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Withdrawal/Redaction Sheet Clinton Library DOCUMENT NO. SUBJECT/TITLE DATE RESTRICTION AND TYPE 001. list Indian Health Board of Billings [partial] (2 pages) 4/15/93 b(6) 002. fax From: Cindy Dwyer, To: Patty Solis, Re: Meeting with Lancaster Co. 4/14/93 b(6) Medical Society [partial] (1 page) 003. fax From: Cindy Dwyer, To: Patty Solis, Re: Meeting with Lancaster Co. 4/14/93 b(6) Medical Society [partial] (1 page) COLLECTION: Clinton Presidential Records First Lady's Office Liz Bowyer OA/Box Number: 5432 FOLDER TITLE: [HRC Daily File] Friday, April 16 [1993] 2014-0483-S sb334 RESTRICTION CODES Presidential Records Act - 144 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 PRAJ b(4) Release would disclose trade secrets or confidential or financial P5 Release would disclose confidential advice between the President information l(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. FRIDAY, ApRil 16th PHOTOCOPY PRESERVATION P.4/8 APR 15 193 13:35 WILLIAMS BILLINGS A Tribute to Natalie Hertz and Runaway Teens FOR FOR FOR 8081 Sharon Swindler Where Are The Roses FORM Where FOR March 16,1993-April 16, 1993 Opening March 19 7:00-9:30 TUR Are FOR: YWCA Bridenbaugh Room The 909 Wyoming Ave. sat Billings, MT Hours Open 8:00 A.M.-5:00 P.M. Roses Monday-Friday TOP 8:00 A.M.-3:00 P.M. Thursdays THE NATIONAL HEALTH SERVICE CORPS Begun more than 20 years ago, the National Health Service Corps (NHSC) is a national service program which encourages doctors and nurses to serve in areas that have shortages of health providers in exchange for medical scholarships and loan repayment. The Corps, made popular by the television show "Northern Exposure," is one way we increase the number of health providers in rural communities. - In 1986, 70% of the 3,127 health professionals serving under the NHSC program served in rural areas. [Department of Health and Human Services] - State officials in 35 states rated the National Health Service Corps as effective in improving the availability of health services in rural areas. [Robert Wood Johnson Foundation] Note: After 1986, NHSC field strength dipped sharply due to Reagan era budget cuts, but has rebounded since. Many rural Americans hope that this program will be reinvigorated to increase the numbers of health providers serving in rural areas. 04/15/93 12:01 002/007 Montana Indian Health Board of Billings, Inc. Marjorie Bear Don't Walk, Director Last Year -- 1992 4700 came through to see the doctor 21,000 came for consultations for substance abuse, immunization and mental health services. health educ, transport for other Withcare FOR Tour 4/16 5:00 p.m. Billings, Montana 406/- Questions? Diane Hill 225-3211 245872 ask about NEC briefing HC NAmericans askes them to do covernous buil Ding They did it Hwell prob ask forf-up meeting didn't meet pisses w/ off Ron Brown Audit Groups A HORG asks HRC boit of Rislic will Cono, Legal, Quan, Ana Admin simplica consultants Reg what If format at outset of structure Ina orig saiD he wanted Legal, Financial A Evaluation sheets subject to FOOA APR6- Develop themes HPR6 Names will be released Maggie reg / meet w/ (wal/steve pt by By point Conama RAnels not HRG-difinethe scope no Surprises 1) How solected 27 why cantrol discussed CT ThursDAY Rm 4:00 100 Trip Meeting Billings 3398 overmght LawRence Byne 1 H.C. FORUM 2 MJd & GReet av TOTO LLLS ITSN] THE Health Care in the 21st Century: National Challenges, Nebraska Solutions April 16-17, 1993 University of Nebraska - Lincoln, Nebraska Senator J. Robert Kerrey, Chairman Governor E. Benjamin Nelson, Co-Chair DINNER ATTENDEES Carol Aschenbrener, M.D. University of Nebraska Medical Center Jack Baker Baker's Supermarkets, Inc. Prem Bansal, Ph.D. Governor's Policy Research Office Governor E. Benjamin Nelson Frank Barrett Blue Ribbon Coalition Robert Bartee University of Nebraska Medical Center Robert Bates Guarantee Mutual Life Company Bob Bell Omaha Chamber of Commerce Jim Botkin Sandoz Pharmaceuticals John Braasch, Ph.D. Share Health Plan of Nebraska/United HealthCare Gretchen Brown Kaiser Family Foundation E. Richard Brown, Ph.D. President's Task Force on National Health Care Reform Thomas Cinque, M.D. Creighton University Catherine Coleman Office of Senator J. Robert Kerrey Sister Norita Cooney Mercy Midlands Bernard Dana Vetter Health Services, Inc. Dick Davis Northern Plains Natural Gas Co. Paul Ellwood, M.D. Jackson Hole Group Allen Fredrickson Accent Service Company, Inc. James Geist Lincoln Telecommunications Company Elaine Guffey Richard Guffey Blue Cross and Blue Shield Allen Hager Clarkson Hospital Terry Hager Mark Hanley Abbey Home Health Care Mary Dean Harvey Nebraska Department of Social Services Jack Hogan Physicians Mutual Insurance Co. Randall Horn Mutual of Omaha Companies Karen Horn Dave Hunt Nebraska Citizen Action Donna Hunt William Kaizer Central States Health and Life Company Mrs. Kaizer Matthew Kurs AMI St. Joseph Hospital Darroll Loschen, M.D. Nebraska Medical Association Lon Lowrey Dorsey-Sandoz Pharmaceuticals Kathy Mallatt Share Health Plan of Nebraska\United HealthCare Charles Marr Immanuel Medical Center Ken Mass Nebraska AFL-CIO Sheila Murphy Office of Senator J. Robert Kerrey Herman Myers, Jr. Continental General Insurance Company Betty Myers Governor E. Benjamin Nelson Diane Nelson Charlie Nields Physicians Mutual Insurance Co. Joan O'Brien Richard O'Brien Creighton University David Palm Nebraska Department of Health Kim Robak Office of Governor E. Benjamin Nelson Fred Runington Northern Plains Natural Gas Co. Gene Schellpeper Continental General Insurance Co. William Schellpeper Nebraska Medical Association Robert Shapiro, M.D. Nebraska Medical Association Janet Shikles U.S. General Accounting Office Tom Sick Physicians Mutual Insurance Co. Richard Spellman Guarantee Mutual Life Company Arlan Stromberg Lincoln General Hospital Jack Vetter Vetter Health Services, Inc. Lora Villarreal First Data Resources Larry Villarreal Senator Don Wesely Nebraska Legislature Neal Westphal Lincoln Telecommunications Company Ross Wilcox Union Bank & Trust Company Bill Williams Dorsey-Sandoz Pharmaceuticals Ronald Wilwerding Accent Service Company Clinton Presidential Records Digital Records Marker This is not a presidential record. This is used as an administrative marker by the William J. Clinton Presidential Library Staff. This marker identifies the place of a publication. Publications have not been scanned in their entirety for the purpose of digitization. To see the full publication please search online or visit the Clinton Presidential Library's Research Room. HEALTH CARE IN THE 21ST CENTURY: NATIONAL CHALLENGES, NEBRASKA SOLUTIONS Friday, April 16, 1993 Saturday, April 17, 1993 University of Nebraska, Lincoln Kimball Hall & Student Union KEYNOTE PRESENTATION: Hillary Rodham Clinton First Lady of the United States of America Senator J. Robert Kerrey, Chairman Governor E. Benjamin Nelson, Co-Chair A COLUMBIA INSTITUTE Coordinated Event Clinton Presidential Records Digital Records Marker This is not a presidential record. This is used as an administrative marker by the William J. Clinton Presidential Library Staff. This marker identifies the place of a publication. Publications have not been scanned in their entirety for the purpose of digitization. To see the full publication please search online or visit the Clinton Presidential Library's Research Room. HEALTH CARE IN THE 21ST CENTURY: NATIONAL CHALLENGES, NEBRASKA SOLUTIONS Friday, April 16, 1993 Saturday, April 17, 1993 University of Nebraska, Lincoln Kimball Hall & Student Union KEYNOTE PRESENTATION: Hillary Rodham Clinton First Lady of the United States of America Senator J. Robert Kerrey, Chairman Governor E. Benjamin Nelson, Co-Chair A COLUMBIA INSTITUTE Coordinated Event Clinton Presidential Records Digital Records Marker This is not a presidential record. This is used as an administrative marker by the William J. Clinton Presidential Library Staff. This marker identifies the place of a publication. Publications have not been scanned in their entirety for the purpose of digitization. To see the full publication please search online or visit the Clinton Presidential Library's Research Room. COLUMBIA INSTITUTE i An independent public policy group specializing in conference management and research services. NOTE: Mrs. Clinton's address will be held in Lied Center. NOTE: The Senator wil introduce Mrs. Clinton, she will speak for 30 minutes. She will take questions after her remarks. 12:45p.m. LUNCHEON ADDRESS: A VIEW FROM WASHINGTON AND THE TASK FORCE Hillary Rodham Clinton Current: Chair, President's Task Force on National Health Care Reform First Lady of the United States of America Previous: Partner, Rose Law Firm Founder, Arkansas Advocates for Children and Families Education: Wellesley College Yale Law School 12:00 p.m. LUNCHEON " we will now break for lunch. The luncheon will be held in the Centennial Ballroom at the Student Union. Due to the size of our crowd, we will be providing box lunches instead of a buffet so please feel free to begin eating as soon as you receive your lunch and you are welcome to eat outside or in any part of the Union you wish. We do ask that you please go to the LIED CENTER NO LATER THAN 12:40 so that we may seat people for the keynote address by Hillary Clinton. TICKETS WILL COLLECTED AT THE DOOR. Enjoy your lunch PLEASE RECONVENE at 12:40 p.m." NOTE: Make a brief announcement reminding the audience to turn in the surveys on health care as they proceed outside for the luncheon. BOB KERREY U.S. Senator for Nebraska J. ROBERT KERREY OF NEBRASKA In the four years since Bob Kerrey was elected to the U.S. Senate, he has impressed political observers with his independence, his candor, and his tireless determination to make government work. Bob Kerrey's devotion, hard work, and leadership has made him one of America's most exciting and effective political leaders. Since his overwhelming electoral victory to the U.S. Senate in 1988, when he defeated an incumbent United States Senator, Bob Kerrey has demonstrated that his is a voice to be heard on the major issues of the day: --ON HEALTH CARE: While the President and the Congress stalemated on health care reform, Bob Kerrey spent three years developing Health USA, the most comprehensive health care reform package in America. As a consequence of Senator Kerrey's tireless efforts, the debate over health care reform has finally begun in earnest on Capitol Hill. --ON AGRICULTURE: As a member of the powerful Senate Agriculture Committee, Senator Kerrey was instrumental in writing the commodities section of the 1990 Farm Bill and has become a recognized leader on agriculture and rural development issues. As evidence of Senator Kerrey's leadership, Agriculture Committee Chairman Patrick Leahy in 1989 named Senator Kerrey to the 1990 Farm Bill Conference Committee even though Kerrey was the most junior member of the Committee. Congressional Quarterly's Almanac of American Politics notes, "Another reason Leahy may have valued Kerrey's presence in the conference was [Kerrey's] unflinching tenacity in the face of administration opposition." --ON EDUCATION AND CHILDREN'S ISSUES: Bob Kerrey's compassion and. understanding of the great needs facing our children have made him one of the Senate's most consistent voices for America's youth. In education, Senator Kerrey's belief that bureaucracies at all levels have become impediments to improving our schools culminated with his sponsorship of the Education Capital Fund Act which provides federal funds directly to local school districts to undertake systemic reform initiatives. Senator Kerrey has also been a consistent voice for children's programs like Head Start, child care, and WIC; his Health USA legislation would guarantee that every American child has full access to high quality health care services. --AS A SENATOR WHO STANDS FOR WHAT IS RIGHT: Bob Kerrey has demonstrated that his is a voice of reason in confronting the hottest and most politically charged issues of our day. Bob Kerrey has beco r cognized as a Senator who is willing to take on the vested interests. and who is willing to ualities re I rhaps b st ex plified in Senator Kerrey's defense of the First Amendm nt during the flag burning controversy in 1989. Senator Kerrcy's work to defeat the controversial legislation was heralded as one of Congress's most. eloquent profiles in courage. --AS AN EMERGING LEADER IN THE AREA OF FOREIGN AFFAIRS: In the four years that Senator Kerrey has served in the Senate, he has proved equally adept in understanding America's role in the World. During his Senate service he has had direct exposure to some of the most dramatic global political changes of the century: U.S. Senale, Washington, D.C., 20510 7602 Pacific Street, Omaha, NE 68114 202-224-6551 402-391-3411 100 Centennial Mall North, Room 294, Federal Building, Lincoln, NE 68508 402-437-5246 MAR 05 '93 10:04 NEBRASKA GOVERNOR'S OFFICE P.4 STATE OF NEBRASKA EXECUTIVE SUITE THE P.O. Box 94848 TRATE Lincoln, Nebraska 68509-4848 OF Phone (402) 471-2244 ORBAT DEDRASEA CHARL R E. Benjamin Nelson Governor BIOGRAPHICAL SKETCH OF NEBRASKA GOVERNOR E. BENJAMIN NELSON Elected in 1990, Governor Ben Nelson immediately began working for his initiatives in Education, the Environment and Economic Development. During his first 16 months in office, Nelson initiated and guided to passage a solution to the state's personal property tax crisis. The tax problem had been building for 20 years and was threatening to strangle local government operations. Resolution of the problem restored confidence in, and stability to, the state's tax system. At the same time, Nelson moved to restore fiscal responsibility to state spending. His tight reign led to a one year budget increase of less than one-half of one percent. The Governor also instituted a Strategic Budget Plan with the goal of making government more efficient and effective. Under the plan, every state agency is required to evaluate programs and priorities for possible reallocations, interagency coordination, and budget cuts. Under Nelson's leadership, Nebraska has moved from 31st to 21st in Financial World magazine's "State of the States" financial health ranking. City and State magazine ranks Nebraska 2nd among all 50 states in terms of a solid financial condition. Governor Nelson also led the way in enacting landmark environmental legislation for the state. The Governor's Environmental Trust Fund has been establish and will provide needed financing for worthy environmental projects. Monies for the Trust Fund will be provided from proceeds from a statewide lottery. The lottery, proposed by the Governor and passed by state lawmakers, received voter approval in November 1992. Governor Nelson is currently serving as Chairman of the National Education Goals Panel. Nelson helped established, and served as Chairman of, the Governors' Ethanol Coalition, a 16- state ethanol promotion and policy group. Additionally, Nelson was selected as Vice Chair of the Midwestern Governors' Association and is past vice Chair of the National Governors' Association's Agriculture Committee. more An Equal Opportunity/Affirmative Action Employer printed on recycled paper MHR 05 '93 10:04 NEBRASKA GOVERNOR'S OFFICE Page Two Nelson Biography In recognition of his work to build Nebraska's economy, the Nebraska Diplomats honored Nelson with the prestigious "Ambassador Plenipotentiary" award and title. He is one of only four Nebraskans to receive the award. Nelson entered the practice of law in 1970, eventually being named General Counsel, President, and Chief Executive Officer for a national insurance group. He also served as Executive Vice President of the National Association of Insurance Commissioners. Nelson joined Kennedy, Holland, DeLacy & Svoboda, one of Nebraska's most prominent law firms, as Attorney-of-Counsel in 1985. He has also served as Nebraska's Director of Insurance. Nelson earned degrees in logic, philosophy and law from the University of Nebraska. In May of 1992, he was awarded an Honorary Doctor of Law Degree from Creighton University for his accomplishments. Nelson, who announced as a candidate for Nebraska governor in January 1990, won the Democratic nomination by 42 votes, one of the closest elections for a statewide race in modern U.S. history. He was elected as the 37th Governor of Nebraska on November 6, 1990, and inaugurated as Governor on January 9, 1991. Nelson was born in McCook, Nebraska in 1941 to Benjamin E. and Birdella Nelson. He is a life-long Nebraskan. The Governor and his wife Diane have four children. 