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Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
SUBJECT/TITLE
DATE
RESTRICTION
AND TYPE
001. list
While House health care briefing invitees [Personally Identifiable
07/07/1995
b(6)
Information] (35 pages)
COLLECTION:
Clinton Presidential Records
First Lady's Office
Jennifer Klein
OA/Box Number: 9147
FOLDER TITLE:
Regulatory Review - Event [2]
2014-0536-S
kc1610
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)]
Freedom of Information Act - 15 U.S.C. 552(b)]
PI National Security Classified Information |(a)(1) of the PRA]
b(1) National security classified information |(b)(1) of the FOIA]
P2 Relating to the appointment to Federal office |(a)(2) of the PRA]
b(2) Release would disclose internal personnel rules and practices of
P3 Release would violate a Federal statute ((a)(3) of the PRA
an agency ((b)(2) of the FOIA]
P4 Release would disclose trade secrets or confidential commercial or
b(3) Release would violate a Federal statute |(b)(3) of the FOIA]
financial information [(a)(4) of the PRA]
b(4) Release would disclose trade secrets or confidential or financial
P5 Release would disclose confidential advice between the President
information [(b)(4) of the FOIA]
and his advisors, or between such advisors [a)(5) of the PRAJ
b(6) Release would constitute a clearly unwarranted invasion of
P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) of the FOIA]
personal privacy [(a)(6) of the PRA
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
b(8) Release would disclose information concerning the regulation of
of gift.
financial institutions |(b)(8) of the FOIA]
PRM. Personal record misfile defined in accordance with 44 U.S.C.
b(9) Release would disclose geological or geophysical information
2201(3).
concerning wells |(b)(9) of the FOIA]
RR. Document will be reviewed upon request.
JUL-10-1995 18:50 FROM ADMINISTRATOR'S OFFICE
TO
94562878 P.01
HEALTH CARE FINANCING ADMINISTRATION
ADDRESSEE:
FROM: Jennifer Boulange
OFFICE OF THE ADMINISTRATOR
Jennifer Klein
200 INDEPENDENCE AVE., S.W.
ROOM 314G
WASHINGTON, DC 20201
PHONE: 202-690-6726
PHONE:
FAX : 202-690-6262
TOTAL PAGES:
ADDRESSEE'S FAX MACHINE NUMBER:
DATE:
2+c
REMARKS:
Revised press fact Sheet.
I did a little more word-smithing
on PASARR
JUL-10-1995 18:50 FROM ADMINISTRATOR'S OFFICE
TO
94562878 P.02
HHS FACT SHEET
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
HEALTH CARE REGULATORY REFORM
JULY 1995
Introduction
Reforming the federal government's regulatory process is a top priority of the Clinton
Administration. Consistent with this commitment, President Clinton and Vice President Gore
asked Health and Human Services Secretary Donna Shalala to assist in meeting this priority by
carefully examining the regulatory requirements of the Health Care Financing Administration
(HCFA). As part of the reinventing government initiative, HCFA reviewed its regulations to
determine which requirements can be reduced or eliminated without compromising Medicare and
Medicaid beneficiaries' access to quality health care.
HCFA serves nearly 37 million Medicare beneficiaries and, in partnership with state
governments, another 36 million Medicaid beneficiaries. HCFA ensures program beneficiaries are
aware of the services for which they are eligible and that those services are accessible, meet
quality standards, and are delivered in an efficient manner. HCFA also ensures that health care
providers of services meet approved standards, and program funds are used effectively.
Regulatory Reform Initiatives
The following are the next major HCFA initiatives to evolve from HCFA's commitment to
the Administration's regulatory reform process. Some of the initiatives result directly from
collaborative efforts and public consultation with industry groups, beneficiary organizations, state
associations, and state agencies. All of the initiatives cut unnecessary red tape and regulatory
burdens and demonstrate HCFA's customer-focus and responsiveness to the changing needs of its
customers and partners.
1. Physician Attestation: Eliminate the physician form required to certify the accuracy of all
diagnosis and procedures before submission for payment by Medicare. Ending this requirement
eliminates Il million forms a year, saving almost 200,000 hours of physician time and decreasing
hospital administrative costs by approximately $22,500 per hospital annually.
2. Clinical Laboratory Improvement Amendments: Improve the CLIA system and reduce
regulatory burden by rewarding good laboratory performance, creating incentives for
manufacturers to develop more reliable testing equipment, allowing private organizations meeting
certain standards to accredit laboratories, and using proficiency testing as an outcome measure to
JUL-10-1995 18:51 FROM ADMINISTRATOR'S OFFICE
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monitor laboratory performance. A flexible, targeted survey system, reduced information
requirements, and streamlined inspection process have been initiated.
3. Outcome Performance Measures: Change focus of regulations to measures of outcomes of
care rather than measures of process requirements. Eliminate unnecessary process requirements
and instead develop outcome-based performance standards; collect and analyze patient care data
needed for continuous quality improvement and performance evaluation; increase consistency of
requirements across providers; and ask the customer to provide input on what the outcome
measures should be, and to evaluate the services they receive. Changes involve:
Home Health Agency Conditions of Participation
Medicare Hospital Conditions of Participation
ESRD Facility Conditions of Coverage
Rules for ESRD Facilities - A Pilot for Good Performers
Elimination of Personnel Requirements for Excellent ESRD Facilities
4. The HCFA-1500 Form: Require participating Federal Employee Health Benefit Plan
(FEHBP) carriers to use the HCFA-1500 form for physicians' and other practioners' claims. The
HCFA-1500 is currently used by physicians and others to submit claims for reimbursement of
health care services under Medicare. This change will mean that physicians and other practioners
will be able to use a single form to submit claims for many patients -- both Medicare beneficiaries
and patients enrolled in the FEHBP.
5. Annual Preadmission Screening and Annual Resident Review (PASARR): Currently, two
federal requirements call for the assessment of nursing home patients. This change eliminates the
requirement under PASARR that mentally ill and mentally retarded nursing home residents are
assessed annually by states. Resident assessments and reassessments conducted by states under
the general nursing home requirements ensure that residents' continuing needs are properly
evaluated and met. The preadmission screening for these residents under PASARR is retained.
6. Nurse Aide Training and Competency Evaluations: Permit states to approve nurse aide
training and competency evaluation programs offered in nursing homes. This flexibility will
safeguard the availability of nursing homes which might otherwise stop participation in the
Medicare and Medicaid programs, especially in rural areas. It will also make it easier for nurse
aides to obtain the training they need to provide quality services to our beneficiaries.
###
JUL 10 '95 09:18 NAT PEFORMANCE REVIEW WASH.
P.2/5
Vice President Gore's Remarks
ReGo 2 - HCFA Regulatory Reform
July 11, 1995
Thank you, Steve, and thank you Mrs. Clinton.
Steve, your description of the attestation (a-tess-TA-shun) form reminds me of the
Henny Youngman joke about the man who goes to his doctor and says, "Doc, it
hurts when I do this."
(Lift your arm above your head.)
The doctor says to him, "Don't do that."
(If you hold the pose, you might get
a laugh - Henny would be proud.)
Now, that's common sense at work.
(NOTE: There is a banner behind you that
reads "Common Sense At Work")
So, when you tell me that signing the "Physician Attestation Form" wastes time
and money and makes you mad, I tell you "don't do that" - that's the common
sense cure: don't sign it any more. We're canceling that regulation.
Last year, HCFA canceled the regulation saying that doctors had to sign a similarly
irritating form every year - it acknowledged the penalties for cheating on
Medicare. Now it's time to get rid of the so-called "attestation form" for each
Medicare patient who is being discharged from a hospital.
The doctor is supposed to certify that none of his diagnoses or charges are
fraudulent before the hospital can send in the claim. Now, is that crazy, or what?
Do we really think that if the doctor were a crook, he would - having been
confronted by that intimidating Physician Attestation Form - Ah! The very name
makes a charlatan shudder - did we think he would suddenly have a change of
heart, and come clean?
More to the point, is it the official opinion of the U.S. Government that the vast
majority of doctors and hospitals in this country are crooks?
1
JUL 10 '95 09: NAT PEFORMANCE REVIEW WASH.
P.3/5
The correct answer is, "None of the above." So, we are relegating the "Physician
Attestation Form" to the trash heap of yesterday's government. From now on, we
will start with trust instead of mistrust. We'll start from the assumption that the
vast majority of America's doctors and hospitals are honest people and reputable
institutions - not dens of thieves.
By the way - each year, America's doctors had to sign 11 million of those forms.
Even if each one only took a minute to look over and sign, that's 200,000 hours of
doctor time that can now be devoted to patients instead of paperwork.
And hospitals will save time and money too. They used to have messengers
driving around town with the forms tracking down signatures. One hospital I heard
about held an occasional "physician amnesty day" and enticed the doctors with
free brownies to come in and sign the forms.
Sorry if our common sense regulatory reform is messing up a good thing there.
(Laughter)
A few weeks ago, President Clinton announced the progress we've made with
regulatory reform - 16,000 pages of federal regulations are being cancelled
outright, and another TK pages are being infused with a new spirit of partnership
and common sense.
That kind of regulatory reform is the right way to change government. Regulatory
ruination is the wrong way.
Public opinion poll after poll shows that most Americans do want less government
interference - they do want a smaller government - yes. And we are making it
less intrusive and smaller - the smallest it's been since the Kennedy
Administration.
But, most Americans don't want to give up completely on government. Most
Americans believe as President Clinton and I believe - that government is the
way a free people work together to solve their biggest national problems.
But if government does not work well - if it never seems to solve the problems it
sets out to solve - problems like crime or poverty, disease or ignorance, threats to
our security or to our economy - then Americans loose faith in government. And
when we do that, we are loosing confidence in our own ability to work together as
a free people.
2
JUL 10 '95 09:19 NAT 'L PEFORMANCE REVIEW WASH.
P.4/5
That is a crisis of confidence we face today. Thirty years ago, when asked if
government could be trusted to do the right thing, 75% of Americans said yes.
