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Commissioner The Honorable Mary Rose Oakar

ADDITIONAL VIEWS: THE NEED FOR UNIVERSAL CARE

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The Pepper Commission is perhaps the most important health care forum convened in the last 20 years. It is the brain child of one of the nation's best known and best loved health care experts Claude Pepper. The late Senator Pepper, my friend and mentor, wanted the Commission to find solutions to the two major elements of our health care crisis -- a lack of access to proper medical services for 37 million Americans and the lack of longterm care for most of our citizens. Claude Pepper was a national hero and leader in the fight to provide basic health care and long-term care for all Americans for most of his distinguished His death early in the proceedings of the Pepper Commission was considered a tremendous loss by all. In fifty years of public service, Claude Pepper had one unfulfilled dream to provide universal coverage to every American.

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However, in spite of the loss of Senator Pepper, the Pepper Commission succeeded. Under the able-bodied leadership of Chairman Jay Rockefeller, the Commission came to a consensus regarding both primary health care problems. This was not accomplished without a major effort on the part of the Chairman. For example, the Chairman graciously incorporated into the text of the original recommendations, 12 of the 14 proposals I offered. These improvements include the language regarding alcohol and drug abuse treatment; the provision of annual mammograms and colorectal and prostate cancer screening examinations; prevention through education to change unhealthy behaviors and lifestyles; cognitive impairment language; case management provisions sufficient to meet all needs of long-term care patients; protection against fraud and abuse for consumers of private long-term care insurance policies; and the provisions for scientific research into cures and preventions for long-term aging illnesses and breast cancer. As a result, I salute Chairman Rockefeller and the rest of the Commission for a willingness to meet the requests and needs of individual commissioners, such as myself.

During its virtually endless briefings and discussions, the Commission learned a great deal about the size and scope of our nation's health care problems. For example, thirty-seven million Americans are without health insurance of any kind and perhaps as many as 40 million Americans are underinsured. of the uninsured individuals, one third, or 12 million are children under the age of 18. The area surrounding my home town of greater Cleveland, Ohio has similar difficulties; over 213,000 people do not have health insurance in the four county area making up northeast Ohio. In addition, the trend, nationally as well as locally in Cleveland, is that uninsurance is increasing. In my home area, the rate of uninsurance has increased from 7.9% of the population

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in 1980 to 11.4% of the total population in 1987 -- a 44.3% increase in just seven years. Moreover, one of the more frustrating aspects of our uninsurance problem is that 88% of the uninsured come from hard working, independent-minded families.

Another dimension of the problem is the fact that the United States currently spends almost 12% of its gross national product on health care services. This is a much greater amount than any other nation. For example, Canada spends about 8.5% of its GNP on health care while West Germany and Japan respectively spend approximately 8.1% and 6.7% of their GNPs on health care. Furthermore, as a trend, our nation continues to pay for much greater annual cost increases for health care than any other western nation. One of the obvious implications of this data is that if we lowered our spending to the level spending to the level of our economic competitors, Japan and West Germany, we could invest the saved money into other pressing concerns, such as education, infrastructure development, scientific research and development, and environmental needs which would make our nation more internationally competitive. Our current health care system is helping to place us in an untenable economic situation. We Americans pay more and get less. We are the only industrialized nation, except South Africa, that does not offer universal coverage and long-term care for its citizens.

Long-term care is the other major health care problem faced by the Pepper Commission. The lack of long-term care coverage, perhaps more than the problem of uninsurance, concerns Americans greatly. Approximately 9 million Americans need long-term care; many of these people are children who are accident victims or who are fighting a disease. Further evidence of the problem is that demographic trends indicate that the 85-and-older age group is the fastest growing age group in our country; most members of this group are frail elderly women. By the year 2040, elderly persons will represent 22% of the nation's population, as opposed to 12% today. These facts have not been lost on the American people. In fact, most Americans realize that long-term care is an intergenerational problem since middle aged Americans may have to pay for the health care expenses of their grandparents, parents, themselves and their children. This is a frightening

situation for our middle- and moderate-income citizens.

In response to these pressing problems, the Pepper Commission responded with many positive recommendations. I voted to support both major sections of the recommendations because of my belief that the recommendations take a halting but very significant step toward solving our solving our severe health care crisis. In particular, I strongly support the provisions which provide 1.) universal access to health care for all Americans, regardless of income level; 2.) a new social insurance program with income protection for long-term care; 3.) coverage for preventive

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measures, such as mammograms, colorectal and prostate screening procedures, prenatal care, well-baby care, and a vigorous program of scientific research into the prevention of a wide array of aging diseases and disabilities, and; 4.) extensive coverage for alcoholism and drug abuse prevention and treatment services.