30 : : 2 Lincoln Has THIS IS CLIP PAGE Jun PAPER FROM CLIP PAGE 4-14-93 PAGE / CONTINUED ON PAGE 4 DATE BR EE First lady A WHITE HOUSE advance team and state fire marshal officials will meet Wed- nesday with Ron Bowlin. Kimball Hall direc- to speak tor, to determine if the Kimball space is ade- quate, Larsen said. The conference is being coordinated by in Lincoln the Columbia Institute, an independent. bi- partisan organization based In Washington, D.C. Sen Bob Kerrey is chairman and Gov. Ben Nelson is co-chairman of the confer- Hillary Rodham Clinton ence. Kerrey has been recognized as a expected at health reform leader on health care reform and was one of conference Friday at UNL. the first to develop a comprehensive na- tional health care plan. By JoAnne Young The goal of the forum is to inform Nebras- of The Lincoln Star kans about health reform proposals from First lady Hillary Rodham Clinton will both national and state perspectives $0 they join a list of national and state authorities to can make decisions about which plan to sup- speak on health care reform at a conference port In addition to Clinton and local officials, scheduled for the University of Nebraska- other spcakers are to include: Lincoln campus Friday and Saturday. Dr. Paul Ellwood of the Jackson Hole Although few details Group, the originator of the concept of man- were available Tuesday aged competition He is currently working evening. Clinton is ex- with leaders to develop the "21st Century pected to be in Lincoln American Health System." on Friday. said Phil Janet Shildes, director of health fi- Richmond a spokesman nancing and policy in the U.S. General Ac- for Gov. Ben Nelson. counting Office. She has studied national Clinton is scheduled to health care policies of four other countries speak at 12:45 p.m. and will speak on "Social Values VS. Eco- Clinton Friday during a lunch- nomic Necessity." eon at the conference on "Health Care for the 21st Century: National E Richard Brown of the UCLA School Challenges. Nebraska Solutions." of Public Health who will speak on cost con- trol Her address is titled "A View from Wash- ington" Clinton is the chairwoman of the Gov. Howard Dean of Vermont, who President's Task Force on National Health will deliver the keynote address on Friday. Care Reform. Minnesota state Sen. Linda Berglin, A spokeswoman in Clinton's press office who will deliver the keynote address on said details of her visit would be released Saturday. today. The location for the Friday sessions of the conference was moved from the Nebraska Union Ballroom to UNL's Kimball Hall But that location could change if officials decide a larger space is needed, said Phyllis Larsen, UNL associate director of university rela- tions. THIS IS CLIP PAGE CONTINUED FROM CLIP PAGE CONTINUED ON CLIP PAGE Kerrey's plan would make health care available to everyone A comprehensive reform the tive private and public health care "We must commit to financing to Kerrey. American health care sys- plans for their coverage. All policies health services as fully and equitably "The first principle is that all tem is vital for economic will be required to offer a basic pack- as possible through private and pub- Americans are eligible to receive and medical reasons, according to age of benefits, including hospital, lic dollars," Kerrey said. "Individu- health care. Not only is this the most Nebraska Sen. Bob Kerrey. physician and other services. als should also participate in cost- equitable and compassionate ap- "Without true health reform, defi- "A system of regional purchasing control measures. proach, but universal eligibility is cit reduction will remain a dream, cooperatives contracting with com- "We must finance not only service also the best means to control health our national economy will continue peting private plans will ensure that delivery, but also clinical research, care spending," he said. to stagnate, the number of Ameri- choice and quality remain character- professional training, services for "Only a system which guarantees cans without adequate health cover- istics of American health care," he vulnerable groups and other needs," universal access to health care ser- age will grow and the uninsured will said. he added. vices will address the problems of remain economically vulnerable and Insurers won't be allowed to reject Health USA would be adminis- uncompensated care and cost shift-, medically underserved,' Kerrey said. anyone wishing to enroll in their tered federally by an independent ing, job lock, differential access and plan. Those who don't enroll in a commission similar to the Federal escalating costs which plague our sys- In response to this growing con- private plan will be enrolled in a Reserve Board. The commission tem," Kerrey continued. cem, Kerrey has designed Health state-operated program. would provide general guidelines to Other cost-control and access-en- USA, a proposal that he says would To ensure equity and access, all states, make recommendations on hancing ideas must be considered, make health care affordable and avail- health plans must offer a uniform, federally-prescribed benefit packages, he said. "Appropriate cost-sharing able to all Americans. "Health USA comprehensive benefit package. "In- encourage states to develop ways of measures have proven to reduce un-, is a uniquely American system that surers will not be able to attract young, providing quality health care, dis- necessary utilization, and preven- builds upon the strengths of our cur- healthy enrollees and avoid older, tribute funds, recommend malprac- tive care must be encouraged," he rent system and directly addresses its poprer clients by talloring their ben- tice reforms and work to standardize said. shortfalls," Kerrey said. efit packages," Kerrey said. and simplify billing and other ad- Cost-control strategies should be A More than $11 billion in health "Long-term care benefits must be ministrative procedures. determined on a local level to help 6 vew HORIZONS April 4/9/93 care spending would be saved during a part of this reform, either as part of Kerrey's plan addresses the health addressapecific concerns, Kerrey d, the program's first year, according to the basic package or as a supplemen- care needs of persons living in rural "We want a system which provides the plan's outline. Savings would tal benefit available on a premium and underserved areas. Payments to financial incentives and rewards for DATE PAGE total more than $150 billion over a basis to all Americans," he contin- providers will be assured and adjusted private sector providers, payers and five-year period. ued. according to health care costs in entrepreneurs who deliver high-qual- Health USA reforms the way health each state. A resource development ity, low-cost care." care is financed, notdelivered, Kerrey UNDER HEALTH USA, Indi- fund will help states provide finan- The time to begin implementing said. The program preserves Ameri- viduals and employers would con- clal, educational or other incentives health care reforms has come. "The cans' right to choose among private tribute to the program and their care, to health care professionals practic- United States prides itself on having physicians, hospitals, insurers and based on their ability to pay through ing in these areas. the best health care in the world," health plans, he added. payroll and income taxes. These TO ACCOMPLISH meaningful Kerrey said. "We must act now to Under Kerrey's proposal, Ameri- taxes would replace the private in- health care reforms, Americans must ensure that all Americans enjoy this cans would choose among competi- surance premiums now paid. follow several principles, according care." 20. 04/11/93 14:53 918007363297551 1 03 SEN. KERREY/OMA WASHINGTON DC so OWH CLIPS, AM PM * DATE 4/10/93 THIS IS CLIP PAGE CONTINUED FROM CLIP PAGE PAGE 7 CONTINUED ON CLIP PAGE OMAHA WORLD HERALD BK Health Plan Must Give Consumer Control' BY DONALD F. ORTON, M.D. regulatory and tax burdens for employers. The vast majority of health care costs, up to 95 All these national health care bills would mean: a percent in the case of hospital bills, are paid by someone other crushing new tax burden on senior citizens and others: health than the consumer. care rationing, depriving seniors of care for life-threatening or In the case of President Clinton's plan or Bob Kerrey's terminal illness; a huge new government health care bureau- "Health USA," the third-party effect would be predictably cracy guaranteed to waste millions of tax dollars, and extra disastrous. What is needed is & plan that would revemp tax treatment of health insurance for both employees and employers by giving health care consumers incentives to be aware of costs and allowing financial beacfits to be derived from money saved on premiums. Most importantly it would give the consumer control over decisions made by health care providers at the time of treatment. (The Clinton and Kerrey plans would take control away from citizens) Such plans already exist: one is promoted by the Heritage Foundation. and another is the Medi-Save option sponsored by the National Center for Policy Analysis. I have noticed ads for an April 16 and 17 meeting at the University of Nebraska-Lincoln with Bob Kerrey and Gov. Ben Nelson called "Health Care in the 21st Century." I am wary of this as more Hillary Clinton/Kerrey smoke and mirrors for socialized medicine. Knowledgeable individuals and organi- zations, such as the Heritage Foundation and Dr. Jane Orient. executive director of the Association American Physicians and Surgeons, have not. to my knowledge, been invited to speak at this sympo- siam. The last thing our nation needs now is another huge federal government program with control over every detail of health care, including life and death decisions made by politicians, bureaucrats and computers. It is federal legislation, including Medi- care/Medicaid and current federal tax treatment of private third-party group health plans, that in large part is responsible for ballooning health costs. Results should be the final argument against socialized health care. Citizens of Canada, Mexico and the United Kingdom come here for their health care if they can, not the other way around. NAME NAME OF PAPER News DATE 3/2/93 C CITY, STATE Norfalk, NE PAGE / OF 2 Kerrey shares health, farm opinions By Diane Becker "We have to go away from the cial interest groups rather than News Correspondent government. The government is businesses. In Nebraska they ALBION - Neither budget cuts not going to raise families. The in- brought $8.6 billion worth of reve- nor tax increases by themselves centives right now very often (en- nue and $120 billion nationwide," will solve the federal budget deficit courage) people not to get a job or Kerrey said. problem, U.S. Sen. Bob Kerrey told get married or they'll lose their He said he favors tax breaks for about 100 people gathered here Sat- welfare payments. It's up to the production of ETBE (ethyl tertiary urday at Gragert's Villa Inn. parents to provide the environ- butyl ether), a fuel derived from "Taxes won't get the job done. ethanol that can be added to gas to ment," Kerrey said. The number one problem we've got increase fuel efficiency. On agricultural issues, Kerrey is growth in health care costs. They "It's a win for the oil companies, said it's important to remember grew by $30 billion last year, and a win for the corn producers and a that farm subsidies are the least they'll grow by $30 billion this win for the environmentalists," costly of the top 10 entitlement pro- year," Kerrey said. grams that are part of the federal Kerrey said. Kerrey answered questions He estimated the program would government. posed by numerous members of the create a demand for 4 million bush- "All the other (budgets) went up audience, including Dr. Randy els of corn annually. last year, but the farm program Kohl, who works at Boone County Marvin Fritz of Bartlett told went down 10 percent. So, they Health Center in Albion. He asked can't say we aren't going to do our Kerrey he had been farming for 20 Kerrey about regulations burden- fair share," Kerrey said. years but was "losing motivation" ing small hospitals. He emphasized the need for knowing that the U.S. Environmen- Kerrey said the nation's existing urban senators to understand that tal Protection Agency might find a health care strategy will result in the farm program protects both legal infraction on his farm from 40 depopulation of rural America. consumers and producers. years ago that could put him out of 'Rural health is a losing battie business. Kerrey said he disagreed with until there's reform," he said. much of President Clinton's eco- Kerrey agreed that the EPA's Kerrey said there should be a nomic proposal. The plan to raise major problem is regulation that is simplified version of eligibility for taxes on energy is an example of a medical benefits. He said Ameri- Clinton proposal that he opposes cans spend 9 percent of their too remote from agriculture. He because of its negative impact on income on food, which is the lowest also said personnel changes in fed- small business, Kerrey said. rate in the world, and 14 percent on eral agriculture agencies cause re- He estimated the new tax would health care, which is the highest gulations to vary greatly. add $1 to $2 an acre in costs to rate in the world. "The Soil Conservation Service farmers. When asked an abortion-related recently said that if you have ruts "Farms are too often seen as spe- question, Kerrey said he accepts in your field from last fall, then you the Roe VS. Wade court ruling that can't repair them without their per- established the right of a mother to mission. That's ridiculous," choose to have an abortion in the Kerrey said. first 20 weeks of pregnancy. About the proposed dismantling "After that, the government has of the Rural Electric Administra- the right to intervene," Kerrey tion, Kerrey said the agency still said. provides a vital service and that Keeping government out of mat- the REA will be responsible for ters concerning personal choice is keeping rural communities current not liberal, but conservative in phi- in telecommunications. losophy, he said. Kerrey said he Kerrey said he is against a presi- personally believes abortion is dential line-item veto. He acknowl- wrong. edged, however, that a "substan- Kerrey also said he felt some tial amount of waste, fraud, and parents aren't providing children abuse" exists in government, but it with values they need to live a should be handled by review useful life. boards at a local level. Coash of Albion sponsored Sat- urday's meeting. 