Today, it's less than 20%. Confidence has been lost by Democrats as well as
Republicans - by the old and by the young - among all races and creeds - the
loss has been across the board.
We have to restore America's faith in government. We have to restore our faith in
ourselves. That's why we have to make government work better - not just cost
less. That's why President Clinton and I have been reinventing government.
You know, just listening to the First Lady and Dr. Gleason describe what is wrong
with health care regulation is like a trip down reinvention memory lane for me.
Two years ago, when President Clinton gave me the reinvention job, I found the
very same things wrong all over the government: lots of attention to red tape, but
little interest in results - lots of mistrust and confrontation, but very little
partnership and teamwork - long on rules, but short on common sense.
And just as the First Lady learned about the real problems, and how to fix them,
from physicians like Dr. Gleason and his colleagues who were kind enough to join
us today, I've found that the best ideas about how to make government work better
and cost less always come from the people on the front lines - people who do the
real work day in and day out.
We listened to those people about reinventing the rest of government. And we are
listening to you doctors and other medical professionals about how to fix
government's role in health care.
The parallels are really striking. Take on-the-job worker safety for example:
Government regulation has helped make the American workplace safer over the
years. But, our new approach is making big improvements for workers, with fewer
costly hassles for business owners. It was started by some front-line workers in
Maine, and now, President Clinton has ordered OSHA to take the new approach
nation-wide. It is based on partnership among labor, management, and government
with a common goal of healthy workers in a growing economy.
The same kind of results-oriented partnerships are changing things so that the
government can protect the environment without using up a forest-worth of
paperwork - so that government can ensure the safety and effectiveness of drugs
without being such a pain - and the government can enforce trade regulations
without holding up shippers or shanghaiing travelers. The list of reforms goes on
and on.
3
JUL 10 '95 09:20 NAT 'L PEFORMANCE REVIEW. WASH.
P.6/5
And HCFA has come up with better ways to ensure that Medicare patients get
top notch care - ways focused on results rather than red tape. Instead of
holding frequent inspections to make sure all the proper procedures are being
followed, and all the workers have the specified experience and college
degrees, and all the paperwork is neat and tidy - we will start checking to see
how the patients are doing. And, we will let everyone know which facilities
produce excellent results. That way, government can help consumers make
informed choices.
And for nursing homes that care for the mentally ill, we are cutting out the
duplicate requirements for initial and annual patient assessments. One
regulation requires the assessments if funding comes from Medicare or
Medicaid - another regulation requires states to do a second set of
assessments just because the patient is in a nursing home. We want states to
spend their health care money on first class care - not on federal second
guessing.
And to make life simpler for doctors and their administrative assistants, we will
have all insurance companies that cover federal workers use the standard
Medicare claim form. You won't need to learn a different set of paperwork
rules for each different company.
These are some of the changes we're making. But, this is not the end of it. We will
keep listening - and keep changing - and keep restoring faith in government. As
the First Lady pointed out, when it comes to reinventing government, health care is
no different from any other national problem: We need faith that we can solve our
problems together through government. And to regain that faith, we need to make
government work better and cost less.
That's what Clinton and Gore are all about - making government work better and
cost less. That is - and always will be - the right way.
5
JUL-10-1995 16:23 FROM ADMINISTRATOR'S OFFICE
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Reinventing
HEALTH CARE
Regulation
NATIONAL
PERFORMANCE
REVIEW
PRESIDENT BILL CLINTON
VICE PRESIDENT AL GORE
JULY 1995
JUL-10-1995 16:23 FROM ADMINISTRATOR'S OFFICE
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"I believe we can bring back common sense
and reduce hassle without stripping away
safeguards for our children, our workers, our
families."
President Bill Clinton - February 21, 1995
OVERVIEW
Introduction
The Clinton Administration has made reforming the Federal government's regulatory
process a top priority. Consistent with this commitment, President Clinton and Vice
President Gore asked Health and Human Services Secretary Donna Shalala to assist in
meeting this priority by carefully examining the regulatory requirements of the Health Care
Financing Administration (HCFA).
HCFA has taken the President's and Vice President's commitment to reinventing
government and government regulations seriously and is meeting the challenge. HCFA has
a new customer service focus: we are working in partnership with the rest of the health care
community to institute better, more common sense ways of operating. HCFA has reviewed
its regulations to determine which requirements could be reduced or eliminated while
assuring that we continually improve the quality of services to some of America's most
vulnerable populations -- Medicare and Medicaid beneficiaries. This report contains the
initiatives that have resulted to date from the review of HCFA's regulations.
Agency Overview
The Health Care Financing Administration's primary mission is to assure health care
security for nearly 37 million Medicare beneficiaries and, in partnership with State
governments, another 36 million Medicaid beneficiaries. HCFA ensures that program
beneficiaries are aware of the services for which they are eligible and that those services are
accessible, meet quality standards, and are delivered in an efficient manner. HCFA also
ensures that health care providers of services meet approved standards and that program
funds are used efficiently.
Reinventing Health Care Regulations
1
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Regulatory Reform Principles
Regulatory reform means regulating only when necessary and no more than needed. When
regulations are issued, they must be the most cost effective, least intrusive, and most flexible
types of regulations that achieve the stated objectives. This common sense way of regulating
is accomplished by working with our partners, including industry groups and States, and by
keeping in touch with the needs of our customers. For HCFA, this means knowing what our
beneficiaries want and need, and then working with our partners to fulfill and even exceed
these expectations.
To guide the regulatory review process, HCFA relied on three basic principles that help
define the Agency's new and improved approach to regulations and customer service.
Communicate not dictate -- The number one tenet of this principle is to communicate
through listening and consulting, thereby increasing our understanding of what our
customers need, what they like and dislike about our programs, and how we can serve
them better overall. This principle says that HCFA will consult with our partners and
beneficiaries about how our programs and policies should improve, instead of dictating
such changes to them as has been done too often in the past. When changes are a result
of legislative initiatives, HCFA will consult with partners and stakeholders on the full
range of implementation issues that needs to be addressed.
Educate rather than inundate -- Top-rate customer service also means making sure that
customers understand our programs and policies. Providing reams and reams of
information is not enough and probably not effective. The "new" HCFA is committed to
educating instead of inundating. This principle ensures that HCFA will educate our
customers by developing effective educational techniques and disseminating information
about how our programs operate rather than inundating them with information that is
difficult to understand and doesn't speak to their needs.
Innovate more than regulate -- HCFA's regulatory reform and improved customer
service initiatives are driven more by innovation than regulation. This means that HCFA
is relying upon innovation in program operations and administration more than
regulation to foster improved customer service capabilities. For example, by
streamlining Medicare claims processing and information exchange, the Medicare
Transaction System will make electronic interaction with Medicare easier for providers
and beneficiaries and will enable Medicare contractors to devote more time to customer
service activities.
2
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Accomplishments
During the Clinton Administration, HCFA has improved its regulatory process to focus on
results, not red tape.
In March 1994, HCFA published a regulation that replaced the requirement for
physicians to provide hospitals annually with a signed acknowledgment concerning
penalties for misrepresenting certain information with a one-time signing requirement at
the time a physician is initially granted hospital admitting privileges. Almost 24,000
hours of physician time will be saved. One major medical association characterized this
change as one that will alleviate the "hassle factor" for physicians and an important step
toward restoring mutual trust between the Federal Government and the medical
profession.
HCFA is totally redesigning its system to pay claims for Medicare services. Currently,
providers must cope with 9 different claims processing systems operated by 72 insurance
companies at 57 sites. The development of the Medicare Transaction System (MTS)
will increase control of program expenditures, simplify administrative operations, and
improve services to beneficiaries and providers. This integrated, national system will
replace the diverse existing systems and significantly simplify administrative operations
for beneficiaries, providers, and the Medicare program. Final contracts for the analysis,
design, development, testing, and implementation of the MTS were awarded in January
and March 1994.
HCFA has re-invented its evaluation of Medicare contractors. The newly restructured
Medicare contractor performance evaluation establishes Medicare beneficiaries and
medical care providers as integral partners in the evaluation process. This new
evaluation process, which began October 1, 1994, allows for greater flexibility in
evaluating Medicare contractor operations and performance.
The process for btaining Medicaid home and community-based services waivers was
simplified and now enables States to offer a wide variety of home and community-based
services as cost-effective alternatives to more expensive institutional care. Without this
regulatory change, published July 25, 1994, joint State and Federal efforts to expand
opportunities to provide cost-effective alternatives to institutional care would have been
frustrated. The regulatory provisions were worked out in collaboration with the States
(through the National Governor's Association).
Reinventing Health Care Regulations
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Regulatory Reform Initiatives
The following proposals are the next major HCFA initiatives to evolve from our
commitment to the regulatory reform process.
I. Physician Attestation: Eliminate the physician form required to certify the accuracy of
all diagnosis and procedures before submission for payment by Medicare.
2. Clinical Laboratory Improvement Amendments: Reduce burden and improve the
CLIA system by rewarding good performance by laboratories, creating incentives for
manufacturers to develop more reliable testing equipment, allowing private organizations
that meet certain standards to accredit laboratories, and using proficiency testing as an
outcome measure to monitor laboratory performance.
3. Outcome Performance Measures: Change current regulations that focus solely on
requirements for measuring processes, rather than outcomes of care. Changes affect:
Home Health Agency Conditions of Participation
Medicare Hospital Conditions of Participation
ESRD Facility Conditions of Coverage
Rules for ESRD Facilities - A Pilot for Good Performers
Elimination of Personnel Requirements for Excellent ESRD Facilities
4. The HCFA-1500 Form: Require participating Federal Employee Health Benefit Plan
(FEHBP) carriers to use the HCFA-1500 form for physicians' and other practitioners'
claims. The HCFA-1500 is currently used by physicians and others to submit claims for
reimbursement of health care services under Medicare. This change will mean that
physicians and other practitioners will be able to use a single form to submit claims for
many patients - both Medicare beneficiaries and patients enrolled in the FEHBP.
