attention to this and tell you that I think we need a fresh look at this issue. During a discussion that we had with the Federal Inter-Agency Task Force and representatives of my people, including myself and the governor of my territory, Gale Cozins from SSA headed a group of your Department's people. They came and we talked, and for the first time in an awful long time there was a refreshing attitude of, "let's look at this."

It would be very difficult for me to continue to justify to my people the continued exclusion of the SSI program. I have a vested interest in this thing, as you can see. I am at a point in life where what happens to this program has a special meaning to me.

So I thought I would let you know that I am introducing a piece of legislation one more time because someone has to tell me why the Chamorros, our people are called Chamorros-the same name as Violetta Chamorros-why the Chamorros of the northern Marinas in Saipan, Rota, Tinian are entitled to SSI and why Chamorros like me are not, because it would be culturally disruptive to me. Connie Morella will tell you I am not a culturally disruptive person. If you would, look at this issue with the idea of, "why not Guam."

Thank you.

Thank you very much, Mr. Chairman.

Secretary SULLIVAN. Let me say I will review this with my department, and we will get a response back to you. I will be happy to do that.

Chairman ROYBAL. Mr. Duncan?

Mr. DUNCAN. First, I want to say that I have been very impressed, Mr. Secretary, with your testimony here today, and I am thankful that we have a man like you serving as Secretary of Health and Human Services.

I especially appreciate your response to the question about mandated health benefits in regard to its potential impact on small

business because it seems that so much that we have done here in the Congress in recent years has had the unintended consequence of driving small business out of existence through rules, regulations, red tape and other things that hit harder on small business than on large or giant corporations.

So I appreciate very much your comment on that.

I want to ask you, sir, I have seen estimates as high as 45 to 50 percent of the medical dollar today being spent on administrative bureaucratic paperwork costs. When you count the amount of time that doctors' offices have to spend on this, and that insurance companies have to spend on this and that the government has to spend on this, is there any effort being made in your department to try to simplify this process or cut down on the enormous amount of paperwork and bureaucracy and trying to get more of the medical dollars going to medical care?

I am told that many senior citizens have trouble sometimes figuring out the forms or understanding what they are really entitled to and I would appreciate it if you have a comment on that.

Secretary SULLIVAN. Yes, Mr. Duncan.

Let me say that I share with you the concern about the tremendous administrative burden that we have, both that we imposed upon the providers, physicians, hospitals and others as well as what we have within my department.

I have asked for a study of this by my HCFA individuals to see if there aren't ways that we can reduce that administrative burden so that we can have more of the dollars going into programs rather than to overhead and administration.

Again, one of the reasons that I have been so strong in my opposition to separating out the Social Security Administration into another agency is this would directly counter what we have been trying to do with our one-stop shopping initiative.

Our Social Security offices provide information and help, not only on Social Security and its various programs administered by that agency, but also on Medicare and Medicaid programs, information concerning eligibility, help in filling out forms, referral to appropriate agencies.

So this is one of those specific instances where we are trying to be administratively efficient, save dollars and provide better constituency service, whereas if we have Social Security as a separate, independent agency, that would be disruptive, and that would be one example where an action by the Congress would really add to the very problem that you have pointed out.

But we are concerned about that problem. I have heard from a number of providers-from physicians, from hospitals-and I know that in many instances clerks have to be hired simply to manage the paperwork burden, and we want to reduce that.

Mr. DUNCAN. You commented earlier on the recommendations of the Pepper Commission and the some $60 billion cost estimate. Of course, governmental costs have a way of exploding and it seems that we always underestimate on the front end or become overly optimistic about the cost.

You have already said you think the initial cost estimates or you have heard, that they may be extremely low; is that correct?