03/19/93 17:57 918007363297551 1 03 SEN. KERREY/OMA ALL 001 OWH CLIPS, AM DATE 3/19/93 THIS IS CLIP PAGE CONTINUED FROM CLIP PAGE PM X PAGE 145 CONTINUED ON CLIP PAGE BK Mrs. Clinton Kerrey Pushes Health-Care Plan Hears Kerrey In Meeting With Mrs. Clinton Continued from Page 1 reform." Health Plan accounting system would not save any Kerrey said he agreed to help the money this year but would reduce next administration in developing and enact- year's budget deficit. ing a health-care plan. Several Kerfey. BY PAUL GOODSELL Instead of borrowing money to cover WORLD-HERALD BUREAU staff members are working with Mrs. an estimated $30 billion increase in Clinton's task force. Washington - Sen. Bob Kerrey, D- health-care spending. be said, federal "It's a very important issue for the Neb., used an hourlong meeting Thurs- officials would have to cut spending country," Kerrey said, "and I'm pleased day with Hillary Rodham Clinton to or raise taxes to make ends meet. that the first lady has asked me to help.' advocate his plan to place all health-care "It creates an immediate fiscal disci- spending on a pay-as-you-go basis. pline," Kerrey said. Mrs. Clinton was not particularly Since health-care spending is a major receptive to the plan, Kerrey said Friday. and rapidly growing part of the budget, "She politely considered it," he said. deficit-reduction efforts for health care "It's a new idea; it takes time. Tm just would reduce the overall federal deficit, beginning to lean into it" be said. The first lady, who heads a White A pay-as-you-go system might force House task force on health-care reform, more managed-care requirements for met with Kerrey in his Senate office. Medicaid recipients or lead the federal Kerrey has proposed his own compre- government to prod private insurers hensive health-care legislation, although to adopt Medicare reimbursement rates, he said. he has expressed support for the admin- Kerrey said he did not consider his istration's general proposals. plan to be a substitute for a more Kerrey said he told Mrs. Clinton that sweeping reform of the nation's health- he was not enthusiastic about using short-term price controls as a way to care system including both private and restrain health costs. Clinton advisers public spending "I would prefer to have recently said they were actively consider- it as a first step toward comprehensive ing some kind of medical price controls. "They're deadly serious about doing something to get health-care costs under control," Kerrey said. But he said he questions whether price controls would be effective or wise. Instead, Kerrey said, he believes that it would be better to create a federal trust fund to cover all $250 billion to $300 billion in current federal spending for health care. The trust fund would be fully funded through existing revenues, without the deficit financing Kerrey said such an Please turn to Page 5, Col. 5 2 WASHINGTON DC 003 04/04/93 14:41 918007363297551 1 03 SEN. KERREY/OMA OWH CLIPS, AM * DATE 4/4/93 THIS IS CLIP PAGE 5 CONTINUED FROM CLIP PAGE PM PAGE 9-A CONTINUED ON CLIP PAGE Wesely: States Key In Health Planning BY MARY MCGRATH WORLD-HERALD MEDICAL WRITER Nelson to Get Architects of President Clinton's health-care plan are fashioning a key role Progress Report for state governments in carrying out Gov. Nelson will be among reforms. Nebraska State Sen. Don Wese- the governors meeting with White ly said Saturday. House officials Mondav for an "They have come to the conclusion update on the progress of propos- states need to have an important role in als for health-care reform. bringing employers and consumers to- Nelson and other members of gether into health insurance purchasing the National Governors Asso- cooperatives." Wesely said. ciation will attend an all-day The-cooperatives would bargain with insurers and the providers of health care meeting. to obtain higher-quality care at lower Medicare, the nationwide program prices, Wesely said from Washington, that covers the elderly and disabled, D.C., where he took part in a health-care would remain outside the cooperatives. reformimeeting Friday. Wesely said. The federal-state Medicaid The Lincoln lawmaker was one of 13 program for the poor probably would be representatives of the National Confer- included in the cooperatives. he said. ence of-State Legislatures who met with Wesely said the health-care reform several-members of the Clinton health- plannets "are looking toward global care reform task force and its director, budgeting" The budget would target Ira Magaziner. how much U.S. health-care costs should This-was the first time that legislators increase annually. themselves have had direct input," said Each state likewise would have its own Wesely an officer of the National Con- goal. he said. If costs exceeded a state's ference of State Legislatures and chair- goal the state would have to make up the man of the Nebraska Legislature's Healthand Human Services Committee. excess. Wesely said. "I fdt they (task force members) were "I got very positive feelings out of the aware of the concerns of the state meeting" he said. senators," Wesely said. "I don't know Wesely said it is good news for that they have all the solutions, but at states that they apparently will be major least they are aware of the problems." players in carrying out health-care re- forms. Wesely said the task force members were aware that programs that could That-involvement should help ensure work in cities would not work in rural that the national plan can be adapted to area's and that many people on Medicaid the needs of different states. he said. have health-care needs that exceed basic "The federal role will be to set the coverage and no way to pay for those framework for reform. decide what will services. be included in 2 basic package of cover- Wesely said that considering the time age and establish the basic mechanisms it could take to pass federal and state for financing." Wesely said. legislation. it might be January 1997 Financing has not yet been spelled before a health-care reform plan could out be in place in all states. Wesely said states apparently would "Some states such as Oregon. Florida determine how many health insurance and Colorado are moving ahead very cooperatives would be needed, oversee quickly." he said. "We talked about their development and monitor their letting~them move ahead and letting operation other states learn from their experience.' 918007363297551 1 03 04-04-93 P003 #17 010 Wesely: Don't fear health care plan THIS IS CLIP PAGE By James Joyee will-be tied more to where they live. Although the details are still being FROM CLIP PAGE CONTINUED ON PAGE doesn't think managed care is such 8 Linooin Journal-Ster This is because the Clinton plan worked out, because of the Presi- big deal If you're worried about how Presi- calls for the creation of "local health dent's strong advocacy of the concept dent Clinton's reform proposal will at THE CONCEPT of managed care purchasing alliances" within which a of "managed health care," this is fect your healt h care, you're worrying likely to be a strong element of the has caught on throughout the health variety of bealth insurance plans will insurance Industry, and even If Clin- unnecessarily. be offered to employers and employ- timal proposal. At least that's ees. In other words, it's Mkaly that many ton hadn't bought into is, sooner .or plans will require you to have a pri- later it-will be part of every plan any- the opinion of The employers would have to offer Sen. Don Wearly Insurance to their workers, but the mary care physician who will "man- way, Wesely said. SEN KERREY/LINC of Lincoln, who workers would be able to aboose be- ago" your treatment and who will The Clinton plas, which is currently scheduled to be submitted to Con- recently attended tween their employer's plan or an- have a lot to say about whether you & White House other plan available within the at receive specialized treatment for greas La late May, is almed at extend- briefing on the liance. your illness, such as a heart or liver ing coverage to the 37 million Amer- loans, including 155,000 Nebraskans, plan and came In other words, what plans would transplant. who DOW lack health insurance and to away satisfied be available to the residents of a Lin- Although some might consider this with what be compurchasing alliance might be dif- a big deal - It has been suggested by bring the skyroaketing costs of health forent from what might be offered by some critics as a system that takes care, which now comprises about 14 learned. Furthermore, Wessly away a patient's freedom to choose percent of the nation's gross national an Omaha or & Panhandle alliance. 6 be said, for most Americans - those Hiven then, though, there would be a his or her physician, an allegation the product, under control who get their. health insurance inimum la val of benefits that would Clinion administration denies - Wes- One of Wesely's main concerns be- through their employers - the have to be available in every plan re- lay is among those who think We fore has White House-briefing was changes. proposed by Clinton will gardless of where the purchasing at much ado about nothing. that the plan wouldn't take into ac- PAGE hardly be noticed. liance is located. Since 1979, Wesely has belonged to count the differences, such as popula- C402 437 5109 "For the employee who already has As with current employer-based Health America-Lincoln, one of the tion densities and geography, that health insurance, there's not going to plans, the cost even for one not of first managed care health insurance exist among the states. be a lot of difference," Werely said. fored by the employer would be programs In the state. However, be said, he was assured According to Wenely, who's chaired shared between employer and em- "I've been through managed care the plan will not only allow for differ- the Health and Human Services Corp- playee. and I have no problem with H. I think ences among the states but differ- mittee for most of bis 14 years in the it's great," he said. ences within a state, such as exist be- Legislature, the most noticemble FOR SOME. however, there might There is another reason why he tween Omaha and the Panhandle. 4.10.93 change for the average American will be another noticeable change. be in the way he or she gets health in- 10:23 suranes. IN THE current system, most peo- ple select from one or two group plans offered through their employ- $ 04/12/93 Under the Clinton plan, however, a person's choice of Insurer won't be PAPER DATE tied to where they work. Instead, it HRC MEETING WITH GOVERNORS DEAN (VT) AND NELSON (NEB) APRIL 16, 1993 I. GOVERNOR HOWARD DEAN, M.D. (D-VT) (spouse = Judith Steinberg, M.D.) A. Background Governor Dean was born in New York City in 1948 and grew up in East Hampton, N.Y. He received a B.A. in political science from Yale in 1971 and a medical degree from the Albert Einstein College of Medicine in New York in 1978. He then completed his residency in Vermont and remained there as a general practitioner (internal medicine). Governor Dean was a member of the Vermont House of Representatives from 1983 to 1986. He was elected lieutenant governor in 1986 and reelected in 1988 and 1990. He became Governor upon the death of Governor Richard Snelling in August 1991, and was elected to a full term in November 1992. His current term expires in January 1995. B. Health Care In 1992 Governor Dean signed into law a health care reform bill that won overwhelming support in both houses of the state legislature. The legislation commits Vermont to universal access, centralized health planning and a global budget. The Vermont Health Care Authority ("VHCA") is now preparing models for single-payer and multi-payer systems that would provide universal health care. Governor Dean wants to present the models to the legislature by November 1, 1993, after which he will conduct extensive public education. His goal is to provide universal access by October 1, 1994. As you know, Governor Dean is a member of the National Governors Association's bipartisan health care committee, and you have met with him (as a member of this group) several times in the Roosevelt Room. As a former doctor (general practitioner/ internist) he will make an ideal surrogate for the Administration's health care reform legislation. Last month he had dinner with Ira Magaziner and "expressed serious concerns about the proposals for achieving health care cost savings during the next two years [and] any attempt to impose strict controls on health care expenditures in the absence of universal access and health care delivery system reforms. " Governor Dean followed up the meeting with two letters to Ira that set forth his own proposals for cost controls. Attached are copies of Governor Dean's correspondence with Ira, as well as the Governor's February 16, 1993 letter to you expressing concern over proposed to "cut expenses in the Medicare program." II. GOVERNOR E. BENJAMIN NELSON (D-NEB) (spouse = Diane Nelson) A. Background Governor Nelson was born in rural southwestern Nebraska in 1941. He earned a B.A. in philosophy in 1963, a master's degree in philosophy in 1965, and a law degree in 1970 from the University of Nebraska. From 1965 to 1972 he worked for the Consumer Division of the Nebraska Department of Insurance, in 1975 he was named Director of Insurance, and in 1982 he became executive vice- president of the National Association of Insurance Commissioners. During much of the period from 1972 to 80 Governor Nelson worked for a major Omaha insurance provider, serving as general counsel, president and later CEO. In November 1990 Governor Nelson was elected to a four year term as Governor. B. Health Care Nebraska does not have any health care reform legislation, either enacted or pending, although the Nebraska Legislature is currently looking at plans to cut Medicaid spending because of a budget shortfall. In January 1992 Governor Nelson formed the "Governor's Blue Ribbon Coalition to Study Health Care in Nebraska,' to look at all of the health care issues in Nebraska and recommend "solutions" (not legislation) for the state's problems. The Coalition is a diverse group of 33-35 consumers, business leaders, doctors, insurance executives, etc. (There were no legislators or other electeds on the Coalition.) In December 1992 the Coalition issued its preliminary report, stressing universal access, quality of care, cost containment, responsibility, flexibility/freedom of choice, innovation and financing. The report described a basic benefit package for all Nebraskans, having relied on its insurance industry to identify a package that reflected an average of what all Americans were currently receiving. The Coalition is now focused on how Nebraska can afford to pay for health care reform, and whether to have an employer mandate. They hope to have their work completed by summer. Governor Nelson is viewed as a moderate, swing-vote among his fellow governors and is therefore potentially an important ally. He is concerned about rural health care issues, and has two primary reservations about the work of the Health Care Task Force: 1. cost containment - the ability to achieve real savings with such a comprehensive benefits package; and 2. state flexibility - not all states have the same constraints. We suggest that you communicate to him that you are aware of his concerns and would like to speak to him about them at a later date. Health Care in the 21st Century: National Challenges, Nebraska Solutions April 16-17, 1993 University of Nebraska - Lincoln, Nebraska Senator J. Robert Kerrey, Chairman Governor E. Benjamin Nelson, Co-Chair PARTICIPANTS AND SPONSORS Participants: Carol Aschenbrener, M.D. Chancellor, University of Nebraska Medical Center Frank Barrett Chair, Blue Ribbon Coalition State Senator Linda Berglin Chair, Health Care Committee Minnesota State Senate E. Richard Brown, Ph. D. U.C.L.A. School of Public Health Task Force on Health Care Reform Sister Norita Cooney President and Chief Executive Officer Mercy Midlands Hospital Howard Dean, M.D. Governor, Sate of Vermont Lynn Dierker Health Policy Analyst Office of Colorado Governor Roy Romer Charles Dougherty, Ph.D. Director, Center for Health Policy and Ethics Creighton University Paul Ellwood, M.D. President and Chief Executive Officer Jackson Hole Group Bill Gradison President Health Insurance Association of America Richard Guffey Chairman and Chief Executive Officer Blue Cross and Blue Shield of Nebraska Randall Horn Executive Vice President Mutual of Omaha Companies Mark Horton, M.D., M.S.P.H. Director of Health State of Nebraska Dave Hunt Consumer Advocate Nebraska Citizen Action Darroll Loschen, M.D. President Nebraska Medical Association John Luehrs Senior Coordinator of the Health Team of