5. Annual Preadmission Screening and Annual Resident Review: Eliminate the
requirement that mentally ill and mentally retarded nursing home residents are assessed
annually. Resident assessments and reassessments required under the general nursing home
requirements are entirely adequate to assure that residents' continuing needs are properly
assessed and met. The preadmission screening for these residents is retained.
6. Nurse Aide Training and Competency Evaluations: Permit States to approve nurse aide
training and competency evaluation programs offered in nursing homes.
4
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HCFA INITIATIVES
1. Physician Attestation
Background: Since the Medicare hospital inpatient prospective payment system (PPS) was
implemented by HCFA in 1984, HCFA regulations have required physicians to sign an
"attestation form" for each Medicare patient discharged from a hospital. The form certifies
the accuracy of the diagnoses and procedures for each patient. This information is used to
ensure that the correct coding is on the claim, the correct diagnosis-related group (DRG) can
be assigned, and the proper Medicare payment can be made.
Feedback from physicians, hospitals, and intermediaries has told us that obtaining the
physician's signature is burdensome and results in billing delays that hurt hospital cash flow
and hinder service to the beneficiary. Peer Review Organization (PRO) review of
attestations has resulted in less than a 0.01 percent denial rate of sampled claims. In
addition, the improvement in hospital record keeping and coding sophistication make the
hospitals the appropriate focus for combating fraud and abuse.
Proposal: Eliminate the form requirement and instead hold hospitals responsible for the
accuracy of their diagnoses and procedures. With improved technology and software coding
capabilities, hospitals are more equipped than ever to combat billing fraud and abuse, the
form's original purpose.
Impact:
Reduces paperwork burden and "hassle" on physicians and hospitals.
Decreases administrative costs for hospitals.
11 million forms will be eliminated.
Almost 200,000 hours of physician time will be saved.
Hospitals will have improved cash flow and reduced labor costs by approximately
$22,500 per hospital per year.
Implementation and Timeline: HCFA will publish this final regulation by
September 1, 1995.
Reinventing Health Care Regulations
5
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2. Clinical Laboratory Improvement Amendments
Background: The Clinical Laboratories Improvement Amendments (CLIA) of 1988
established baseline quality standards that ensure the accuracy, reliability, and timeliness of
laboratory testing. These requirements are based on the complexity of the test performed,
rather than where the test is performed. Compliance with the standards is determined
through on-site inspection.
HCFA and the Centers for Disease Control and Prevention, which share responsibility for
the CLIA program, continually review ways to reduce the burden and improve the entire
CLIA system. A flexible survey system that employs data analysis to target good
performers and allow for self-attestation and off-site review has already been initiated for
certain laboratories. HCFA has reduced information requirements and eliminated
unnecessary paperwork and has taken steps to reduce personnel requirements. HCFA also
revised and streamlined the inspection process. Additional burden reductions are being
undertaken that will virtually eliminate oversight for certain laboratories, establish
performance standards in place of process requirements, and use information and education
as a substitute for sanctions.
Proposal:
1. Waive the routine 2-year survey of users of "black box" technology, conducting surveys
only if there are indications of problems or complaints. ("Black box" technology refers
to simple and easy to use test systems that have demonstrated accuracy and precision
through scientific studies.) We will develop and implement criteria for accurate and
precise "black box" technology that will be followed to determine if the technology
qualifies for waiver of the routine 2-year survey. A small number of surveys will be
conducted to validate the criteria for determining "black box" technology and to assure
quality.
Impact:
Creates incentives for manufacturers to develop more reliable testing equipment by
stimulating demand for accurate and precise technological testing systems.
Reduces paperwork and costs for providers, especially for physician office
laboratories, as well as reducing costs of program management.
Implementation and Timeline: Proposed rules will be published in September 1995.
6
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2. Clarify and expand the waiver criteria and streamline the waiver process so that CLIA
regulations can be waived for more tests. CLIA requirements will be waived for tests
approved for home use by the Food and Drug Administration -- that is, tests that do not
require trained personnel.
Impact:
Decreases burden, especially for physician office laboratories because of less
regulatory oversight.
Increases access to greater variety of tests. Physician office laboratories may expand
the range of tests they perform without an increase in costs/burden.
Creates incentives for manufacturers to develop more test systems that meet the
clarified waiver criteria and criteria for approval for home use.
Eliminates inspection fees for many of the 60,000 physician offices and other small
laboratories not now waived that decide to perform only tests from the expanded
waiver category.
Many additional laboratories will face lower inspection fees because, while they will
continue to perform non-waived tests, many more tests will fall into the expanded
waiver category.
Implementation and Timeline: Proposed regulations will be published in
September 1995.
3. Use performance standards and require less frequent on-site inspections (surveys) of
excellent performers. Private accrediting organizations may be approved for Federal
accrediting status ("deemed status") when their accreditation standards are as stringent as
CLIA. Exempt laboratories from CLIA requirements when the State in which they are
located has requirements equal to or more stringent than CLIA's.
Impact:
Reduces inspection burdens.
Rewards good performers with fewer inspections. This is a positive incentive to
improve performance.
Offers laboratories oversight by peers by approving private accrediting organizations
Reinventing Health Care Regulations
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FROM ADMINISTRATOR'S OFFICE
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for Federal accrediting status.
States with strong licensure programs are being approved for exemption from CLIA.
Implementation and Timeline: To date, notices to approve four accrediting
organizations (College of American Pathologists, Joint Commission on Accreditation of
Healthcare Organizations, Commission on Office Laboratory Accreditation, and the
American Society of Histocompatibility and Immunogenetics) and the State of
Washington have been published. Notices for two additional accrediting organizations
and one additional State are pending. Final rules to eliminate redundancies or
unnecessary requirements for Federal review and approval will be published in
March 1996.
4. Use proficiency testing (PT) "failures" for education and as an outcome indicator in
laboratory quality. (PT is testing samples of known values to assess the accuracy of a
laboratory's results.) Sanctions (for example, loss of Medicare payment or loss of
approval to do testing) are imposed only in cases of immediate jeopardy or when the
laboratory has refused to correct the problem or has had repeated failures on proficiency
testing.
Impact:
Less intrusive than traditional regulation and oversight.
Allows use of proficiency testing as an outcome measure to monitor laboratory
performance, provides laboratories with feedback on test quality, and as an incentive
to improve performance.
Minimizes the fear of sanctions in 60,000 non-waived laboratories.
Implementation and Timeline: A proposed rule will be published in March 1996.
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3. Outcome Performance Measures
Background: Medicare, as a purchaser of health care, requires hospitals, home health
agencies (HHAs), and End-Stage Renal Disease (ESRD) facilities to meet health and safety
requirements to participate in the Medicare program. Historically, these requirements
measure "process" (procedural and administrative systems as proxies for quality health care)
rather than "outcomes" (evaluations of actual patient care) and the adequacy of quality
management programs.
HCFA is committed to changing current regulations that focus solely on requirements for
measuring processes. The Agency realizes that not focusing on outcome measures results in
several inherent problems. First, regulatory requirements vary by type of facility and
provider even when the services provided in each facility are the same, creating inequities
and inappropriate incentives. Second, without outcome measures, there is very little
information available for consumers on the quality of care at a given facility. Third, by law,
HHAs must be surveyed yearly--even though historical data show that this frequency is
excessive for many HHAs and does not improve care.
HCFA is revising regulations for hospitals, home health agencies, and End-Stage Renal
Disease facilities to address these issues, eliminate unnecessary process requirements, and
focus on the outcomes of care.
Proposal: Eliminate unnecessary process requirements and instead develop outcomes-
based performance standards; collect and analyze patient care data needed for continuous
quality improvement and performance evaluation; increase consistency of requirements
across providers; and ask the customer to provide input on what the outcome measures
should be, and to evaluate the services they received. We are seeking legislation to give us
flexible survey cycles.
Impact:
Eliminating unnecessary process requirements for compliance will reduce compliance
and survey burdens and make it possible to focus on actual patient care.
Educating the consumer will produce a strong, non-regulatory force to improve quality
of care
Powerful data will be available to regulators and providers.
Produces savings because providers are free to achieve high quality outcomes in the
most cost-effective manner.
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Outcomes Performance Measures Initiatives
HCFA is currently involved in the following new initiatives that focus on the concept of
"Outcomes Performance Measures" and the consensual approach to developing regulations.
Home Health Agency Conditions of Participation:
HCFA is developing revisions to the Medicare Home Health Agency (HHA) conditions of
participation. The purpose of the revision is to place greater emphasis on patient outcomes
while reducing the current emphasis on process requirements (e.g., elaborate professional
qualifications and other "paperwork" requirements) and enhancing an HHA's flexibility in
meeting patient needs. The Agency has actively involved home health beneficiaries,
providers, physicians, professional organizations (American Association of Retired Persons,
National Association for Home Care, American Federation of Home Health Agencies,
American Medical Association, Visiting Nurses Association of America, American
Academy of Home Care Physicians), States (State Survey and Medicaid Agencies), and
intermediaries in order to receive input on developing revisions to the conditions of
participation. A work group of HCFA staff and representatives of Medicare beneficiaries,
home health providers, physicians, and State Survey Agencies will develop a Standard Core
Assessment Instrument for use in home health care. The use of this tool is central to
HCFA's efforts to place the emphasis of survey and enforcement on patient outcomes.
Implementation and Timeline: HCFA will publish a proposed rule in September 1996.
Hospital Conditions of Participation:
HCFA is revising the current hospital conditions of participation to center on the patient,
support a cross-functional approach to patient care, and focus on quality. In developing
these revisions, HCFA has worked closely with organizations representing hospitals,
practitioners, patients, and States and has already distributed informal pre-regulatory drafts
to approximately 70 outside groups for comment.
Implementation and Timeline: HCFA will publish a proposed rule in January 1996.