However, since the Pepper Commission recommendations are a compromise set of recommendations, by definition, they represent a middle path solution. Because of the extreme crisis nature of our health care problem and the inherent weaknesses of simply modifying the current failing system, I believe the ultimate solution to our health care crisis requires a more fundamental transformation of our health care system. I believe a universal access, national health care system should be established and that it should be based on the following:

* Nationwide polls prove that Americans consistently support the creation of a universal national health system which provides health care as a right for all our citizens. In contrast, the Pepper Commission proposal relies on an adjustment to our current employer-based system -- the system which is failing us so miserably today. Instead, I firmly believe we should enact a universal health care system now, just as the American people demand;

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* The Pepper Commission recommendations do not emphasize enough the need need to contain costs. This is ignoring perhaps the most important aspect of of our health care crisis rapid cost escalations. As an answer to this problem, we need to enact a national health care system with a single payer, or, preferably, a state governmentadministered system which can exert much more effective cost containment powers;

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* Polls also show that Americans want that Americans want a state-based health care system similar to Canada's health care program instead of a federally-based system like the new public insurance plan in this report. Americans believe that bringing health care administration closer to home makes the system more more familiar and friendly and that it allows greater control over benefits and expenditures. A state-based system also allows greater flexibility over the design of health care plans tailored to meet the special needs of local, state and regional areas;

* There is no consumer choice within the new public insurance plan. Instead, it is based on a "one size fits all" benefits package. Americans prefer and demand choice over their health care plans. We need a state-based, universal access national health insurance program which

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will allow Americans to choose the coverage plan they want, yet one that will allow the participation of providers, insurers and others;

The Commission recommendations offer only three months of nursing home coverage, in spite of the fact that most nursing home stays last at least 4 months. This is clearly inadequate coverage. I offered an amendment to the Commission's plan to increase coverage from three months to six months, but unfortunately my amendment was not accepted. However, the new long-term care plan should offer at least 6 months of nursing home coverage without the necessity of a spend down of personal assets;

* The Commission's long-term care plan is based on a 3-or-more activities of daily living (ADL) requirement instead of the more realistic and humane 2-or-more ADL condition. The Commission's 3-or-more ADL limitation means that approximately 250,000 needy and disabled Americans will not qualify for coverage. I offered an amendment to change this unreasonable part of the proposal to 2-or-more-ADLs, but my proposal was not accepted. I strongly believe this provision of the Commission's plan should be changed.

In summary, the severity of the health care problems we face ultimately requires a much more aggressive answer than the compromising recommendations made by the Pepper Commission. Specifically, we need to move now to create a universal health care system which offers state government administration, federal oversight, consumer choice, a strong concentration on prevention, and competition among providers.

I have incorporated all of the improvements to the Pepper Commission recommendations mentioned above into a bill, H.R. 4253. This legislation offers a complete restructuring of our health care system by offering universal access to a comprehensive set of acute care and long-term care benefits to every citizen of our nation. The federal government provides basic oversight of the program, quality assurance guidance, and partial funding. The state governments are charged with day-today administration and must make up the rest of the funding of the program. Special care has been taken to allow consumer and group participation in the formulation and offering of statequalified health care plans from which consumers can choose. I am convinced that because of the state administrative features of my bill, we will more forcefully and effectively control unreasonable cost increases.

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Effective cost containment should form a central feature of any health care legislation. During the Commission's mark-up session, I offered my plan as a substitute, but by a 6 to 9 vote the amendment was not accepted. However, I was heartened by the support of six Commissioners who voted for my substitute amendment.

Moreover, H.R. 4253 offers an excellent long-term care plan which not only provides six months of nursing home coverage and access to benefits based on a two-or-more activity of daily living (ADL) qualification, it also provides for the option to it "purchase" extended nursing home insurance through the federal government. Furthermore, like the Pepper Commission plan, the long-term care program in H.R. 4253 is case managed which ensures a high standard of quality care. I have also included a hospice care program for the terminally ill and coverage for skilled nursing facility care. In addition, the long-term care benefits are available for people of all ages.

Another major feature of H.R. 4253 is the strong emphasis placed on prevention programs and scientific research for the prevention and cures of diseases. Since my provisions regarding these subjects were accepted virtually virtually unchanged by the commission, my bill offers a similarly extensive program of coverage for preventive care services such as mammograms, pap smears, colorectal and prostate cancer screening exams, prenatal care, well baby care from the moment of birth and well child care through age 22, basic immunizations, and nutrition counseling. I strongly believe preventive care is the wave of the future, not only for preventing pain and suffering or enhancing the quality of life, but for purposes of saving lives and money. This is a common sense approach to health care management.

My bill also incorporates provisions regarding scientific research and development of preventions and cures for a wide variety of diseases. Not only does H.R. 4253 include similar proposals to aggressively fund research into aging diseases to those I offered and were and were installed into the Pepper Commission plan, it also provides more research into diseases which affect minority populations and women. Research money is provided for studies to prevent and cure sickle cell anemia, hypertension, infant mortality, aids and breast cancer. This kind of farsighted research is needed to save money and lives.

Additional preventive care in my bill can be found in the form of the National Health Objectives provisions. This section of the bill contains block grants for state-based prevention programs based on a report issued by the Department of Health and Human Services which urges attainment of 21 National Health Objectives (e.g. cessation of tobacco use, reduction of alcohol use, improve nutrition, increase physical activity, prevent and

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