the Public Policy Institute American Association of Retired Persons Ken Mass Secretary and Treasurer Nebraska AFL-CIO Janet Shikles Director of Health Financing and Policy U.S. General Accounting Office Senator Don Wesely 26th Legislative District Nebraska State Senate Neal Westphal Personnel Director Lincoln Telecommunications Company Sponsors: Mr. Mark Hanley Abbey Home Health Care Mr. Allen Fredrickson Accent Service Company, Inc. Mr. Matthew Kurs AMI St. Joseph Hospital AMI St. Joseph Center for Mental Health Mr. Jack Baker Baker's Supermarkets Mr. Richard Guffey Blue Cross and Blue Shield of Nebraska Byerly & Company of Nebraska, Inc. Mr. William Kaizer Central States Health & Life Co. Mr. Max Francis Clarkson Hospital Mr. Herman Myers Continental General Insurance Company Dr. Richard O'Brien Creighton University Ms. Lora Villarreal First Data Resources Mr. Rick Spellman Guarantee Mutual Life Company Bill Gradison Health Insurance Association of America Mr. Charles Marr Immanuel Medical Center Mr. James Geist Lincoln Telecommunications Company Medical Rehabilitation Education Foundation Ms. Jane Huerter Mutual of Omaha Companies Mr. Bill Schellpepper Nebraska Medical Association Mr. Dick Davis Northern Plains Natural Gas Company Mr. Fred Petersen Omaha Public Power District Mr. Robert Reed Physicians Mutual Insurance Company Mr. Jim Botkin Sandoz Pharmaceuticals Corporation Dr. John Braasch Share Health Plan of Nebraska/United HealthCare Mr. Ross Wilcox Union Bank & Trust Company Mr. Robert Bartee University of Nebraska Medical Center Mr. Bernie Dana Vetter Health Services, Inc. LATORIA I from Janet Shikles office will Call for you, if I am not ] here. Their number is 512-7119 THE WHITE HOUSE WASHINGTON Leff Janet Shikles, DirectoR of Health Financing & Policy from the GAO is testifying before Hillary at throrrow's evente Would you please cAll to find out if she has a preparen Statement we canget our hands on ? of not, please ask her (OR an assistant) to walk through what she - 'll be spyny. Thanks - Kim 275-5388 512-5388 7119 Being AXED 2:30p.m. PHOTOCOPY PRESERVATION Kerry Speech "Social Values Versus Economic Necessity" (Sacrifices society must make in order to provide health care services to everyone while trying to reduce the deficit) 1. Introduction Thank you. I really appreciate the opportunity to participate in this important conference that Senator Kerry and Governor Nelson have convened As the Senator told you,the GAO is a congressional agency and I am responsible for the health studies that we do for both Senators and Congressmen, both Democrats and Republicans. Over the past several years we have reported on the considerable and increasing problems in our system and have urged the Congress to take some tough actions. And that is what I am really going to talk about this morning. Areas are: Acess, Cost, and the Catch 22 we're in How did we get in this mess German Health Care Reforms provide an example of leadership (will seem odd, but the problems will sound very familiar to you as will some of the fixes--this is a study I am doing for the Senate that we will issue next month) Nine tough decision areas where Congress has to act if we're going to begin to address our access and cost problems 11. Access, Cost and the Catch 22 We're In A. Access -The access problem is very serious and getting worse-it is estimated that about 100,000 individuals are losing their health insurance each month -A recent study found that nearly half of families in america currently have a member who doesn't have insurance, will lose insurance this year or have insurance that fail to cover major medical costs --Individuals who don't have insurance pay a big price: one in three did not go to a doctor during the year for financial reasons and we know they put off treatment to the point of endangering their health 20'd 64566244 01 FROM 02:31 B. Costs -At the same time that the number of individuals without insurance are growing, so are our costs--in fact we have the most expensive health care system in the world. --It is estimated that our costs will be $939 billion this year and more than a $trillion in 1994. -The Commerce Dept. predicts that unless significant changes are made in the health delviery system costs could jump to more than $2 trillion by 1999-6 years from now C. Catch 22 This is a growing problem for workers, who are seeing lower wages, and business, state and federal government. But why is it a catch 22? The more we try to contain costs the more these efforts seem to backfire on US. For example, President Clinton can not reduce the federal deficit unless he makes significant cuts in the Medicare and Medicaid programs. (Together we're spending about $260 billion this year and these programs are expected to double by 1988)/ These two programs are the fastest growing in the federal buget; absent any change they will account for 60% of the increase in the deficit over the next several years. --Currently Medicare pays about 90% of a providers costs and Medicaid about 80%. To make up the difference and to cover the costs of serving the uninsured, providers charge private insurers 128% of costs. If medicare and medicaid are cut further this will increase charges to private insurers who will pass these higher costs on to business. As these costs to business continue to increase many are dropping their insurance (one estimate is 100,000 it month). Yet these individuals still will get sick, will show up at hospitals or will end up on Medicare and Medicaid thereby driving the costs up further. 11. How did we get in this mess? --Factors driving health care costs include: an aging population, increasing availability of expensive technology, consumer demand for more services, a fee for service system that rewards more the more services are performed --What's interesting is that every other industrialized nation is wrestling with these same issues and yet all have a level of health care spending significantly below ours, insure all of their citizens, manage to have health care outcomes about the same as ours 20'd 94566244 01 APR-15-1993 02:31 FROM GAO-HLTHFIN&POLICY --We have been asked to look at these systems for the Congress to identify why they seem to be doing better than us--are they rationing, living off of our technology. what? Issued reports on Canada. France, Germany, Japan --Lessons, back in the 1970s many of these countries were not covering all of their citizens. may have had cost increases as large as ours --Instituted comprehensive (rather than piecemeal) reforms. have made adjustments to these systems constantly III. Germany a. In 1991 spent about 8.5% of GDP compared to 13.4% US. (Germany spends 63.4% of what the US does on health care each year B. Germans covered at the workplace. standardized benefit package (dental and preventive. drugs, rehabilitation, eyeglasses, home health care, even spa visits as part of work therapy) and very minimal copayments C. Payroll tax. average is 13.7% split equally between employee and employer/payment is the same regardless of health status, age or familiy size d. GErmans choos their own does and hospitals and does are reimbured on a fee for service basis. e. Quality seems to be high, no queuing, Germans see their doctors more often than Americans f. Cost reforms --aggressive cost containment strategies (Concerted Action in the 80s) --global budgets to pay hospitals and doctors (reduced real physician spending by 17% between 77 and 87) --problems in 92: cost or reunification payroll rate jumped a point sickness funds deficits public angry over does income angry over high drug prices, high dental fees, excessive testing by does inefficiencies in hospital sector --passed most sweeping reform in 50 years (no one thot it could be done) P.04 94566244 01 APR-15-1993 02:32 FROM -what did they do? tightened budgets on hospitals and doctors/can only increase at same rate as wages ;new budgets on dentists and drugs reduce no. of specialists and no. of doctros increased preventive services (for 3 years until new system reforms passed/ 6% reduction in expected spending) -(dentists threatene to state aoctors checkenging 42.00 ) IV What Do We Need to DO? --Past piecerneal strategies won't work/ plan has to be comprehensive --Can;`t duck the tough decisions --What our work for congress, both from issued reports and those in progress show that there are a set of elements that have to be part of any comprehensive strategy: 1. coverage has to be universal and mandatory--can't be voluntary if it is voluntary many people will not purchase insurance: yet they still may get sick and require care: you can't impose cost constraaints on physicians and hospitals and other health professionals at the same time you are asking them to continue to provide care to a large group that is uninsured 2. eliminate certain insurance practices need to prohibit denials for preexisting conditions, guarantee coverage, portability, community rating (Rochester report) 3. change the mix of physicians have 70% specialists;30% primary care physicians this ratio is a major contributor to our rising health care costs SO'd 94566244 01 FROM 02:32 --a recent study found that doctor bills for older Americans varied dramatically across the couthry and are twice as high in some large cities as in others-average payment to a doctor in Miami was $1874 (in 1989) and in San Francisco $872 The differences were not due to health of elderly or in outcomes; charges were lowere in places with relatively more family doctors and fewer specialists. --what do we need to do: subsidize the education of doctors who plan to become family physicians 4. reduce administrative burden a recent study showed that Canadian hospitals are providing care at costs significantly lower than US hospitals without compromising patients treatment. but it is not because US hospitals are delivering more clinical services per patient Instead US hospitals incur higher overhead and are less efficient users of clinical equipment and personnel. overhead at Can. hospitals is about half that of their US coutnerparts (if US hospitals exhibited same spending patterns as Can. hospitals the US could have saved $40 billion) need one form, one card, standardized benefits package, savings from elimination of insurance practices (Toronto versus US hospitals) 5. insitute measures to reduce fraud and abuse --self referral issue 6. revamp how we pay for technology to reduce excess supply; proliferaiton --payment changes do not have to lead to the end of new drugs or technology or long waits --change payment (MRI study in Florida and Michigan)/planning 7. address malpractice problem --a successful reform plan must reduce doctors fear of malpractice suits--this could save the nation about $36 billion in five years according to some estimates from reduction in defensive medicine P.06 94566244 01 GAO-HLTHF IN&POL ICY APR-15-1993 02:33 FROM 8. institute measures of quallity --this is especially important particularly in a cost containment environment --now we assoicate high costs with high quality --recent study in PA of bypass surgery and outcomes-one hospital charged 21,000 and had sig. fewer deaths than expected: another hospital charged 83,000 and had sig. more deaths than expected 9. public health; prevention stragies and ways to increase personal responsibility --reinvest in our public health department, school nurses, health care support to rural areas. immunization screening, home visiting 10. identify strategies to pay for uninusred --hard for public to understand why they need to be taxed to pay for the uninusred when we have a system that many feel already is too costly and has excess capacity --difficulty is that whatever cost controls we put in place will take years to see benefits --in meantime need to finance coverage for uninsured, need to increase medicaid payments SO they are fair to providers. need IU finance public health strategies --no way to get around the fact that if we ultimately want to lower costs need to increase health care spending--estimates 30 plus billions 11. identify strategies to begin to slow spending --I've left the most politically sensitive til last --there are no good strategies to slowing rate increases --managed care is offered as one model-- yet we and others looking at research find that only closed punel HMOS at least in the past produced savings and these are not the form of managed care that is growing most rapidly --most countries have used global budget stragies--produce inefficiencies, or queing 20'd 94566244 01 FROM 02:24 United States GAO General Accounting Office Washington. D.C. 20548 Human Resources Division Fax Transmittal Sheet DATE: 4/15/93 TOTAL PAGES: Cover sheet plus 7 pages TO: Kim Tilley Telephone No. Fax Machine No. 456-6244 FROM: Janet Shikles U.S. GENERAL ACCOUNTING OFFICE NGB/HEALTH FINANCING AND POLICY ISSUES 441 G Street, NW Washington, DC 20548 Telephone No. (202) 512-7119 Fax Machine Telephone No. (202) 336-6642 REMARKS: 10'd 94566244 01 FROM 02:20 02/24/93 17:20 202 547 1893 COLUMBIA INST. 002 February 24, 1993 Mrs. Hillary Rodham Clinton President's Task Force on National Health Care Reform The White House Old Executive Office Building Washington. D.C. 20500 Dear Mrs. Clinton: As you know, the health care crisis has become a top priority in our domestic agenda. With nearly 37 million Americans lacking health Insurance and health care costs contributing significantly to our national deficit, it is obvious that the need for reform is urgent. In constructing a new hcalth care program we must consider three often conflicting aspccts of health care: affordability, accessibility, and quality. Our citizens must be informed about all of our health reform options so that they may make solid decisions about which proposal they support. With this in mind. I. along with Governor E. Benjamin Nelson, have decided to convene and chair a forum on Friday, April 16 and Saturday, April 17. 