End Stage Renal Disease (ESRD) Conditions of Coverage:
HCFA's ESRD Conditions of Coverage (COC) have not been comprehensively revised
since their original implementation in the late 1970's. The current COC are primarily
focused on process-oriented requirements, and do not provide adequate support for a modern
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survey system based on an outcome-oriented approach. Under the current regulation,
facilities have a substantial paperwork burden. As a result, revised regulations must be
issued to increase facility flexibility and to bring the ESRD COC up to current standards of
practice in the ESRD community. The revised COC will address the outcome-oriented,
patient-centered standards process where appropriate, reflect innovations in the dialysis and
transplant community, and address new issues such as adequacy of dialysis to ensure that the
Medicare beneficiary is receiving the most progressive quality of care possible. Thus,
HCFA's emphasis will be on the total patient experience with dialysis, including patient
functional well-being and continuous quality improvement. The revised regulations will
include development of performance expectations for the facility that result in quality,
comprehensive care for the dialysis patient.
Implementation and Timeline: HCFA will publish a proposed rule in March 1996.
Rules for ESRD Facilities - A Pilot for Good Performers:
HCFA is conducting a pilot project to apply a different, less prescriptive set of rules to
excellent ESRD facilities. Under the pilot project, an ESRD facility's performance will be
measured using only three key patient care outcome indicators. The pilot differs from the
current system in three important ways. First, these indicators will be used in place of the
current certification standards and surveys will be waived. Second, the pilot project will
focus on helping facility staff use outcome measures in an ongoing way to improve the care
provided to dialysis patients. Third, facilities that document sustained achievement in the
outcome indicators over six consecutive months will be awarded a HCFA certificate of
excellence
The indicators measure the quality of hemodialysis in three areas critical to the health of the
patient: adequate dialysis, control of anemia, and adequate water supply. They will be used
by the facilities to monitor the condition of each dialysis patient and to achieve improvement
in the patient's health status. For the pilot project, excellence will be identified through a
process focused on the quality indicators. The process will look at whether facilities have an
internal quality monitoring system, whether the results of such monitoring are documented,
and whether results are sustained. The facilities that qualify in this pilot will have
established certain internal quality control mechanisms in order to participate. Routine
surveys of these facilities will be waived and HCFA will examine other appropriate means
of providing regulatory relief for good performers. Surveys will be conducted in response to
complaints about the quality of care or if the data indicate a potential serious problem.
Information about project results will be packaged in brochures and newsletters so that
ESRD patients and non-participating ESRD facilities will be aware of the results. In this
competitive industry, a successful project will stimulate many other providers to seek
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recognition as "EXCELLENT" facilities.
ESRD facilities will be notified of their eligibility to participate and participation will be
voluntary. The pilot will be limited to facilities in the States of Colorado, Idaho, Montana,
and Washington.
Implementation and Timeline: Planning for this pilot is underway. Regulations to permit
this pilot will be published in November 1995.
Elimination of Personnel Requirements:
HCFA is conducting a pilot project that will evaluate the impact of the elimination of
Medicare personnel requirements for ESRD facilities. Currently, the Medicare conditions
for coverage for ESRD facilities include fairly detailed specifications for several types of
personnel employed in furnishing ESRD services to Medicare beneficiaries. For example,
the medical director of the facility must be a physician, board eligible in internal medicine;
the nurse in charge must have 12 months of clinical experience, with 6 months experience
with ESRD patients; the social worker must be master level educated, etc. Over the years,
HCFA has received comments from the industry both in favor of elimination of the
personnel requirements and in favor of strengthening them. Those in favor of relaxing the
requirements commonly cite the difficulty rural facilities can face in recruitment of
personnel with the requisite experience. They believe that the job does not require the level
of experience and education prescribed in order to perform adequately. Those in favor of
maintaining personnel requirements cite the medical condition of ESRD patients as
justification for the skills level requirements. They express concern that if the personnel
requirements are weakened or eliminated, ESRD facilities, most of which are proprietary
entities, would hire less experienced and more inexpensive personnel to provide care that is
of inferior quality.
The pilot project would be conducted in concert with another proposed project establishing
new rules for historically good ESRD performers (see above). HCFA will collect
information regarding the skills level of all personnel employed by those facilities
participating in the project. Facilities would be informed that as part of the project,
Medicare would not apply any of the personnel requirements contained in the conditions for
coverage. At the end of the two-year project period, HCFA will re-collect information
regarding the education and experience level of all the facility's staff and evaluate the impact
of the changes on predetermined measures of quality of care.
Implementation and Timeline: Planning for this pilot is underway. Regulations to permit
this pilot will be published in November 1995.
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4. The HCFA-1500 Form
Background: The HCFA-1500 form is currently used by physicians, other practitioners,
and durable medical equipment suppliers to submit claims for Medicare reimbursement of
health care services. The HCFA-1500 is also used by many other insurers for claims
submission. Although many Federal programs require the use of the HCFA-1500, use of the
form is not required by the Federal Health Benefit Plan (FEHBP). Currently, more than a
dozen different forms are used by fee-for-service carriers participating in FEHBP. In
addition, instructions for the forms vary across programs.
Proposal:
After a phase-in period, the Office of Personnel Management (OPM) will
require participating FEHBP carriers to use the HCFA-1500 form for physicians' and other
practitioners' claims.
Impact: Physicians will be able to use one form to submit claims for services provided to
many patients. The number of claims forms that are used will drop from more than a dozen
to one and instructions will be standardized.
Implementation and Timelíne: OPM phase-in of the HCFA-1500 will begin in January
1996 and will be completed in September 1996. By the year 2000, the majority of provider
claims will be submitted electronically.
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5. Preadmission Screening and Annual Resident Review (PASARR) of Mentally III
and Mentally Retarded Residents
Background: Nursing homes under Medicare and Medicaid are currently required by law
to conduct an initial assessment of each resident within 14 days of admission, with a
reassessment whenever a significant change in condition occurs but in any event at least
once a year In addition, there is a statutory requirement that for persons with serious mental
illness or mental retardation entering a nursing home, the State is required to conduct: (1) a
preadmission screening to assure that the individual is being appropriately placed in a
nursing home, and (2) an annual reassessment to assure that the patient continues to be
appropriately diagnosed and treated.
Proposed Solution: Legislation would be proposed to eliminate the duplicate annual
assessment Resident assessments and reassessments required under the general nursing
home requirements are entirely adequate to assure that residents' continuing needs are
properly assessed and met. Preadmission screening, which deters inappropriate admissions,
would continue.
Impact: By eliminating the redundant annual PASARR reassessment, costly duplication of
effort by States would be reduced and nursing facilities would be relieved of intrusive
annual inspections.
Implementation and Timeline: Legislation will be proposed.
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6. Nurse Aide Training and Competency Evaluations
Background: To assure quality of care in nursing homes, current law prohibits nursing
homes from using nurse aides that have not successfully completed a training or competency
evaluation program. The statute requires the Secretary to establish requirements for the
approval of nurse aide training and competency programs. The law further forces States to
prohibit, for a period of two years, nurse aide training and competency evaluation programs
operated by or in nursing homes that were subject to an extended survey or partial extended
survey or certain other sanctions. (Extended or partial extended surveys are conducted as
more intensive follow-up investigations after a routine survey has demonstrated that a
facility is furnishing substandard care.)
When a facility's program has been disapproved, the facility may not even be the site of an
aide program conducted by others during the time that the two-year penalty is imposed. The
prohibition on approval of nurse aide training and competency evaluation programs causes a
special problem for rural nursing homes where a community college or other training facility
may be inaccessible to nurse aides. Rural facilities can face a serious shortage of trained and
competent staff due to the expense and inconvenience of sending prospective aides to remote
locations. Alternative training programs may not be available.
Proposed Solution: Specify that a State could choose to approve a nurse aide training and
competency evaluation program offered in (but not by) a nursing home subject to an
extended or partial extended survey or certain other sanctions if the State determines that
there is no other nurse aide training and competency evaluation program offered within a
viable distance. States would be required to provide ongoing oversight of these programs in
the interest of patient health and safety.
Impact: This proposal would safeguard the availability of nursing homes which might
otherwise stop participation in the Medicare and Medicaid programs as a result of losing a
training programs' approval. It would also make it easier for nurse aides to obtain the
training they need to provide quality services to our beneficiaries.
Implementation and Timeline: Legislation will be proposed.
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Conclusion
Under President Clinton's leadership, HCFA has made communication, cooperation, and
partnership the guiding principles of the regulatory process, replacing the adversarial
environment that often existed in the past. At a time when the American health care system
is undergoing dramatic changes, HCFA is committed to putting the federal government's
customers -- the American people -- first. We are pleased to report that the initiatives
described in this report represent just the beginning phases of HCFA's ongoing work on
regulatory relief.
16
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07/07/95 07:40 FAX 515 222 7257
MERCY WEST ADMIN
001
FAX COVER SHEET
Dr. Steve Gleason
1601 N.W. 114th Street, Suite 130
Des Moines, lowa 50325
Phone: (515)222-7252
Fax: (515-222-7257
Staff Contact: Nicki
DATE:
7-7-95
TO:
JeNNifer KleiN
COMPANY:
FAX NO. 202-456-2878 PHONE NO.
DELIVERY INSTRUCTIONS:
URGENT
ROUTINE
THIS IS PAGE 1 OF
PAGES (INCLUDING THIS PAGE).
COMMENTS: Jennifer - Dr. Wants you to fax Changes
to his home this weekend. Call first
@ 515-277-1777. Fax is same as shone #.
Thanks
CONFIDENTIALITY STATEMENT
The information in this facsimile message is privileged and confidential information intended only for
the review and use of the individual or entity named above. If the reader of this message is not the
intended recipient, you are hereby notified that any disclosure, dissemination, distribution or copying
of this communication or the information contained herein is strictly prohibited. If you have received
this communication in error, please immediately notify us by telephone and return the original message
to us at the above address.
07/07/95
07:41 FAX 515 222 7257
MERCY WEST ADMIN
002
DRAFT
Reducing Bureaucracy in Health Delivery
DRAFT
Comments by Dr Steve Gleason
The White House
July 11, 1995
Thank you, Mrs. Clinton, for a most gracious introduction, but it should be me
and all Americans, in fact, thanking you for your courage in tackling Important health
issues. You have been a champion for paperwork reduction, for preserving Medicare,
for patient choice, and, of course, for the uninsured. In reminding us that we are,
indeed, our brother's keeper, you have provided moral balance to the health debate.