1993 entitled "Health Care in the 21st Century: National Challenges, Nebraska Solutions." The conference will be held at the University of Nebraska in Lincoln. We feel this forum will provide our constitucnts an unsurpassed opportunity to learn more about our national hcalth care options. I would like to extend to you an invitation to participate as the keynote speaker at this conference. Your insight would prove invaluable to the over 350 business leaders, policy makers, educators. health care professionals, and consumers who will be attending the forum. We believe that your experience and expertise will provide the audience the information it needs to make informed decisions. NOT PRINTED AT GOVERNMENT EXPENSE 02/24/93 17:21 202 547 1893 COLUMBIA INST. 003 The day's agenda will cover a range of topics including the future of our health care system, policy options facing Congress, and the challenges facing Nebraska including some difficult value decisions. We hope during the conference not only to promote a better understanding of these issues. but also to solicit responses from the audience on the variety of reform initiatives which have been proposed. The recommendations of my constituents will surely prove beneficial to me as the Congress faces increasingly controversial health reform proposals in the coming months. Your participation will help to ensure the success of this project, and I sincerely hope that you will bc able to join us. Randi Footlick of the Columbia Institute will be in touch with you within the next few days to discuss the logistics involved in your participation. As always, I encourage you to call my office at (202) 224-6551 or Randi at (202) 547-2470 should you have any questions or comments. I look forward to secing you soon. Sincerely, J. ROBERT KERREY United States Senate 08-24-93 05:23PM P003 #21 - - who does it serve? a:\apribcli. how funses? April 14, 1993 INDIAN HEALTH CARE CLINIC: BILLINGS, MONTANA W 406/245-8872 H 406 259-3026 DATE: April 16, 1993 from LOCATION: Indian Health Care Clinic TIME: 4:50 p.m son Phoses ScholaR FROM: Kim Tilley the was invited to partice w "FACED of Hope K I. PURPOSE IHS 406/245-7318 II. BACKGROUND - Fed $ - Don't #5 charge anythe III. PARTICIPANTS IHS, - Clinic Director, Marjorie Bear Don't Walk - 000 1 IV. PRESS PLAN Closed press - Less than 100 & total ITS - 65% FACTS of NA live off eservation budget owen to URBAN V. SEQUENCE OF EVENTS 134 accross Q.S.) IN Hith progo o 10 minute tour o Proceed to YWCA - At adate there is 11 IV. REMARKS person for URBAN Health V. thousands overall. PHOTOCOPY PRESERVATION FAmily showl necklace, headbAND husband works in N.D. is immunized Andrew Kline Nightmare walk through PHOTOCOPY PRESERVATION Apr. 15 '93 13:49 1946 LHB Billings TEL 4062458872 P. 2 259 9519 P.02 ROBYN MUNDY RH MS CRC Indian Health Board of Billings, Inc. The Indian Health Board of Billings, Inc. (IHBB) is a not-for- profit organization developed under Title V of the Indian Health Improvement Act of 1974. The intent of the act was to develop a plan to improve health care delivery for Native Americans living in urban areas. IHBB has provided health care and other services to 6,000 Indian residents of the Billings area for over 13 years, despite being woefully underfunded. Although the Indian Health Service employs 409 persons at national headquarters in Rockville, MD, there is only one employee at the facility to represent the national urban Indian health programs across the country. Although the Indian Health Service employs over 1,000 persons in the Billings area alone, IHBB continues to struggle to support less than ten full time positions. Despite the fact that 65% of Native American people in the area live OFF reservations, less than 1% of the Indian Health Service budget has been allocated for urban based services. Currently, IHBB offers health care clinics, allied health clinics, dental services, substance abuse counseling, AIDS education and alcohol awareness programs, among many others. It is our hope that the result of health care reform for Native American people will include strong support for urban based programs. We welcome the opportunity to show Mrs. Clinton and task force members how we manage to provide badly needed services in an underfunded and inadequate setting. 04/15/93 16:22 0001 Post-It" brand Fax Transmittal Memo 7672 Na. / Payes Time To Kim Tilley From Diane Hill Company Mrs. Clinton Location Location Company Cong. Pat Williams UCDL Charge Fax & Telephone # Fax # Telephone * 202-225-3211 Comments United Disposition Mexicy Return Call for plekup Purpose of Indian Health Care Meeting: * Give tribal leaders an opportunity Lu discuss health care with Mrs. Clinton without buffering or intervention from federal entities, e.q. IHS. Tribal leaders are clected by their respective tribes and have the best knowlodge and information on the needs of their people. * The federal government has a long-standing obligation to provide health care to Native American pcople. When national reform is enacted it ic critical that health care coverage for the Native American people be carefully considered and incorporated into that reform. & While Mrs. Clinton and the Health Care Reform Task Force have heard Lestimony from national organizations representing Native Americans, she has not met tribal leaders in their home states to discuss health care reform. Purpose of nural Health Care Meeting: * Billings serves AR a major regional center for health care. There are two major hospitals and a mental health care hospital. Eastern Montana is extremely rural in nature. Small rural hospitals and Medical Assistance Facilities rely on the Billings health Care community for support and referral. * The meeting will include by ief remarks on how 1 Billings serves as a regional center what it Lakes to recruit and retain employees in rural aleas, and what educational components of health care reform would best serve rural areas, That will set the tone for an open discussion of health care reform in a rural setting like Montana. + Participants include hospital administrators, doctors, nurses, physician assistants, nurse practitioners, public health providers, and others who are directly involved in the provision of health care. 1593 COLUMBIA INST. 0 0023002 NOTE: The introduction of the speakers in the Lied Center as agreed upon by the participants and their respective representatives: Jonathan Ortmans, Executive Director, Columbia Institute will introduce Senator J. Robert Kerrey. Senator Kerrey will introduce both Governor E. Benjamin Nelson and Governor Howard Dean. Senator Kerrey will introduce Hillary Rodham Clinton. Ms. Clinton speaks. Following her speach, Governor Nelson will then introduce Governor Dean. Governor Dean speaks. The audience then leaves Lieds and returns to Kimbal Hall for the continuation of the conference. HEALTH CARE TALKING POINTS Summary Americans are getting killed by skyrocketing health care costs. What you're charged for health care is rising four times faster than your wages. That doesn't make sense -- and it threatens your family's future and the future of every business, large and small. President Clinton is committed to fundamentally reforming our nation's health care system. The Clinton plan will control your health care costs and provide security to every American family. We will preserve what is best in the American system -- the highest quality medical care in the world and the individual's right to choose a doctor. Within days of taking office, President Clinton established the Task Force on National Health Care Reform, chaired by First Lady Hillary Rodham Clinton, to develop a comprehensive health care reform proposal. Hundreds of health care experts -- doctors, nurses, professors and businesspeople -- have been brought in from around the country to work with officials from government agencies and White House staff in a series of policy working groups that have been set up to advise the Task Force. In addition, diverse panels of consumers and health care professionals will be brought in regularly to advise the working groups as they develop their recommendations. Powerful lobbies and special interests are already lining up to defeat any plan we develop. They oppose change because they profit from the waste and inefficiency of today's system. But we are committed to breaking the gridlock. The American people demand and deserve change now. Washington can delay no longer. Interest groups can obstruct us no longer. Without immediate reform, the annual cost of health care for American families will more than double by the end of the decade -- to a whopping $14,000 per family -- while workers will lose an anticipated $650 increase in their incomes. It won't be easy and it won't happen overnight. But we will stand with you and take on the special interests. No American will feel secure again unless we bring health care costs under control now -- and make it possible for your family to get ahead again. Goals The Clinton health reform proposal will: Control the rapid spiralling of your health care costs. Provide security and peace of mind, so that you don't have to worry about losing your insurance when you change jobs or being denied coverage because you're sick. Root out fraud and overcharges. Simplify the system and reduce paperwork. Maintain the highest quality medical care in the world and preserve your health care choices. Apr. 15 '03 15:13 1040 LIID Dillings TCL 4062450072 r. 1 TO: Kim Tilly OFFICE: White House CITY, STATE: FROM: marjorie Bear Don't walk INDIAN HEALTH BOARD OF BILLINGS 915 BROADWATER SQUARE BILLINGS, MT 59102 PHONE (406) 245-7318 FAX (406) 245-8872 DATE: 4-15-93 MESSAGE... FOR Hillary Rodham Clinton RE: U.S Health Care Reform Task Force NUMBER OF PAGES (including cover page): : Withdrawal/Redaction Marker Clinton Library DOCUMENT NO. SUBJECT/TITLE DATE RESTRICTION AND TYPE 001. list Indian Health Board of Billings [partial] (2 pages) 4/15/93 b(6) COLLECTION: Clinton Presidential Records First Lady's Office Liz Bowyer OA/Box Number: 5432 FOLDER TITLE: [HRC Daily File] Friday, April 16 [1993] 2014-0483-S sh334 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] h(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] h(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 h(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. h(9) Release would disclose geological or geophysical information 2201(3). concerning wells |(b)(9) of the FOIA] RR. Document will be reviewed upon request. Apr. 1946 1111 billings III 4062480072 1002 Indian sealth Board of Billings Jurson T. Bear Nixt walk Thayaric Bear Dont wack Scate Bear Don't Naik - Zidena Bear Dort walk Old 8ck anna Old Ell clarton of ad Elk Jr. Rosemary Simon Gary stuben Chersa Valle JRobin Valle Brian Vallie Joseph Vallei Shomes Vallie Monnor The Falley There Londs - Jouyne mather Billy Honson - Road Marie mislett Little - Light (b)(6) Mr. Schnilger - (b)(6) (b)(6) John Stewart Rosemary Shevert - (b)(6) John Patter - 677 Janna Brewer - Coroline Homber Wing Joon me Cricken - 21 Rose Harris - Minsator apr sary Pitte - (b)(6) within 12 or from Bear Nort walk (b)(6) Junes Buird - (b)(6) WM Bell Far John Sey - (b)(6) 001 Jr. Buice Chessen - (b)(6) / John Old Elk - Clayton Old 806 - (b)(6) Duone Jeanstle -- Jul Personage (b)(6) 001 to Apr. 15:15 1946 EDD Hillings III 4062450072 4 1ken nichabson chick Kassie Marce richalson griup, Richie Kwn menism (b)(6) Affir Lenda Lofferty Margaret Rhades 001 Karen Our Ell slawa all sen thet our Elk Misty and Elk Sherna and 8ll Colien Brinnelt (b)(6) Karen stevent Iron Joanson Jack Robbit Head which Shired 001 Brod Lexsing Burton Phetty on up. (b)(6) 001 Mor. 15 '93 15:15 1946 LHB Billings TEL 4062458872 F. YWCA CA JACK Rebbit HEAR. MI NETA DAWN JUAN JOHNSON KOREN KASSIE DRESSED- KAREN steases Calvin GAINNE 11 -Dr. X 15mithy Job Phermase DAME JENNITERS Kim, Kov Nicholson MINE 5. BRACK he DR. 361F BRUCE R.LittlE Light I Baind Wilbur unher T. VAILE R. VALIE J. VANIE B VALLE I UPHIE Retty ENGENE TROTHER ENKY DONOVAL Cordon CAVALLEY STATE G. Our EIK cleuton Pharmacy DK. A+15. J.014 EIR ANNA some OFFICE Soft (We) Lobby Rosis ANNA B. Ship RHALES MANAGE! KUNDEN Joan X CAROLIN Their DIRECTORS Rosenty ENTRANCE 155h FROM THE DESK OF Sheila M. Nix Patti - If you need any more information on the conference please call me on my direct line, 224-0295. Thank you for your help. Aherla 04-15-93 05:56PM FROM SENATOR KERREY TO 94562239 P002/003 ADL ACTIVITIES OF DAILY LIVING L INCOLN, Neb. - In early 1990, the leadership of the MAKING I also was concerned about what the state legislature photo Lancaster County Medical might do I really felt that the Society was shaken when a medical community was in by survey revealed that virtually none of the the best position to solve the John community's primary care physicians 3C- How physician initiative problem." Dollendorfs cepted new Medicaid patients. This view may have seemed unrealistic, The society had commissioned the sur- vey, suspecting a problem. Medicaid ac- MEDICAID since physician dissatisfaction with Med- icaid was at the root of the crisis. But Dr. cess had been inadequate for years in this Caudill was right, as it turned out. community of 213,000 residents. of whom The Lancaster County Medical Society about 15,000 are Medicaid eligible. But formed an ad hoc Medicaid committee, the results confirmed the physicians' worst solved the Medicaid problem chaired by Dr. Caudill It joined with the fears. Lincoln-Lancaster County Health Dept. "There were a couple of things I was and the Nebraska Dept. of Social Services concerned about after it hit me," recalls Lincoln cardiologist WORK to fashion a Medicaid referral system that Chris Caudill, MD. a remedied the access problem almost as story by soon as it was implemented in February WayneHearn who was chairman of 1991. the Nebraska Medical in one U.S. community Since the program's inception, more Assn.'s Medicaid Com- than 90% of about 100 primary care physi- mittee at the time. cians in the county have agreed to partici- "One was the absolute reality of pate - a 180-degree shift in their the situation. with so many patients level of commitment to serving Med. out there without physicians and icaid patients. without knowing what they were go. Because Medicaid varies from ing to do for medical care." Many, he state 10 state, it's difficult to measure says, were seeking care in emergency the degree of physician participation departments at the county's three nationally. However, is recent survey hospitals or at a county clinic for in- of self-employed physicians by the digent patients. Physicians treated a AMA's Center for Health Policy Re- handful as charity cases without fil- search found that 65.5% of 4,848 pri- ing for reimbursement. It was clear mary care physicians participated in that quality of care was suffering. Medicaid in 1991. Dr. Caudill's other concern was the Last September, the Lancaster public-relations dilemma posed by the In Lincoln, Neb. physician willingness to County Medical Society and the Lincoin- finding. participate in Medicaid has been transformed, Lancaster County Health Dept. were hon- "I wondered how long it would he be- thanks to the local medical society. ored by the U.S. Health Care Financing fore il became known 10 the public in 8cn- Administration with a Beneficiary Ser- eral, and what the reaction might be. And See INITIATIVE, next page AMERICAN MEDICAL NEWS/MARCH 22/29, 1092 23 04-15-93 05:56PM FROM SENATOR KERREY TO 94562239 P003/003 ADL Initiative transportation and assigns a prima- ventive-medicine orientation that aged physicians 10 call with com- ry care physician. benefits both patients and physicians, plaints or reimbursement questions. Assignments rotate among partici- the providers say. Dr. Wright adds that the new sys- Continued from preceding page pating internists, pediatricians, family We stress to the physicians the tem also provided her department with vices Certificate of Merit for im- physicians and obstetrician-gynecol- importance of the preventive services a forum for updating physicians on proving health care delivery to Medic- agists. Each physician's name IS kept in and tell them 10 make sure they bill Medicaid reforms they had missed be- airt recipients. One of four local ef- 3 card file. New patients are 05- for it," Lopez explains. "The physi- cause they weren't participating. For forts honored. this was the only one signed 10 the doctor whose card is in clans are getting the maximum ben- example, fees for primary care and ob- targeted 10 Medicaid patients. front: the card is then moved to the efit for billing purposes and at the same stetrics had been increased, and red The system is simple in concept: back. Easy. Efficient. Equitable time, the patients are Betting the tape had been reduced through the in- Any Medicaid-eligible patient who But best of all, it enables Medic- maximum benefit from having contin- troduction of a universal billing needs care but has no regular physi- aid patients to break the fragmented- uous care. The kids are getting the form. "This helped us overcome a lot cian calls the referral line at the county care cycle that crodes quality and well-child check-ups, and the women of the old history," she says. health department. Within minutes, wastes health care resources. are Retting their Pap smears when The medical-society surveys a public health nurse confirms the call- By Jan. 31, nurses had assigned they should." helped prove that the Medicaid access cr's eligibility via computer, assesses more than 5,655 patients to participat- The system is successful because problem was real. Dr. Michels says. the patient's medical needs, screens for ing physicians, and had distributed it was built on the problem-solving It forced heads out of the sand. Many "access barriers" such as lack of 4,305 vouchers for free cab rides 10 and model, its proponents say. Through doctors "assumed someone else was from appointments. Since the pro- follow-up surveys. the committee taking care of things. Once we took gram began. the family physicians have learned why physicians did not want care of that, we could start talking accepted an average of 71 new pa- to treat Medicaid patients. about fairness and making (paticat dis- tients each: pediatricians, 52 each; in- "That meant the basic compo- tribution) equal or at least close ternists, 27: and obstetricians. 