And I believe bureaucracy reduction is, indeed, a moral as well as a fiscal issue.
Highlighting that point was the herald event that transformed me into a political
activist.
Frustrated by the many conflicting rules and regulations that seemed to be
coming from all different directions, 1, like many other physicians, tended to address
this problem in 1986 by arguing with colleagues in the doctors' lounge-an exercise
that was supposed to effect change. But, in reality, it just reinforced our anger and
our political ineptitude.
But when my father went to the Emergency Room, saying that he was sicker
than he had ever been, I found I needed to find better ways to effect change. This
was in the days when pre-admission paperwork approval was in vogue and the
Emergency Room staff was struggling with the fact that his chest x-ray, EKG,
1
DRAFT
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003
laboratory data, and vital signs were all normal. In spíte of complaints of pain from
my normally stoic father, he appeared, on paper, to be perfectly healthy. It took many
hours before we were able to gain the approval to proceed with surgery for what
ended up being a ruptured bowel and subsequent septicemia. Following surgery, he
went into respiratory arrest and was on a ventilator the better part of three months
before he died. During a short period when he was off of the ventilator, I stayed with
my father almost night and day, discussing with him life in general. But one particular
night his curiosity led us to a pressing question. Why was it that physicians who are
charged with the health of a Nation couldn't affect and streamline the process by
which patients are admitted to the hospital. It was one of his last clearly spoken
thoughts.
That's why this initiative is so critical to me. Unnecessary bureaucracy diverts
time and money away from patient care and, at times, delays important procedures.
Reducing paperwork in health care is, 1 believe, a moral as well as a fiscal issue.
The number of regulations and rules concerning health care are similar, in some
respect, to Winston Churchill's definition of history. "History", Mr. Churchill said, "is
just one damn thing after another." And the regulations which have been
promulgated on consumers and providers of health care over the past two decades
have often been confusing, and, certainly, at times, conflicting in their purpose.
It has seemed that some Republicans and Democrats have been out of touch
with this Country's founding ideals. Thomas Jefferson, (the first Democrat) fought
against government oppression and eloquently defended individual liberty and
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DRAFT
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tolerance. Burdensome regulations can have a fearsome oppressive effect on the
quality, creativity, and fiscal good sense necessary for great medical care. By creating
a myriad of regulations and forms, each one designed to protect the very few,
government has, at times, created a tremendous burden for the vast majority. It is,
therefore, notable and refreshing that this Administration is willing to tackle the issue
of reinventing government and regulatory relief.
I'm pleased to be here today to participate in this announcement as part of the
Administration's ongoing effort. I have the job of highlighting just one small piece
from the array of recommendations which the Vice President will soon review.
And I should add, Mr. Vice President, we all appreciate very much your efforts
to move us into the next millennium. Your work on our behalf to reduce unnecessary
bureaucracy and develop new technologies is appreciated more than you know.
The pile you see before you represents physician attestation statements. For
those of you unfamiliar with this form, it was a form designed during some previous
Administration to do several things.
It was designed as an additional summary sheet of the diagnoses in a
medical case. This form, of course, is in addition to a fully complete
discharge summary that already had such information.
It was designed to legally bind the physician by requiring an "attestation
or "truth oath" concerning the accuracy of the dictated discharge
summary.
Under Medicare law some thought this form made it easier to put pressure on
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physicians to dictate accurate medical records. We later found out, of course, that
the regular discharge summary suffices fully for that activity. In the end, the only
result was that it added more work to the physician's day, more costs in the Medical
Records Department, and effectively delayed hospital payments by an additional thirty
days. This pile of paper represents the number of attestation statements signed in a
single year by a single, middle sized community hospital in lowa.
This particular pile of attestation statements represents 11,127 discharges
representing one full year for one hospital:
Nine medical records staff spent 6,100 hours in one year to prepare the
forms.
The forms required an additional 927 hours of physician time.
Total hospital and physician costs per year for this effort was $158,000.
136.8
When extrapolated to the entire Nation, this form creates 369 million dollars in
6.1
unnecessary expense and 16.8 million hours in unnecessary paperwork, not to
mention the over 9 billion dollars in delayed Medicare payments per year to the
Nation's hospitals.
Eliminating this form is a very important step on our road to recovery from
bureaucracy. It helps return physicians to the bedside and cuts bureaucracy-related
costs. And this represents only one of over a thousand different kinds of forms which
consume 20 to 30 percent of our healthcare professionals' workday throughout the
Nation.
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I cannot leave today without offering two important thank yous. The first to
Bruce Vladek and HCFA for the monumental effort involved in making HCFA a
customer-friendly organization.
I also want to thank those of you in the audience, many of whom have been
instrumental in bringing this important work to fruition.
Thank you very much, Mrs. Clinton, for allowing me to share in part of this
historic announcement. I look forward to working with the Administration in the
months to come to further implement these initiatives.
DRAFT
5
THE PRESIDENT'S ECONOMIC PLAN:
A BALANCED BUDGET THAT PUTS PEOPLE FIRST
I. FRAMEWORK TO BALANCE THE BUDGET: Building on his 1993 plan that reduces
the deficit by $1 trillion over seven years, the President today is releasing his economic
framework for balancing the budget by the year 2005 while still investing in education and
training; taking serious steps toward health reform while strengthening the Medicare Trust
Fund and protecting beneficiaries; and targeting tax cuts only to working families. The
President's plan builds on the savings and investments in his FY1996 budget and calls for real
cuts in most areas of government spending other than Social Security.
II. THREE FUNDAMENTAL DIFFERENCES: While the President shares the goal of
reaching a balanced budget with the Republican Congress, there are three fundamental
differences in what the President will call for to make this a balanced budget that puts
working families first.
1. FIRST STEPS TOWARD HEALTH CARE REFORM WHILE STRENGTHENING
THE MEDICARE TRUST FUND:
Republican Plan: The Republican plans call for deep Medicare savings that would
require a senior couple to pay $1500-$2000 a year more by the year 2002 -- only to
pay for unjustifiable tax cuts.
President's Plan: The President's plan calls for half the Medicare savings of the
Republican plans ($124 billion), no new Medicare beneficiary cuts, and takes the first
steps toward serious health reform. The President calls for one-third the level of
Medicaid savings ($55 billion) of the Republican plans, gives states additional
flexibility, and protects Medicaid coverage by including a per person cap. Elements of
the health reform plan include:
Protecting the Medicare Trust Fund to 2005
Health Security for Working Families After a Job Loss: (6 months of
health coverage for families who lose insurance when they lose a job)
More Options for Medicare Managed Care that Protects choice
Prevention: No Co-payments for Medicare Mammography Screening
Alzheimer Respite Benefit
Downpayment on Home and Community-based Long-term care
Insurance Reforms including Portability and Limits on Exclusions for
Pre-existing Conditions
Give Small Businesses Pooling Options, including Participation in FEHBP
Self-Employed Tax Deduction Increased to 50%
1
2. PROTECTING INVESTMENT IN EDUCATION AND TRAINING:
Republican Plans: The Republican plans cut investments in education by $43 billion
over seven years, cutting Head Start and seeking to eliminate or dramatically cut
GOALS 2000, Safe and Drug-Free Schools, AmeriCorps, student aid, and job training
at all levels.
President's Plan: The President's plan puts people first by preserving investments in
education and training, with significant increases in Head Start, Goals 2000,
AmeriCorps, student aid, a new GI Bill of Rights for Workers that increases training
through Skill Grants, and a $10,000 education tax deduction.
3. A TAX CUT THAT IS TARGETED ONLY TO WORKING FAMILIES:
Republican Plans: The Republican House plan calls for a $630 billion tax cut over
ten years that would give a $20,000 tax cut to the top 1% of taxpayers, and the Senate
budget calls for increasing taxes on 14 million working families.
President's Plan: The President's plan keeps his full Middle Class Bill of Rights tax
cuts: a $500 tax credit for children under 13; a $10,000 education deduction, and an
expanded IRA that allows more working families not only to save for retirement but
also to use the savings for education, a first home, or long-term care for a sick
relative.
III. COMPONENTS OF SAVINGS FOR BALANCING THE BUDGET: The President's
plan does not change the basic budget for FY1996, but it extends the savings pattern in
domestic discretionary spending through 2005 while calling for serious, but reasonable
entitlement savings.
Medicare savings are $124 billion over seven years, less than half of the Republican
plans, while protecting beneficiaries, securing the Medicare Trust Fund through 2005
and taking the first steps toward health reform.
Medicaid savings are $55 billion in over 7 years -- one-third the size of the
Republican proposals -- and include a per person cap to protect coverage, rather than
an aggregate block grant.
Welfare reform has savings of $35 billion which is less than half of the Republican
proposals and essentially consistent with major Democratic alternatives.
Corporate contribution of $25 billion over seven years through a bipartisan effort to
close corporate loopholes, special interest tax breaks, and unwarranted corporate
subsidies.
2
Other than education, research and selected investments in the environment and other
areas, domestic discretionary spending is cut by over 20% in real terms near the end
of the plan.
Defense outlays in the President's plan are above both the House and Senate levels in
FY2002, yet savings are achieved by keeping budget authority constant from FY2002-
2005.
IV. A MORE BALANCED APPROACH TO BALANCING THE BUDGET:
Republican Plan: The Republican plan calls for deep Medicare cuts and education
cuts in order to pay for a tax cut going largely to the most well-off. A top national
forecaster, WEFA, (formerly Wharton Econometrics) has projected that this seven-year
path would slow growth, increase unemployment to over 8.5%, and delay their deficit
projections by at least two years.
President's Plan: By limiting a tax cut to working families and by calling for a
moderately longer time path to balance the budget, the President's plan avoids the
necessity of cutting education or calling for new Medicare beneficiary cuts. This 10-
year plan has the benefits of a solid balanced budget path with less of the downside,
contractionary risks of the Republican seven-year proposals.
3
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17:57
002
DRAFT HRC INSERT FOR DOCS SPEECH:
Everyone in this room is well aware that the hcalth care challenges we all worked to
address in the last Congress remain with us. As health carc professionals, you don't
just read about it, you live it. You see it every day and every night.
The fear of losing health insurance when you leave one job for another still remains.
The inability of small businesspersons to find and keep affordable health insurance for
themselves and their employees is no less a problem. The numbers of the uninsured,
and thereforc uncompensated care, continue to increase at an alarming pace of about
one million Americans a year. The upcoming aging of the baby boom population and
their accompanying and currently unmet long-term care needs is looming just over the
horizon.
The concerns about how pressures to contain public and private health care spending
effect quality and choice are even greater than they were last year. Our academic
health centers and other centers of excellence for research and training are growing
increasingly concerned about the impact of tightening payment rates from managed
care cntities and Medicare and Medicaid. Our rural and inner city hospitals feel
equally threatened.
All of this is to say that we must stay engaged in addressing these and many more
present and future health care challenges. There is no better group of individuals than
those in this room to help craft the responses. We must defend against approaches
that would take our system backwards and move forward, in a bipartisan basis, to craft
constructive steps forward.
You are the professionals who are best positioned to help bridge the differences and
political gaps between the parties and competing approaches. The President and I
look forward to working with you in this regard.
OUTLINE OF FIRST LADY'S MEETINGS ON TUESDAY, JULY 11
11:30 AM - 12:00 NOON
POLITICAL MEETING WITH SUPPORTIVE DOCTORS:
Indian Treaty Room
This meeting is with the 60 physicians who have come to
Washington as a part of the Steve Gleason's group (the
National Health Policy .Council). Doug Sosnik plans to give
a quick update of the reelect; First Lady will comment on
why it is so important for health care providers to be
involved in the political process; Steve Gleason and Irwin
Redlener will give a personal pitch about how these
physicians can stay involved.
12:15 pm - 12:45 pm (they will be ready at 12:00 noon)
PRIVATE PRE-BRIEF WITH THE HEADS OF THE NATIONAL PHYSICIAN
ORGANIZATIONS:
Room 472, OEOB
The purpose of this meeting is to pre-brief the heads of the
national physician organizations in a discussion setting, so
that they fully understand our reg. reform recommendations,
and will be more prepared to make supportive statements
following the official event.
07-10-95 11:57AM FROM OASPA NEWS DIV
TO 94562878
P001/002
HUMAN SERVICES USA
DEPARTMENT OF HEALTH & HUMAN SERVICES
4
HEALTH
A fax message from:
OF
Melissa T. Skolfield
Deputy Assistant Secretary for Public Affairs
Phone: (202) 690-6853
Fax: (202) 690-5673
To: JennifuKeun
DPC
Fax: 456-2878
Phone: : 456.2599
Date: 7/10
Total number of pages sent: 2
Comments:
Here's the media adrisory which your press
office has cleared. Victor Zonana (690-6343)
wise cc: you when he sends the fact sheet &
press release to mike Russell.
m.
07-10-95 11:57AM FROM OASPA NEWS DIV
TO 94562878
P002/002
HHS NEWS
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
July 10, 1995
ADVISORV
For Tuesday, July 11
Medicare Regulatory Reforms:
Presentation, Media Briefing
1 p.m. -- PRESENTATION -- Vice President Gore, First Lady
Hillary Rodham Clinton and HHS Secretary Donna E. Shalala will
unveil Medicare regulatory reforms that reduce paperwork for
doctors and other health care providers. Also participating will
be Dr. Steve Gleason of Des Moines, Iowa, chair of the National
Health Policy Council. (Presentation and photo opportunity only:
no q and a.)
WHERE: Room 450 old Executive Office Building.
3 p.m. -- MEDIA BRIEFING -- A briefing regarding the reforms
will be given by Bruce Vladeck, administrator of the Health Care
Financing Administration.
WHERE: Humphrey Building Auditorium
200 Independence Ave. SW
CONTACT: HCFA Press Office
(202) 690-6145
July 10, 1995
MEMORANDUM TO JENNIFER KLEIN
FROM:
MARILYN YAGER
OFFICE OF PUBLIC LIAISON
WHAT:
BUDGET AND PRE-BRIEFING FOR PHYSICIANS ATTENDING HCFA
REGULATORY REFORM EVENT.
DATE/TIME: Tuesday, July 11
9:30am - 11:00am
LOCATION: Room 450
PURPOSE: To provide a detailed briefing on the regulatory reform
proposals and the current congressional situation for
the supportive physicians who traveled to Washington
for our HCFA Reg. Reform event.
BACKGROUND:
Several weeks ago we asked Dr. Steve Gleason to extend
an invitation to members of the National Health Policy
Council (NHPC) to join us for an update on Phase I of
our health care regulatory reform recommendations. In
response 60 of their members will comprise the majority
of the audience for the 1:00pm REGO event. Although
most of NHPC are physicians, some are nurses, teaching
hospital administrators, and other health
professionals.
As you will recall, the NHPC actively supported the
Health Security Act with many of their members official
surrogate speakers for the health care war room here at
the White House. There has been little opportunity
since the last Congress adjourned, to tell these folks
how much we appreciated their support and to let them
know that we still welcome their input. By providing
additional briefings for those attending the REGO
event, we hope to send the message that they have not
been forgotten.
We also wanted to provide a detailed briefing of our
REGO recommendations, because many of these individuals
will be doing local media after the 1:00 event.
FORMAT:
Welcome
Harold Ickes
Budget Overview
Alice Rivlin
Details of GOP budget and
Nancy-Ann Min
Clinton Proposal
Chris Jennings
Health Cared Regulatory
Bruce Vladeck
Reform Recommendations
Jennifer Klein
Q & A
PARTICIPANTS:
List attached.
July 10, 1995
POLITICAL MEETING WITH GLEASON GROUP
DATE:
Tuesday, July 11
TIME:
11:30 am
LOCATION: Room 474, OEOB
FROM:
Marilyn Yager
I.
PURPOSE
To personally thank these supportive physicians and other
providers for their time and commitment to health care reform in
general, and specifically their advocacy on behalf of the Health
Security Act. To urge them, as health care professionals, to
stay involved in the political process during the months ahead.
II. BACKGROUND
As stated in the purpose, this is an opportunity to let these
supportive health care providers know that we have not forgotten
all the time and dedication they gave to the health care reform
debate. Many of these physicians are not only discouraged with
the results of the health care reform debate, but also with the
resulting void left to interact with the Administration.
The ongoing regulatory reform process demonstrates that their
input continues to have results, especially since Steve Gleason
(on behalf of the National Health Policy Council) helped to drive
the process which resulted in today's recommendations.
This private meeting with these folks provides an opportunity for
you to remind them how important it is that health care
professionals stay active in the political process and that they
can make (and have made) a difference.
III. PARTICIPANTS
Approximately 60 members of the National Health Policy Council.
List attached.
IV. SEQUENCE OF EVENTS
HRC arrives in Room 474
HRC briefly works the crowd (providing photo opportunities)
Steve Gleason and Irwin Redlener make brief remarks.
Steve Gleason introduces HRC.
HRC makes brief remarks.
HRC departs (Doug Sosnik will remain to take questions about
the political process during the months ahead).
V. PRESS
Closed.
VI. REMARKS
Talking points attached.
July 10, 1995
PRE-BRIEF MEETING WITH THE LEADERSHIP
OF THE NATIONAL PHYSICIAN GROUPS
DATE:
Tuesday, July 11
TIME:
12:15 pm
LOCATION: Room 474, OEOB
FROM:
Marilyn Yager
I.
PURPOSE
To privately brief the heads of the national physician
organizations on the recommendations to be released. More
specifically to help them place in perspective the regulatory
reform recommendations to be announced, and to assist them in
providing a positive reaction to our recommendations.
II. BACKGROUND
Knowing that most health care providers receive their federal
information through their professional organizations, we felt it
was critical to have a private meeting with the heads of national
organizations. In addition, it is important that they are clear
about our recommendations and intentions so that they feel
informed should reporters contact them for comment.
In this meeting we hope to clarify that although they may have
hoped our recommendations would go further or be more
significant, we hope they will place in context all of the
changes we have made to date and recognize that we have truly
instituted a process by which we are constantly seeking ways to
reduce or eliminate burdensome requirements on provider. If
possible, we should make it clear that supportive comments of the
steps the Department of Health and Human Services has taken so
far will make it that much more easier for us to continue on this
path.
It should be noted that several of the associations represented
in this meeting differed greatly in their support for the Health
Security Act (HSA), although the majority of the groups
represented were active supporters. As you will recall, groups
like the American College of Physicians, the American Association
for Family Physicians, and the American Academy of Pediatrics
were active supporters. Other physician groups like the American
Medical Association and the American Society for Internal
Medicine, while supporting the five principles, took strong
exception to many parts of the HSA.
III. PARTICIPANTS
List attached.
IV. SEQUENCE OF EVENTS
O
HRC arrives in Room 472.
O
HRC makes brief remarks.
O
Secretary Donna Shalala and Administrator Bruce Vladeck will
provide more detailed description of the recommendations.
O
Discussion.
O
HRC departs.
V.
PRESS
Closed.
VI. REMARKS
Talking Points attached.
TENTATIVE SCHEDULE FOR PHYSICIANS
Tuesday, July 11
NOTE: You should come to the Pennsylvania Avenue entrance to the
Old Executive Office Building at the corner of Pennsylvania and
17th Street (this building is right next to the White House).
Please try to arrive by 9:00 am to allow for your security
clearance.
9:30am 10:45am
Budget/Issues Briefing
Room 450, Old Executive Office Building
(This will include a substantive
briefing on Medicare and Medicaid)
11:00am 11:45am
Special Event Pol
11:30 - 12:00
-
The White House
11:45am 310 - 12:30pm
Indian Treaty Rm.