22. nents of the system were the solutions to equal because things hadn't been The University of Nebraska Med- to the problems the doctors cited." very equal before." ical Center's family practice residency Dr. Caudill says "It also showed the Previously, Lancaster physicians program also participates, exercising physicians that we listened to what say, when word got out that a practice Overwhelmed a "right of first refusal" to help it main- they had to say." was accepting Medicaid patients, it tain an adequate case mix. If it de- The complaints were familiar: low created a deluge. by medical clines, the intake nurse refers the pa- reimbursement. too much paperwork, "Periodically, the medical society license or tient to the next physician in line. too many claims denied on techni- would BO to as couple of groups and ask The residency program. with 15 10 20 calities and long delays in receiving them to help us out and see some privilege physicians, had accepted 809 refer- payment. Physicians also criticized Medicaid patients. and they'd get inun- applications? rais as of Jan. 31. Medicaid patients for missing appoint- dated because they were the only "When we started this. I think we ments and being noncompliant. group doing it. Dr. Caudill says. really put together a new medical sys- Such problems are addressed by Eugene Schwenke, MD. was in a Let the experts handle tem," Dr. Caudill says. "Berween the state Social Services Dept. and the group family practice when the pro- tham for you. the physicians and the patients and the participation of the public health Turn the todious work of applying nurses. it approaches some people's no- for medical licensure or hospital tion of an ideal situation. In terms The system is successful because it was built on the privileges over to the American of delivery of care, we have something problem-solving model, supporters say. Through sur- that may not be available in the best Medical Association's National private-pay coverage situations. veys. the committee learned directly from physicians Physician Credentials Verification "It may not be that you can just why they did not want to treat Medicaid patients. Service" (AMA/NCVS*). take this plan and plunk it down any- where and have it work, but I think It's easy. Simply complete your the way it evolved could be useful in city-county Health Dept. Intake aram began. "There were three in AMA/NCVS application. We'll use putting together a program that nurses stress the importance of compli- my group at the time, and 1 think we'd it to creute a portfolio of verified could work somewhere rise." ance and keeping appointments. always done our fair share." he re- oure credentials and professional Under a contract between the Social calls. "but you'd open the door for one information on you. he plans founders acknowl- Services Dept. and the Health or two [Medicaid recipients), and T edge that there are drawbacks, Dept.. federal money is earmarked for pretty soon it would just bc over. Then, when you want to apply for such as the lack of choice cab vouchers for patients without whelming." medical licensure, hospital privileges. for patients, who must accept transportation and for other adminis- Once the referral program was im- employment and professional mem the assigned physicians unless both trative case-management services. plemented, "everybody else started patient and physician agree they can- Physicians are encouraged to TC- contributing and taking some of the berships. we'll submit your portfolio not work together. port patients who miss appointments, load. and it did make things much for you. Offsetting this restriction, howev- so that Health Dept. nurses can fol- smoother," says Dr. Schwenke, who AMA/NOVE CURRE time for hospitals, er. is the access that Medicaid patients low up - with home visits, if neces- now practices emergency medicine at a sometimes gain to practices closed sary. Occasionally. the nurses ob- local hospital. licensing boards and group practices, to private-pay patients. Pat Lopez, RN, serve evidence of other problems, such The program also offers flexibility too. Using this service, they need district public health supervisor and as domestic violence or substance to participating physicians. who may never reverify your AMA/NCVS coordinator of the referral program, re- abuse, and communicate it to the ap- withdraw temporarily as needed, credentials. calls asking a colleague to follow up propriate agencies. Patients who re- such as when a practice partner is sick on one of the Medicaid patients. peatedly abuse the referral program are or on maternity leave or the practice Rid yourself of a time-consuming "When she saw who the doctor was, simply dropped: it's happened 10 is at full capacity. Their cards are kept task by letting AMA/NCVS do the she said. My god, I've been trying to about 35 over the first two years. out of the rotation until they return. work. To request your AMA/NCVS get in 10 sec him for two years!' "All of us have leverage with our It's all based on good faith. Physician Sign-up Kit or to Not how Another drawback is that the pro- private patients." anys family physician Pegay Barbee says the referral sys- gram excludes non-primary care spe- Date Michels, MD. who was presi- tem has made it much easier to deal NCVS can verify your applicant's cialists. so consultations and refer- dent of the county medical society with Medicaid patients at Smith and credentials for your organization. rals largely depend on the strength of when the program began. "If they Reed Clinic, the four-physician IM call 800 677-NCVS. the relationships between primary continually fail to keep appointments, practice where she's the office man- care physicians and the specialists with we can do something about it ager. whom they regularly work. we'll threaten to charge them for it. But "If the referral system calls. at "It's hoped that the support of the with Medicaid you can't do that; it's least we know the patient is qualified referrer would send a message to the considered fraud. So we didn't have a for Medicaid coverage because the physician being referred to that if mechanism for (noncomphant) public health nurses have already they enjoy the patient flow. it would be Medicaid patients. and now we do." screened for eligibility," she says. appreciated if they would take care Says Dr. Caudill: "When we took "Plus, people are much less likely 10 of this person," Dr. Caudill says. Sub- this plan back to the physicians for abuse the system when they know specialists rarely have refused to ac- their approval and explained why il someone's keeping track on things." cept Medicaid referrals. was necessary and what the rules were. The referral system has redefined After two years. the organizers are we were trying to extract from them the Medicaid problem for the commu- analyzing hospital emergency depart. an obligation to participate. In return. nity, Dr. Caudill says. mont records for signs that the pro- they wanted assurances from us that "What it boiled down to was that American Medical Association gram has reduced unnecessary visits by there would be accountability within there was this access problem for a long Medicaid patients. Preliminary re- the patient population and fairness time, and it looked like physicians sults show emergency visits increased within the rotational system." simply wouldn't take Medicaid pa- 7% since 1989. while the number of tients. But that really wasn't the is Medicaid eligibles jumped by 67%, he referral system also at sue In the end there was a spirit of to- from 9,000 10 15,000. "That has to T tempts to case the bassles. operation and a willingness 10 do speak positively of the program some- Chris Wright, MD. the So- their tair share. Once this system was how." Dr. Caudill says cia) Services Dept. medical di- in place. the good will of the physi- The involvement of public health rector. made it known her office was cians could manifest iself. 11 enabled nurses gives the program a strong pre- fully behind the system and encour- them 10 do it. 24 AMERICAN MEDICAL NEWS/MARCH 22/29, 1993 04/15/93 17:18 202 547 1893 COLUMBIA INST. 002/002 NOTE: The introduction of the speakers in the Lied Center as agreed upon by the participants and their respective representatives: Jonathan Ortmans, Executive Director, Columbia Institute will introduce Senator J. Robert Kerrey. Senator Kerrey will introduce both Governor E. Benjamin Nelson and Governor Howard Dean. Senator Kerrey will introduce Hillary Rodham Clinton. Ms. Clinton speaks. Following her speach, Governor Nelson will then introduce Governor Dean. Governor Dean speaks. The audience then leaves Lieds and returns to Kimbal Hall for the continuation of the conference. Apr. . 15 '03 13:40 1040 LND Dillings TCL 4062450072 Γ. 1 TO: Kim Telly OFFICE: White House CITY, STATE: Washingto D.C. FROM: Marjorie Bear Don't Walk INDIAN HEALTH BOARD OF BILLINGS 915 BROADWATER SQUARE BILLINGS, MT 59102 PHONE (406) 245-7318 FAX (406) 245-8872 DATE: 11-15-93 MESSAGE For: Hillary Rodham Clinton NUMBER OF PAGES (including cover page): 2 ADARD. quie keep copy TO: Patty Solis FROM: Cindy Dwyer Ju return. used let know Kerrey Scheduler RE: Mrs. Clinton's visit to Lincoln, NE X you'll will ido Patty, as we talked yesterday, I am faxing you the article on the Lancaster County Medical Society. It would be a tremendous favor to Senator Kerrey if Mrs. Clinton would meet briefly with a small group representing this effort for the purposes of presenting Mrs. Clinton with a copy of their report, brief introductions and a photograph. There would be 7 people representing the group and I will give you their names and their social security numbers. This is also a good news story for both Mrs. Clinton and Senator Kerrey and we'd like to have our Nebraska AP reporter attend--but not allow him to interrupt or ask questions--simply to cover the story. I have spoken about this event with both Steve Graham and Pat Hally. The time frame and location for this would be roughly 12:20-12:35 p.m. in the holding room after Mrs. Clinton and Bob have met privately. Call me when you can, Patty. Thanks, Cindy (202) 224-4425 (direct) (202) 224-7645 (fax) I LANCASTER 94562317 ADL ACTIVITIES DAILY LIVING INCOLN, Neb. - In carly 2 MAKING I also was concerned about 1990, the leadership of the what the state legislature photo Lancaster County Medical migh: do. : really felt that the Society was shaken when a medical community was in by survey revealed that virtually none of the the best position to solve the John community's primary care physicians ac- How physician initiative problem." Roilendorf cepted new Medicaid patients. This view may have seemed unrealistic, The society had commissioned the sur. vey, suspecting a problem. Medicaid ac. cess had been inadequate for years in this MEDICAID since physician dissatisfaction with Med- leaid was a: the root of the crisis. But Dr. Caudill was right, as it turned out. community of 213.000 residents of whom The Lancaster County Medical Society about 15,000 are Medicaid cligible. But formed an ad has Medicaid committee, the results confirmed the physicians' worst solved the Medicaid problem chaired by Dr Caudill. It joined with the fears. Lincoln-Lancaster County Health Dept. "There were a couple of things I was and the Nebraska Dept. of Social Services concerned about after it hit me." recalls Chris Caudill. MD, 1 WORK to fashion a Medicaid referral system that remedied the access problem almost as story by Lincoln cardiologist soon as it was implemented in February WayneHearn who was chairman of 1991 the Nebraska Medical Assn.'s Medicaid Com- in one U.S. community Since the program's inception, more than 90% of about 100 primary care physi- mittee at the time. cians in the county have agreed to partici- "One was the absolute reality of pate - a 180-degree shift in their the situation, with so many patients level of commitment to serving Mcd- out there without physicians and icard patients. without knowing what they were 80- Because Medicaid varies from ing to do for medical care." Many. he state to state, it's difficult to measure says, were seeking care in emergency the degree of physician participation departments at the county's three nationally. However. it recent survey hospitals or at a county clinic for in- of self-employed physicians by the digent patients. Physicians treated a AMA's Center for Health Policy Re. handful AC charity cases without fil. search found that 65.5% of 4.848 pri- ing for reimbursement. It was clear mary care physicians participated in that quality of care was suffering Medicaid in 1991. Dr. Caudill's other concern as the Last September. the Lancaster public-relations dilemma posed by the la Lincoin, Neb. physician willingness to County Medical Society and the Lincoln- finding participate in Medicaid has been transformed. Lancaster County Health Dept. were hon- "I wondered how long it would be be- thanks to the local medical society. ored by the U.S. Health Care Financing fore it became known to the public in sen- Administration with 1 Beneficiary Scr- crai, and what the reaction might be. And See INITIATIVE nest page AMERICAN MEDICAL NEWS/MARCH 22/29. 1993 23 P004/004 ADL Initiative transportation and assigns a prima- ventive-medicine orientation that aged physicians to call with com- ry care physician. benefits both patients and physicians. plaints or reimbursement questions. Assignments rotate among partici- the providers say. Dr. Wright adds that the new sys- Continued from preceding page pating internists, pediatricians, family "We stress to the physicians the tem also provided her department with vices Certificate of Merit for im- physicians and obsteirician-gynecol- importance of the preventive services a forum for updating physicians on proving health care delivery 10 Medic- agists. Each physician's name is kept in and tell them 10 make sure they bill Medicaid reforms they had missed be- aid recipients. One of four local of. 3 card file. New patients are as- for it," Lopez explains. "The physi- cause they weren't participating. For forts honored, this was the only one signed to the doctor whose card is in cians are getting the maximum ben- example. fees for primary care and ob- targeted 10 Medicaid patients. front: the card is then moved to the efit for billing purposes and at the same stetries had been increased. and red The system is simple in concept: back. Easy. Efficient. Equitable. time. the patients are getting the tape had been reduced through the in- Any Modicaid-eiigible patient who But best of all, it enables Medic- maximum benefit from having contin- troduction of a universal billing needs care but has no regular physi- aid patients to break the fragmented- uous care. The kids are getting the form. "This helped us overcome a lot cian calls the referral line at the county care cycle that crodes quality and well-child check-ups. and the women of the old history. she says. health department. Within minutes. wastes health care resources. are getting their Pap smears when The medical-society surveys a public health nurse confirms the call- By Jan. 31, nurses had assigned they should." helped prove that the Medicaid access er's eligibility via computer. assesses mure dian 5,655 patients to participat- The system is successful because problem was real, Dr. Michels says. the patient's medical needs, screens for ing physicians, and had distributed it was built on the problem-sciving 11 forced heads out of the sand. Many "access barriers" such as lack of 4,305 vouchers for free cab rides to and model. its proponents say. Through doctors "assumed someone else was from appointments. Since the pro- follow-up surveys, the committee taking care of things. Once we look aram began. the family physicians have learned why physicians did not want care of that, we could start talking accepted an average of 71 new D3- to treat Medicaid patients. about fairness and making [patient dis- tients each; pediatricians, 52 each: in- "That meant the basic compo- tribution) equal or at least close termists, 27; and obstervicians. 