Lunch (on your own) (many local sandwich
shops near the Old Executive Office
Building)
12:45pm - 2:00pm
Healthcare Regulatory Reform Event with
the Vice President and First Lady
Room 450, Old Executive Office Building
2:00pm - 3:30 pm
Potential press interviews for
individual physicians (for those who are
able to stay during this time period, we
will try to arrange press interviews
with your home state press).
ADDITIONAL NOTE:
We apologize for changes in the schedule
which have moved the length of the meetings
into the afternoon. We hope this will not
inconvenience anyone's scheduled travel
plans.
Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
SUBJECT/TITLE
DATE
RESTRICTION
AND TYPE
001. list
While House health care briefing invitees [Personally Identifiable
07/07/1995
b(6)
Information] (35 pages)
COLLECTION:
Clinton Presidential Records
First Lady's Office
Jennifer Klein
OA/Box Number: 9147
FOLDER TITLE:
Regulatory Review - Event [2]
2014-0536-S
kc1610
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)]
Freedom of Information Act - [5 U.S.C. 552(b)]
P1 National Security Classified Information [(a)(1) of the PRA]
b(1) National security classified information [(b)(1) of the FOIA]
P2 Relating to the appointment to Federal office [(a)(2) of the PRAJ
b(2) Release would disclose internal personnel rules and practices of
P3 Release would violate a Federal statute |(a)(3) of the PRA
an agency [(b)(2) of the FOIA]
P4 Release would disclose trade secrets or confidential commercial or
b(3) Release would violate a Federal statute |(b)(3) of the FOIA]
financial information [(a)(4) of the PRA]
b(4) Release would disclose trade secrets or confidential or financial
P5 Release would disclose confidential advice between the President
information [(b)(4) of the FOIA]
and his advisors, or between such advisors [a)(5) of the PRA]
b(6) Release would constitute a clearly unwarranted invasion of
P6 Release would constitute a clearly unwarranted invasion of
personal privacy |(b)(6) of the FOIA]
personal privacy [(a)(6) of the PRA]
b(7) Release would disclose information compiled for law enforcement
purposes |(b)(7) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
b(8) Release would disclose information concerning the regulation of
of gift.
financial institutions [(b)(8) of the FOIA]
PRM. Personal record misfile defined in accordance with 44 U.S.C.
b(9) Release would disclose geological or geophysical information
2201(3).
concerning wells [(b)(9) of the FOIA]
RR. Document will be reviewed upon request.
TO:
Melanne Verveer
FROM:
Jennifer Klein
Marilyn Yager
DATE:
4/27/95
RE:
Health Care Regulatory Relief Event
Here is a summary of our proposal for the Health Care Regulatory Relief Event.
DATE:
As you know, Steve Gleason was unable to organize the doctors in time for an April
27 event. He needs at least three weeks to notify the doctors so that they can
change their patient schedules and get plane tickets.
Patti has suggested May 22. However, we were subsequently told that the Vice
President also wants to participate and is unavailable on that day. Maggie and
Jennifer (who both spoke with Elaine Kamarck) agreed that it will be difficult not. to
include him if he wants to be part of the event. He is available on May 24 and 25.
PARTICIPANTS:
Remarks: The First Lady
The Vice President
Secretary Shalala or Bruce Vladeck
Audience: Dr. Gleason's doctors
Other supportive physician and hospital groups
HHS Regional Directors
EVENT PROPOSAL:
9:30 a.m.
Gleason's group gets briefing on health care reform from Carol Rasco and/or
Laura Tyson and details of regulatory relief proposals from Bruce Vladeck or
Helen Smits and Jennifer.
10:00 a.m.
HRC holds private meeting with representatives from Dr. Gleason's group
and the presidents of the physician and hospital associations.
11:00 a.m.
Event in East Room. HRC announces new regulatory relief proposals as well
as progress on other initiatives that the Administration has already undertaken
and plans for ongoing efforts to reduce regulatory burdens. The Vice
President highlights the importance of these efforts as part of our overall
effort to reduce burdens and make our progams more customer-service
oriented. Secretary Shalala or Bruce Vladeck provide more detail on the
initiatives.
12:00 p.m.
Participants from key states do radio and print interviews highlighting the
impact of these changes.
cc:
Patti Solis
EXECUTIVE OFFICE OF THE PRESIDENT
17-Feb-1995 04:19pm
TO:
Jennifer L. Klein
FROM:
Barbara D. Woolley
Public Liaison
SUBJECT:
Format for Regulatory Releast
Regulatory Release Format
Location: Hospital in one of the key states
Press: Both, National and regional
Format:
Audience: Approximately 100 made of those folks that benefit from
regulatory release: Physicians and Hospitals folks from our
supportive hospital, physician, other groups that benefit from the
regulatory relief. Also have 30 or SO folks from location.
Panel: 14 people on panel. The First Lady, 2 Hospital
Administrators, 2 Physicians, 1 or 2 HHS rep (Donna Shalala and
Bruce V.) 6 consumers with personal nightmare highlighting
regulatory issues. 1 insurer. 1 employer. 1 service provider. 1
expert outside the government, maybe from one of the groups who
provide expertise on issue.
Full List for One O'Clock
Event
1:00
Attendees for the 9.30 Meeting, "The Steve Gleason Group"
Raymond Adleman, MD
Gerben DeJong, PhD
Norfolk, Virginia
Bethesda, Maryland
Stephen Michael Ahner
L.C. Dorsey, DSW, LCSW
Washington, DC
Mt. Bayou, Mississippi
Gloria Jackson Bacon, MD
Charles Dougherty, PhD
Chicago, Illinois
Omaha, Nebraska
Alan Baskin, MD
Gail Douglas, RN, MPH
Dumont, New Jersey
Boston, Massachusetts
Robert Berenson, MD
Beth Doaoretz, MD
Bethesda, Maryland
Norfolk, Virginia
Allah Bhatti, MD
Ron Dozoretz, MD
Milwaukee, Wisconsin
1st Hospital Co.
Norfolk, Virginia
Richard Boxer, MD
Milwaukee, Wisconsin
Jack Michael Dutzar, MD
Spokane, Washington
John (Jack) Bresch
Catholic Health Assoc.
Kevin Fickensher, MD
Washington, D.C.
Milwaukee, Wisconsin
E. Richard Brown, PhD
Pat Ford-Roegner
Los Angeles, California
HHS-Regional Director
Atlanta, Georgia
Karen Burke, MD
Kaiser Permanente
Howard Freed, MD
Raleigh, North Carolina
Slingerlands, New York
David Cawley
James Harold French, Jr. MD
1st Hospital Co.
Fairfax, Virginia
Financial Systems
Reston, Virginia
Ms. Terry Gaffney
American Nurses Assn
Jerome Connally, PT
Washington, DC
Billings, Montana
David Gencarelli
Lynn Cutler
Washington, DC
The Kamber Group
Washington, D.C.
Timothy Gleason
Des Moines, Iowa
Carol Daniels
Texas Dept. of Health
Steve Gleason
Austin, Texas
Natl Health Policy
Council
Des Moines, Iowa
Herb Gleason
Judy Kline Leavitt, RN
Boston, Massachusetts
Ithaca, New York
Steve Gorin
William Licamele, MD
Canterbury, New Hampshire
Washington, DC
Robert Grayson, MD
Irving Loh, MD
Surfside, Florida
Thousand Oaks, California
Mary Hansen, RN, PhD
Gordon MacLeod, MD
Des Moines, Iowa
Pittsburgh, Pennsylvania
Mary Hayes, DDS
Tammy Mann, PhD
Chicago, Illinois
Washington, DC
Richard Hollis, MD
Robert Millman, MD
Amory, Mississippi
New York, New York
John Holloman, MD
Mary Mundinger, RN, DrPh
New York, New York
New York, New York
Allen Hyman, MD
Janet O'Keefe
New York, New York
Washington, D.C.
Kenneth Ingber, DMD
George Rapier, MD
Washington, DC
San Antonio, Texas
David Jackson, MD, PhD
Irwin Redlener
Columbus, Ohio
New York, New York
Lawerence Jindra, MD
Neil Redlener, MD
Garden City, New Jersey
Boston, Massachusetts
Charles Johnson
Susan Reynolds, MD
Des Moines, Iowa
Malibu, California
Gloria Johnson-Powell, MD
Elena Rios, MD
Boston, Maryland
Washington, DC
Harry Jonas, MD
Alan Rosenfield, MD
Chicago, Illinois
New York, New York
Florence July, RN, BSN
Barbara Ross-Lee, MD
Okemah, Oklahoma
Athens, Ohio
Mi Ja Kim, RN, PhD
Robert Ruben, MD
Chicago, Illinois
Bronx, New York
Richard Knapp, PhD
Karen Walsh Rutledge
Washington, DC
Washington, DC
Carol Kuhle
Vin Sahney, PhD
Des Moines, Iowa
Detroit, Michigan
Elizabeth Shannahan
Des Moines, Iowa
Aaron Shirely, MD
Jackson, Mississippi
Suzanne Smith
Cleveland, Ohio
Particia Starck, RN
Houston, Texas
David Swicskowski, MD
Des Moines, Iowa
William Terry, MD
Boston, Massachusetts
Jorge Valle, MD
Northbrook, Illinois
Victor Vela, MD
San Antonio, Texas
Robert Waters, Esq.
Washington, DC
Sterling Williams, MD
New York, New York
Kathy Wood Dobbins
Nashville, Tennessee
Marilyn's Doctor's Groups at 1pm Briefing
The American Academy of of Pediatrics
Elizabeth Noyes
Rachel Schaffer
Deborah Ringel
Adam Ellis
Anne Webster Green
American Osteopathic Association
Elizabeth Beckwith
Stacy Bohlem
Michael Conrad
American Group Practice Association
Donald Fisher
Susan Whitaker
M. Kathleen Kenyon
Rebecca Gray
R. Brian Lewis
American Society of Internal Medicine
Alan Nelson
John Philip DuMoulin
Kristin Louisa Miller
Physicians Advisory Council
Kenneth Viste, Jr., MD
American College of Emergency Physicians
Richard Aghababian, MD
John Scott
Lee Robert Godown
Roslyne Debbie Weiner Schulman
American College of OB/GYNs
Kathy Bryant
Carol Vargo
American Academy of Family Physicians
Charles Huntington, III
American College of Preventive Medicine
Hazel Keimowitz
Donna Grossman
Barbara Anne Clark
Tracey Lynne Ialeggio
Marcus Randall Eng
American Medical Women's Association
Eileen McGrath
Diane Helentjaris, MD
Omega Cecile Logan Silva, MD
Willa Marlene Brown, MD
Deborah MArtina Smith, MD
American Medical Association
Randolph Smoak
Rich Deem
John Emery
Mary Jo Malone
Margaret Garikes
American College of Physicians
Howard Shapiro, PhD
American Association of Homes and Services for the Aging
Edgar Rivas
Michael Rodgers
Maureen Sullivan
Heidi Young
American Association of Physicians of Indian Origin
Bhimsen Rao, MD
Madhu Mohan, MD
Protestant Heatlh Alliance
Sherry Hayes
Office of Personal Management
Lorraine Green
William Flynn
Lucretia Myers
Abby Block
American Health Care Association
Bruce Yarwood
Richard Miller
Jack MacDonald
Blaine Hendrickson
Steve Chies
THE WHITE HOUSE
WASHINGTON
SCHEDULE AT THE WHITE HOUSE
NATIONAL HEALTH POLICY COUNCIL MEMBERS
Tuesday, July 11
9:30 am - 11:00
Briefing on the Medicare/Medicaid Budget
Room 450, OEOB
and Pre-Briefing on the Regulatory
Reform Recommendations.
11:00 am - 12:30 pm
Private Meeting with First Lady and
Room 474, OEOB
Buffet Lunch
12:45 pm - 2:00 pm
Health Care Regulatory Reform Event
Room 450, OEOB
with the Vice President and First Lady
2:00 pm to 3:00 pm
Regional Press Interviews for
Room 450, OEOB
Individuals from outside of Washington,
DC.
THE WHITE HOUSE
WASHINGTON
June 28, 1995
Dear Mr. Speaker:
We share the goal of balancing the federal budget, and I
look forward to working with you on this important matter.
But as we work together to reach our shared goal, we must
ensure that we do so the right way -- the way that will raise the
standards of living for average Americans.
My plan to balance the budget over 10 years will help raise
average living standards by cutting unnecessary spending while
investing in education and training, targeting tax relief to
middle-income Americans, and taking incremental but serious steps
toward health care reform. By contrast, the conference agreement
cuts too deeply into Medicare and Medicaid and cuts education and
training both to pay for a tax cut that is too large for too many
who don't need it, and to meet the 7 year time frame.
Though I am determined to work with you to balance the
budget, I cannot accept legislation that will threaten the living
standards of American families.
I hope we can work together and avoid a situation in which I
would have no choice but to use my veto authority broadly. The
American people want us to work together to balance the budget
and to do it the right way. I am ready to do that.
Sincerely,
Bin Crinton
The Honorable Newt Gingrich
Speaker of the
House of Representatives
Washington, D.C. 20515
THE WHITE HOUSE
WASHINGTON
June 28, 1995
Dear Mr. Leader:
We share the goal of balancing the federal budget, and I
look forward to working with you on this important matter.
But as we work together to reach our shared goal, we must
ensure that we do so the right way -- the way that will raise the
standards of living for average Americans.
My plan to balance the budget over 10 years will help raise
average living standards by cutting unnecessary spending while
investing in education and training, targeting tax relief to
middle-income Americans, and taking incremental but serious steps
toward health care reform. By contrast, the conference agreement
cuts too deeply into Medicare and Medicaid and cuts education and
training both to pay for a tax cut that is too large for too many
who don't need it, and to meet the 7 year time frame.
Though I am determined to work with you to balance the
budget, I cannot accept legislation that will threaten the living
standards of American families.
I hope we can work together and avoid a situation in which I
would have no choice but to use my veto authority broadly. The
American people want us to work together to balance the budget
and to do it the right way. I am ready to do that.
Sincerely,
Bin crinton
The Honorable Bob Dole
Majority Leader
United States Senate
Washington, D.C. 20510
+
EXECUTIVE OFFICE OF THE PRESIDENT
CENTER
UNITED
OFFICE OF MANAGEMENT AND BUDGET
STATE
WASHINGTON, D.C. 20503
June 28, 1995
THE DIRECTOR
The Honorable Pete V. Domenici
Chairman
Committee on the Budget
U.S. Senate
Washington, D.C. 20510
Dear Mr. Chairman:
I am writing to transmit the Administration's views on the
conference report on H. Con. Res. 67, the concurrent resolution
on the budget for fiscal years 1996-2002.
We stand at an important moment in the nation's history.
For the first time in recent memory, the President and leaders in
Congress have agreed that we must put in place a plan to balance
the federal budget. We want to work with Congress on this
important goal.
The key question is: How? With this conference report, the
American people now have before them two profoundly different
approaches -- the President's 10-year plan and the conferees' 7-
year plan.
As the Administration has indicated to Congress on many
occasions, we have very serious concerns about the approach taken
in this conference report. The conferees would balance the
budget too quickly and, at the same time, provide a huge tax cut
whose benefits would flow disproportionately to the wealthy. To
do so, the conferees would cut deeply into Medicare and Medicaid
and cut discretionary spending so much that funds for education
and training, science and technology, and other priorities that
would help raise the living standards of average Americans would
be seriously depleted.
If reconciliation and appropriations legislation
implementing these policies were presented to the President, I
would strongly recommend that he use his veto authority.
The President's plan to balance the budget over a reasonable
period of time would protect Medicare and Medicaid, invest in
education and training and other priorities, and provide for a
targeted tax cut to help middle-income Americans raise their
children, save for the future, and pay for postsecondary
education.
To reach balance, the President would eliminate wasteful
spending, streamline programs, and end unneeded subsidies; take
the first, serious steps toward health care reform; reform
welfare to reward work; cut non-defense discretionary spending,
aside from the President's investments, 22 percent in real terms
in 2002; and target tax relief to middle-income Americans.
From our early analysis of the conference report, we
continue to have the same concerns that we expressed about both
the House and Senate budget resolutions.
Specifically, I want to express the Administration's deep
reservations about the following elements of the conference
agreement:
Time frame to a balanced budget. Last fall, Congressional
Republicans set an arbitrary goal of balancing the budget
over 7 years while providing a huge tax cut whose benefits
would flow disproportionately to the wealthy. Then, they
had to find the spending cuts needed to reach balance in
2002. That is the wrong approach.
By contrast, the President chose his policies first and let
the date to reach balance flow from them. As a result, he
was able to cut wasteful spending while protecting vital
services.
Tax cuts. The conferees have settled on a $245 billion tax
cut, whose details will be crafted by the congressional tax-
writing committees. Such a tax cut is too expensive; it
will force unnecessarily deep cuts in Medicare as well as
education and other priorities. And, based on the House-
passed tax proposal, we remain concerned that the benefits
will flow mostly to those who do not need them -- the very
individuals who have moved ahead over the last two decades
as others stayed in place or fell behind.
The President has proposed a less expensive, targeted tax
cut to help middle-income Americans raise their young
children, pay for postsecondary education, and save for the
future. That is a much better way to help raise average
living standards.
Health care. The conferees propose to cut Medicare by $270
billion by slowing the annual growth rate to an average of
6.4 percent over 1995 to 2002. They propose to reduce
Medicaid by $182 billion, by converting it into a block
grant and slowing the annual growth rate to 4 percent by
1998. Such proposals would threaten Medicare beneficiaries,
cut Medicaid coverage for millions of children and elderly
Americans, and endanger many hospitals, including academic
health centers. Assuming a 50/50 beneficiary/provider
split, these steps would raise out-of-pocket costs for
couples on Medicare by $5,650 between 1996 and 2002. These
severe out-of-pocket increases would not be necessary if the
conferees opted for the President's tax cut proposal.
As the President has often said, the key to long-term
deficit reduction is controlling health care costs through
health care reform. He proposes a serious first step toward
reform that would strengthen the Medicare Hospital Insurance
(HI) Trust Fund, ensuring Medicare solvency until at least
2005; expand benefits to families; make insurance more
affordable for small business; and reform the insurance
market. At the same time, he proposes less than half the
Medicare savings and a third of the Medicaid savings as
Congress, and would impose no new cost increases on Medicare
beneficiaries.
Education and other investments. In attempting to balance
the budget over 7 years and finance a huge tax cut, Congress
would have to cut virtually everything else, including the
very programs that would help raise average living
standards. Compared to the 1995 level, the resolution would
cut discretionary spending for education and training by $26
billion over seven years. In addition, the conference
report proposes saving $10 billion in the student loan
program, apparently by raising costs to middle- and low-
income students.
By contrast, the President proposes to increase
discretionary funding for education and training by $41
billion over the next 7 years. In addition, the President
would save money in the student loan program not by cutting
in-school interest subsidies and forcing middle- and low-
income students to pay more; rather, he would phase in
Federal Direct Student Loans quicker, cutting subsidies to
wealthy banks, secondary markets, and other intermediaries.
That would assist 6 million people a year -- and save money
for the government, schools, and students.
In addition, the Administration remains concerned about the
size of the proposed welfare cuts; they would cut benefits to
poor families, thus punishing children in the process. Congress
would increase the tax burden on low-income families by rolling
back scheduled increases in the Earned Income Tax Credit, which
is designed to reward work by lifting working families out of
poverty.
Overall, while the Administration and Congress share the
goal of a balanced budget, we have grave concerns about the
approach set forth in this conference report. We hope to work
with you, as the process moves forward, to find an approach that
is acceptable to both the President and Congress.
Sincerely,
Clium.Qia.
Alice M. Rivlin
Director
Identical letter sent to Honorable J. James Exon,
Honorable John R. Kasich, Honorable Martin Olav Sabo