22. nents of the system were the solutions to equal because things hadn't been The University of Nebraska Med- to the problems the doctors cited," very equal before." ical Center's family practice residency Dr. Caudill says. "It also showed the Previously, Lancaster physicians program also participates. exercising physicians that we listened to what say, when word got our that a practice Overwhelmed a "right of first refusal" to help it main- they had 10 say." was accepting Medicaid patients, it tain an adequate case mix. If it de- The complaints were familiar low created a deluge. by medical clines. the intake nurse refers the na. reimbursement. too much paperwork. "Periodically, the medical society license or neat to the next physician in line. too many claims denied on techni- would go to a couple of groups and ask The residency program. with 15 to 20 calities and long delays in receiving them to help us out and see some privilege physicians, had accepted 809 refor- payment. Physicians also criticized Medicaid patients, and they'd get inun- applications? rais as of Jan. 31. Medicaid patients for missing appoint- dated because they were the only "When we started this. I think we ments and being noncomplient group doing it. Dr. Caudill says. really Dut together a DEW medical sys- Such problems are addressed by Eugene Schwenke. MD, was in a Let the experts handle tem," Dr. Caudill says. "Between the state Social Services Dept. and the group family practice when the pro- them for you. the physicians and the patients and the participation of the public health Turn the tedious work of applying nurses. it approaches some people's no- for medical licensure or hospital tion of an ideal situation. In terms The system is successful because it was built on the privileges over 10 the American of delivery of care, we have something problem-solving model, supporters say. Through sur- that may not be available in the best Medical Association's National private-pay coverage situations. veys, the committee learned directly from physicians Physician Credentials Verification "II may not be that you can just why they did not want to treat Medicaid patients. Service* (AMA/NCVS*) take this plan and plunk it down any- where and have it work. but I think It's easy. Simply complete your the way it evolved could be useful in city-county Health Dept. Intake gram began. "There were three in AMA/NCVS application. We'll use putting together a program that nurses stress the importance of compli- my group at the time, and I think we'd 11 to create a portfolio of verified could work somewhere else." once and keeping appointments. always done our fair share." he re- care credentials and professional Under 8 contract between the Social calls. "but you'd open the door for one information on you. he plans Founders acknowl- Services Dept. and the Health or two [Medicaid recipients). and T edge that there are drawbacks, Dept., federal money is earmarked for presty soon it would just be over- Then. when you want to apply for such as the lack of choice cab vouchers for patients without whelming." medical ilconsure hospital privileges, for patients, who must accept transportation and for other adminis- Once the referral program was im- employment and professional mem- the assigned physicians unless both trative case-management services. plemented. "everybody else started patient and physician agree they can- Physicians are encouraged to re contributing and taking some of the berships. well submit your perfectio not work together. port patients who miss appointments. load. and it did make things much for you. Offsetting this restriction, howev- so that Health Dep. nurses can fol- smoother," says Dr. Schwenke. who AMA/NCVS saves time for hospitals. er. is the access that Medicaid patients low up with home visits, if neces- now practices emergency medicine at a sometimes gain to practices clused sery. Occasionally. the nurses ob- local hospital. licensing heards and group practices, to private-pay patients. Pat Lopez, RN, serve evidence of other problems, such The program also offers flexibility too. Caing this service. they need district public health supervisor and 35 domestic violence or substance 10 participating physicians. who may never reverify your AMA/NCVS coordinator of the referral program, re- abuse, and communicate it to the ap- withdraw temporarily as needed, credentials. calls asking a colleague to follow up propriate agencies. Patients who TC- such as when a practice partner is sick on one of the Medicaid patients. peatedly abuse the referral program are or on maternity leave no the practice Rid yourself of a Lime-consuming "When she saw who the doctor was, simply dropped: it's happened to is at full capacity. Their cards are kept cask by letting AMA/NCVS do the she said. My god. I've been trying to about 35 over the first two years. out of the rotation until they return. work. To request your AMA/NOVS get in to see him for two years!" "All of us have leverage with our It's all based on good faith. Another drawback is that the pro- Physician Sign-up KJL or wife how private patients," says family physician Pegay Barbee says the referral sys- gram excludes non-primary care spe- Date Michels, MD, who was presi- tem has made it much caster to deat NCVS can verify your applicant's cialists. so consultations and refer- dent of the county medical society with Medicaid patients at Smith and credentials for your organization, rais largely depend on the strength of when the program began. "If they Reed Clinic, the four-physician IM call 800 677-NCV8. the relationships between primary continually fail to keep appointments. practice where she's the office man- care physicians and the specialists with we can do something about it ager. whom they regularly work. we'll threaten to charge them for it. But "If the referral system calls. at "It's hoped that the support of the with Medicaid you can't do that: it's least we know the patient is qualified referrer would send я message to the considered fraud. So we didn't have a for Medicaid coverage because the physician being referred 10 that if mechanism for (noncompliant) public health nurses have already they enjoy the patient flow, it would be Medicaid patients. and now we do." screened for eligibility." she says. appreciated if they ouid take care Says Dr. Caudill: "When we took "Plus, people are much less likely to 01 this person." Dr. Caudill says. Sub- this plan back to the physicians for abuse the system when they know specialists rarely have refused 10 ac- their approval and explained why it someone's keeping track on things." cept Medicaid referrais. was necessary and what the rules were. The referral system has redefined After two years. the organizers are we were trying 10 extract from them the Medicaid problem for the commu- analyzing hospital emergency depart- an obligation to participate. In return. nity, Dr. Caudill says. meme records for signs that the pro- they wanted assurances from us that "What it boiled down 10 was that American Medical Association fram has reduced unnecessary visits by there would be accountability within there was this Access problem for a long Medicaid patients. Preliminary se- the patient population and fairness time. and it looked like physicians sults show emergency visits increased within the relational system" simply wouldn't take Medicaid pa- 7% since 1989. while the number of tients. But that really wasn the is- Medicaid eligibles jumped by 07% he referral system also at. sue. In the end there was a spirit of co- from 9,000 to 15,000. "That has 10 T tempts to ease the hassles operation and a willingness 10 du speak positively of the program some- Chris Wright, MD. the Se their fair share. Once this system was how," Dr. Caudill says. cial Services Dept. medical di- in place. the good will of the physi- The involvement of public health rector, made it known her office was cians could manifest inself. 11 enabled nurses gives the program a strong pre- fully behind the system and encour- them to do it." 24 AMERICAN MEDICAL NEWS/MARCH 22/29. 1993 Withdrawal/Redaction Marker Clinton Library DOCUMENT NO. SUBJECT/TITLE DATE RESTRICTION AND TYPE 002. fax From: Cindy Dwyer, To: Patty Solis, Re: Meeting with Lancaster Co. 4/14/93 b(6) Medical Society [partial] (1 page) COLLECTION: Clinton Presidential Records First Lady's Office Liz Bowyer OA/Box Number: 5432 FOLDER TITLE: [HRC Daily File] Friday, April 16 [1993] 2014-0483-S sb334 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(I) 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 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. 04-14-93 10:05PM FROM SENATOR KERREY TO 94562317 P002/002 TO: Patty Solis FROM: Cindy Dwyer Kerrey Scheduler RE: Meeting with Lancaster Co. Medical Society Patty: This is a nearly complete list of the people Senator Kerrey would like Mrs. Clinton to meet on Friday in the Green Room at the Lied Center prior to Mrs. Clinton's speech. Previously, I had sent the article on the Medical Society and their efforts to work on solving the medicaid problem in their community. During the meeting, the Society would like to present Mrs. Clinton with a detailed report on how they proceeded and how it's working. The attendees would include: Natalie Clark, Lancaster County Medical Society SS# (b)(6) 002 Jane Ford. Director, Lincoln/Lancaster County Health Dept. SS# (b)(6) 002 Mary Dean Harvey, Director, Neb. Dept. of Health SS# (b)(6) 002 Pat Lopez, Neb. Dept. of Public Health Nurse SS# (b)(6) 062 Dr. Chris Caudill, Cardiologist SS# (b)(6) 002 Dr. Chris Wright, Medical Director for Medicaid SS# (still waiting for this one) David Buntain, Attorney, Nat'l. Dem. Committeeman SS# (b)(6) 002 Lucy Buntain, University of Neb. Foundation SS# (b)(6) 002 *We also would like to include a medicaid patient who has benefitted from this effort. We have one identified and whose name I will forward to you shortly along with their social security number. Thanks, please call. Cindy 4/14/93 6:45 p.m. 04/15/93 16:20 001 Post-It™ brand Fax Transmittal Memo 7672 No. of Pages Today's Date Time TO Kim Tilley From Diane Hill Company Mrs Clinton Company Location Location Cong. Pat Williams Dept. Charge Fax # Telephone # Fax # Telephone 202-225-3211 # Comments Original Destroy Return Call for pickup Disposition: Athing Purpose of Indian Health Care Meeting: * Give tribal leaders an opportunity to discuss health care with Mrs. Clinton without buffering or intervention from federal entities, e.g. IHS. Tribal leaders are elected by their respective tribes and have the best knowledge and information on the needs of their people. * The federal government has a long-standing obligation to provide health care to Native American people. When national reform is enacted it is critical that health care coverage for the Native American people be carefully considered and incorporated into that reform. * While Mrs. Clinton and the Health Care Reform Task Force have heard testimony from national organizations representing Native Americans, she has not met tribal leaders in their home states to discuss health care reform. Purpose of Rural Health Care Meeting: * Billings serves as a major regional center for health care. There are two major hospitals and a mental health care hospital. Eastern Montana is extremely rural in nature. Small rural hospitals and Medical Assistance Facilities rely on the Billings health care community for support and referral. * The meeting will include brief remarks on how Billings serves as a regional center, what it takes to recruit and retain employees in rural areas, and what educational components of health care reform would best serve rural areas. That will set the tone for an open discussion of health care reform in a rural setting like Montana. * Participants include hospital administrators, doctors, nurses, physician assistants, nurse practitioners, public health providers, and others who are directly involved in the provision of health care. 04/15/93 12:13 001/007 Post-it brand Fax Transmittal Memo 7672 lodays Date 4-15 Time No. of Paym 7 From To Company Kim Tilley Jim Foley Company Location Dept. Charge Location Telephone # Fax Telephone . tax # Original Comments Destroy Return Call for gickup Disposition: Please call if you have question on this first Round of info. Allach Document ATI ine BACKGROUND ON CONGRESSMAN PAT WILLIAMS PAT WILLIAMS IS SERVING IN HIS EIGHTH TERM IN THE U.S. HOUSE OF REPRESENTATIVES. CONGRESSMAN WILLIAMS WAS FIRST ELECTED TO CONCRESS IN 1978. IN 1992 PAT DEFEATED INCUMBENT REPUBLICAN RON MARLENEE IN STATEWIDE RACE FOR MONTANA'S LONE U.S. HOUSE SEAT. HE NOW REPRESENTS THE LARCEST U.S. HOUSE SEAT IN THE COUNTRY. HIS DISTRICT IS LARCER THAN ANY HOUSE DISTRICT BY 250,000 PEOPLE. HR TS A MEMBER OF THE HOUSE EDUCATION AND LABOR COMMITTEE WITERE HE SERVES AS CHAIRMAN OF THE LABOR MANAGEMENT SUBCOMMITTEE WILLCH IR ONE OF ONLY THREE COMMITTEES WITH JURISDICTION OVER HEALTH CARE REFORM AND TA ALSO VICE CHAIRMAN OF THE POSTSECONDARY EDUCATION 1113 JURISDICTION ON HEALTH CARE HTRMS PROM ERTSA GOING THRU THE SUBCOMMITTEE. PAT HAS BEEN VERY ACTIVE ON THE HEALTH CARE ISSUE FOR THE PAST FEW YEARS VISITING 39 CLINICS AND HOSPITALS AND HOLDING 12 HEARINGS OR FORUMS ON HEALTH CARE OVER THE LAST TWO YEARS. CONGRESSMAN WILLIAMS HAS MET WITH MRS. CLINTON ON FOUR OCCASIONS INCLUDING A MEETING IN HIS OFFICE A MONTH AGO. HE ALSO HAS STAFF DETAILED TO THE TASK FORCE. FOR SIX YEARS, FROM 1983 THROUGH 1988, REPRESENTATIVE WILLIAMS SAT ON THE HOUSE BUDGET COMMITTEE AND CHAIRED ITS TASK FORCE ON HUMAN RESOURCES. AT THE BEGINNING OF THE 101ST CONGRESS IN 1989, PAT LEFT THE BUDGET COMMITTEE TO RETURN TO THE SEAT HE HELD ON THE HOUSE COMMITTEE ON INTERIOR DURING HIS FIRST TWO HOUSE TERMS. ON THE INTERTOR COMMITTEE, PAT T6 A MEMBER OF THE SUBCOMMITTEE ON PUDLIC LANDS AND NATIONAL PARKS AND THE TNDTAN AFFAIRS SUBCOMMITTEE. THIS CONGRESS PAT ALSO FOUGHT FOR AND GOT A TEMPORARY ASSIGNMENT ON THE HOUSE AGRICULTURE COMMITTEE WHERE HE IS A MEMBER OF THE GENERAL COMMODITIES SUBCOMMITTEE IN THE CURRENT 103RD CONGRESS, REPRESENTATIVE WILLIAMS WAS REAPPOINTED BY HOUSE SPEAKER TOM FOLEY TO HIS FIFTH TERM AS DEPUTY WHIP FOR THE HOUSE MAJORITY LEADERSHIP. A FORMER TEACHER RIGHT, ME IS RECOGNIZED NATIONALLY FOR HIS WORK ON EDUCATION ISSUES. HE HAS PLAYED A MAJOR ROLE IN EVERY SIGNIFICANT EDUCATION BILL TO PASS THE CONGRESS IN THE LAST 12 YEARS. PATS WORK ON BEHALF OF SMALL BUSINESS AND WORKING FAMILIES HAS BEEN ACKNOWDEDGED BY GROUPS AS DIVERSE AS THE AFL-CIO, NATIONAL HOME BUTTDERS, THE NATIONAL PTA FOR HIS OUTSTANDING CHILD ADVOCACY WORK AND THE NATIONAL VOCATIONAL REHABILITATION ASSOCIATION. 04/15/93 12:14 002/007 Montana Indian Health Board of Billings, Inc. Marjorie Bear Don't Walk, Director Last Year -- 1992 4700 came through to see the doctor 21,000 came for consultations for substance abuse, immunization and mental health services. FOR Tour 4/16 5:00 p.m. Billings, Montana Questions? Diane Hill 225-3211 04/15/93 12:15 003/007 Andralth Care endiesse. item Appropriation AIHCA Appropriation FY 1993 AIHCA FY 1992 FY 1993 FY 1993 Budget FY 1994 Recommendation Recommendation Urban Health Base 12,120,582 12,120,502 12,120,582 12,791,808 12,794,808 AIDS/STD 675,569 675,569 675,569 708.049 708,049 Substance Abuse 2,568,308 3,568,308 3,968,308 4,159,094 5,000,000 Grants Substance Abuse 1,954,000 1,964,000 1,964,000 Contracts Mental Health 1,040,541 1,040,541 1,040,541 1,090,567 2,000,000 Health Promotion 395,000 500,000 395,000 413,991 500,000 Discase Prevention Immunization 395,000 500,000 395,000 413,991 500,000 Child Abuse 500,000 2,000,000 Facility Improvement 500,000 1,000,000 Infant Mortality 2,000,000 2,000,000 Expand Capacity 2,400,000 2,400,000 Population Growth 91,500 91,500 Fund Inflation 1,014,505 894.000 2,585,340 Total 17,195,000 24,819,505 21,544,500 21,544,500 32,836,991 *Existing urban substance abuse funding transferred from Alcohol Program Branch to Urban Program Branch 04/15/93 12:15 5 004/007 ACCOMPLISHMENTS There are thirty-four Urban Indian Health Programs (UIHP) funded under Title V of the Indian Health Care Improvernent Act. In addition, two demonstration projects are funded through Indian Health Service (IHS) Hospitals and Clinical Services. During Fiscal Year 1990, 500,317 encounters were provided. These encounters were provided In the following categories: Provider category Number of encounters Outpatient Medical Visits 172,297 Outpatient Dental Visits 76,028 Community Service Outreach and 138,284 Referral Direct Visits Health Education 34,320 Nutrition 79,201 Mental Health 9,997 Optometry 802 Allied Health 48,682 Substance Abuse 104,470 Number of program staff ranges from three persons providing substance abuse and community health services to over one hundred persons offering comprehensive ambulatory care services. There are only three states which categorically fund Indian Health: Michigan, Minnesota, and California. These funds are limited and are intended to supplement federal Indian Health Service activities. Attempts for Indian health legislation in other states have been unsuccessful. There is a feeling among many in state government that the health of the Indian people is a responsibility of the federal government. State grants are highly competitive, and with diminishing state dollars it is extremely difficult for organizations outside the traditional state-county-city health department system to receive funding. While several UIHPs receive state monies for Women, Infants, and Children Supplemental Feeding Program (WIC), and Maternal Child Health (MCH), these funds are very specifically targeted and cannot be used to offset IHS funding. Continuing IHS funding is essential for the very existence of Urban Indian Health Programs. 23 04/15/93 12:16 5 005/007 URBAN INDIAN HEALTH PROGRAMS State Urban Indian Health Program Location Arizona Phoenix Tucson Flagstaff California Bakersfield Fresno Los Angeles Sacramento San Diego San Francisco/Oakland San Jose Santa Barbara Colorado Denver Illinois Chicago Kansas Wichita Massachuselts Boston Michigan Detroit Minnesota Minneapolis Montana Billings Butte Great Falls Helena Missoulo Nebraska Lincoln/Omaha/Sioux City Nevada Reno/Carson City New Mexico Albuquerque New York New York City Oregon Portland South Dakota Plerre/Aberdeen/Sioux Falls/Vermillion Texas Dallas/Ft. Worth Utah Salt Lake City Washington Seattle Spokane Wisconsin Green Bay Milwaukee 04/15/93 12:16 006/007 Health care Concerns Expressed by Montana Tribes I. IHS is a payer of last resort. This causes several burdens for Native Americans. A. Veterans Veterans must use VA facilities -- IHS won't serve them. Often Native American veterans have to travel great distances (there are only 2 veterans hospitals in Montana) to get health care when IHS has facilities on their reservation. The Blackfeet have voiced this concern because their hospital is relatively new, finished in 1985 and could serve veterans. B. Medicaid Eligibility Medical bills for contract care often go unpaid for extended periods because IHS waits to see if individuals are eligible for other government programs, i.e. medicaid, before they will agree to consider making payment. Meanwhile, the individual who received the service is expected to make payment. One Montana hospital turned $250,000 in payments due over to a credit bureau, damaging the credit of many tribal members. C. Fundamental problem is that IHS operates on a discretionary basis, not as an entitlement. What IHS will cover fluctuates. Indian people are never sure what IHS will or will not cover. II. Contract Care A. Native Americans without access to IHS hospitals have to rely on IHS to pay for services from general hospitals, i.e. contract care. While Medicare and Medicaid set a payment schedule for services, IHS does not. What that means is that the cost shifting from Medicare and Medicaid is paid by IHS. This erodes the amount of money available for tribal members relying on IHS. For example, if you look at raw percentage of services a hospital provides to Native Americans, Indians consume 35% while 45% of revenues come from IHS. Hospitals that serve Native Americans often have only Medicare and Medicaid as their other usage. The result, IHS subsidizes Medicare and Medicaid. 04/15/93 12:17 007/007 III. Long Term Care A. Montana's Native American community would like Lo have nursing homes operated by either the IHS or tribes. Right now they must put their elderly in nursing homes far away from the reservation. Last year in the Indian Health Care Amendments we included a demonstration program that would allow tribes to attach nursing homes to IHS facilities. It did not provide bricks and mortar funding. The clear sign from the Energy and Commerce Committee is that they will not support the building of nursing homes with government money. FYI, the Blackfeet Tribe has a nursing home which is operated by the tribe. They need a new building. National Perspective Michael Anderson, Executive Director of the National Congress of American Indians testified before the White House Health Care Task Force on March 29. Following is an excerpt from his testimony. II the answer for American Indians is to permit them the option to participate in nationally provided health care options like insurance while retaining access to Indian health service/tribal services IHS and tribally operated programs should be able to collect for American Indian/Alaska Native people who have other coverage who choose to use IHS or tribally operated programs." Most Montana tribes participate in NCAI. The Crow do not. Dick Trupean Phil hee 04/12/93 15:18 202 547 1893 COLUMBIA INST. 010/014 WHAT IS COL UMBIA INSTITUTE Founded in 1977, Columbia Institute is an independent public policy group specializing in conference management and research services. Combining policy expertise with organizational skills, Columbia Institute plans conferences and workshops, provides public policy research and consulting services, and coordinates international business and political programs. Individually tailored projects advance the exchange of information and ideas and provide a basis for cooperation among leaders at all levels. When managing public policy initiatives, Columbia Institute maintains a non- partisan and independent position by ensuring balanced consideration of the issues at hand. Based in Washington, D.C., Columbia Institure has an affiliate office in Seartle and coordinates projects in all 50 states and many foreign countries. 04/12/93 15:18 202 547 1893 COLUMBIA INST. 011/014 CONFERENCE MANAGEMENT SERVICES Columbia Institute plans and coordinates conferences, annual meetings, and conventions for private companies and trade associations. From developing an initial concept or goal, to on-site management and follow-up, Columbia Institute has established a reputation for both quality and results. Columbia Institute: develops an agenda and program identifies, recruits and confirms prominent business and government speakers evaluates, negotiates and manages conference sites, air travel, audio-visual including electronic polling and satellice links, printers and mail houses, and other subcontractors formulates, prepares and manages computerized registration darabases designs, prints and distributes invitations and event programs generates and manages press and publicity, and conference promotion coordinates and prepares reports, transcripts, videotapes, evaluations, and other follow-up activity manages all finances, providing complete and timely reporting PUBLIC POLICY FORUMS Since 1981, more than 2,000 U.S. corporations have served as sponsors of Columbia Institute's extensive regional conference program. These forums, chaired by members of Congress from both parties, and convened in their states, address policy issues currently on the nation's agenda. Issue areas include: health care reform education economic development the environment international trade policy energy policy In addition to appropriate public recognition, sponsorship provides organizations with the opportunity to: work closely with members of Congress and their staffs on program development; educate personnel on complex policy issues; promote cooperation with others on issues of common interest; and increase public awareness on special matters of concern. 01/15/93 12:00 001-007 Post-B" hand Fax Transmittal Memo 7672 No. di Pages 7 Today's Date 4-15 Time TO Kim Tillery From Jim Foley Company Company Invoice Location Dept. Charge Fax a Telephone# Fax & Telephone # Comments Original Disposition: Sectroy Return Call for pickup Please call if you have question on this first Round of into. BACKGROUND ON CONGRESSMAN PAT WILLTAMS PAT WILLIAMS 15 SERVING IN us EIGHTH TERM IN THE U.S. HOUSE OF REPRESENTATIVES. CONGRESSMAN WILLIAMS WAS FIRST ELECTED TO CONGRESS IN 1978. IN 1992 PAT DEFEATED INCUMBENT REPUBLICAN RON MARLENEE IN STATEWIDE RACE FOR MONTANA'S LONE U.S. HOUSE SEAT. HE NOW REPRESENTS THE LARGEST U.S. HOUSE SEAT IN THE COUNTRY. HIS DISTRICT IS LARGER THAN ANY HOUSE DISTRICT BY 250,000 PEOPLE. HE IS A MEMBER OF THE HOUSE EDUCATION AND LABOR COMMITTEE WHERE HE SERVES AS CHAIRMAN OF THE LABOR MANAGEMENT SUBCOMMITTEE WHICH IS ONE OF ONLY THREE COMMITTEES WITH JURISDICTION OVER HEALTH CARE REFORM AND IS ALSO VICE CHAIRMAN OF THE POSTSECONDARY EDUCATION SUBCOMMITTEE. HIS JURISDICTION ON HEALTH CARE STEMS FROM ERISA COINC THRU THE SUECOMMITTEE. PAT HAE BEEN VERY ACTIVE ON THE HEALTH CARE ISSUE FOR THE PAST FEW YEARS VISITING 39 CLINICE AND HOSPITALS AND HOLDING 12 HEARINGS OR FORUMS ON HEALTH CARE OVER THE GANT TWO YEARS. CONGRESSMAN WILLIAMS HAS MET WITH MRS. CLINTON ON FOUR OCCASIONS INCLUDING A MEETING IN HIS OFFICE A MONTH AGO. HE ALSO HAS STAFF DETAILED TO THE TASK FORCE. FOR SIX YEARS, FROM 1983 THROUGH 1988, REFRESENTATIVE WILLIAMS 3AT ON THE HOUSE BUDGET COMMITTEE AND CHAIRED ITS TASK FORCE ON HUMAN RESOURCES. AT THE BEGINNING OF THE 101ST CONGRESS IN 1989, PAT LEFT THE BUDGET COMMITTEE TO RETURN TO THE SEAT HE HELD ON THE HOUSE COMMITTEE ON INTERIOR DURING HIS FIRST TWO HOUSE TERMS. ON THE INTERIOR COMMITTEE, PAT IS A MEMBER OF THE SUBCOMMITTEE ON PUBLIC LANDS AND NATIONAL PARKS AND THE INDIAN AFFAIRS SUBCOMMITTEE. THIS CONGRESS PAT ALSO FOUGHT FOR AND GOT A TEMPORARY ASSIGNMENT ON THE HOUSE AGRICULTURE COMMITTEE WHERE HR TS A MEMBER OF THE GRNERAL COMMODITTES SURCOMMITTEE IN THE CURRENT 103RD CONGRESS, REPRESENTATIVE WILLIAMS WAS REAPPOINTED BY HOUSE SPEAKER TOM FOLEY 481 1118 FIFTH TERM AN DEPUTY WILLP FOR THE HOUSE MAJORITY LEADERSHIP. A FORMER TEACHER RIGHT, HE IS RECOGNIZED NATIONALLY FOR HIS WORK ON EDUCATION ISSUES. HE HAS PLAYED A MAJOR ROLE IN EVERY SIGNIFICANT EDUCATION BILL TO PASS THE CONGRESS IN THE LAST 12 YEARS. PATS WORK ON BEHALF OF SMALL BUSINESS AND WORKING FAMILIES HAS BEEN ACKNOWLEDGED BY GROUPS AS DIVERSE AS THE AFL-CIO, NATIONAL HOME BUILDERS, THE NATIONAL PTA FOR HIS OUTSTANDING CHILD ADVOCACY WORK AND THE NATIONAL VOCATIONAL REHABILITATION ASSOCIATION. 04/15/93 12:01 1 003/007 Andealth Care endience. Item Appropriation AIHCA Appropriation FY 1993 AIHCA FY 1992 FY 1993 FY 1993 Budget FY 1994 Recommendation Recommendation Urban Health Base 12,120,582 12,120,582 12,120,582 12,794,808 12,794,808 AIDS/STD 675,569 675,569 675,569 708.049 708,049 Substance Abuse 2,568,308 3,568,308 3,968,308 4,159,094 5,000,000 Grants Substance Abuse 964,000 1,964,000 1,904,000 Contracts 3 Mental Health 1,040,541 1,040,541 1,040,541 1,090,567 2,000,000 Health Promotion 395,000 500,000 395,000 413,991 500,000 Disease Prevention Immunization 395,000 500,000 395.000 413,991 500,000 Child Abuse 500,000 2,000,000 Facility Improvement 500,000 1,000,000 Infant Mortality 2,000,000 2,000,000 Expand Capacity 2,400,000 2,400,000 Population Growth 01,500 91,500 Fund Inflation 1,014,505 894,000 2,585,340 Total 17,195,000 24,819,505 21,544,500 21,544,500 32,836,991 *Existing urban substance abuse funding transferred from Alcohol Program Branch to Urban Program Branch 04/15/93 12:02 004/007 ACCOMPLISHMENTS There are thirty-four Urban Indian Health Programs (UIHP) funded under Title V of the Indian Health Care Improvement Act. In addition, two demonstration projects are funded through Indian Health Service (IHS) Hospitals and Clinical Services. During Fiscal Year 1990, 500,317 encounters were provided. These encounters were provided in the following categories: Provider category Number of encounters Outpatient Medical Visits 172,297 Outpatient Dental Visits 76,028 Community Service Outreach and 138,284 Referral Direct Visits Health Education 34,320 Nutrition 79,201 Mental Health 9,997 Optometry 802 Allied Health 48,682 Substance Abuse 104,470 Number of program staff ranges from three persons providing substance abuse and community health services to over one hundred persons offering comprehensive ambulatory care services. There are only three states which categorically fund Indian Health: Michigan, Minnesota, and California. These funds are limited and are intended to supplement federal Indian Health Service activities. Attempts for Indian health legislation in other states have been unsuccessful. There is a feeling among many in state government that the health of the Indian people is a responsibility of the federal government. State grants are highly competitive, and with diminishing state dollars it is extremely difficult for organizations outside the traditional state-county-city health department system to receive funding. While several UIHPs receive state monies for Women, Infants, and Children Supplemental Feeding Program (WIC), and Maternal Child Health (MCH), these funds are very specifically targeted and cannot be used to offset IHS funding. Continuing IHS funding is essential for the very existence of Urban Indian Health Programs. 23 04/15/93 12:03 URBAN INDIAN HEALTH PROGRAMS State Urban indian Health Program Location Arizona Phoenix Tucson Flagstatt California Bakersfield Fresno Los Angeles Sacramento San Diego San Francisco/Oakland San Jose Santa Barbara Colorado Denver Illinois Chicago Kansas Wichita Massachusetts Boston Michigan Detroit Minnesota Minneapolis Montana Billings Butte Great Falls Helena Missoula Nebraska Lincoln/Omaha/Sicux City Nevada Reno/Carson City New Mexico Albuquerque New York New York City Oregon Portland South Dakota Pierre/Abcrdeen/Sioux Falls/Vermillion Texas Dallas/Ft. Worth Utah Salt Lake City Washington Seattle Spokane Wisconsin Green Bay Milwaukee 4/12 RANDY Footlik 547-2470 Keney - Re NC Heavily insurance bases a GovOset up Blue Rofon came Reason for cord. ago since obviously lagenda changes Kenrey initiated it Overa yr Hot Spots: Gov ohig Thinking doing Preely much supportive his own conf, but joines in CrowD: 900 /hequry insurance $ : CoRporate community rasses Ellwood Brown HRC Remarks: - want QAA w/ augjence - she decises length The CORN Huster PURPOSE: To allow N the opp to learn as much as posside about Natil Healthcare Reform. Columbia list: SeRies of ch. conf- Repr Dems : JOHN 3 ROCKEFELLER IV MEST WORKS United States Senate WASHINGTON DC 20510-4802 FROM THE OFFICE OF SENATOR JAY ROCKEFELLER FAX COVER SHEET Melanne verveer TO: OFFICE: First Lady Tanesa Starton FROM: DATE: 6 # OF PAGES (INCLUDING COVER) Problems with transmission call (202) 224-6472 *** Nothing changed. Kerrey's big thing is "financing" it sounded to me like he was searching for an issue related to health care reform to make himself "distinct" from others and decided financing was the issue (this was several years ago) The words he uses alot are "deficit-financing" He argues that we shouldn't go down the path we have with Medicare, Medicaid, and others and finance health care through federal debt. File item 2: HRC-KERR.BOB 3/11/93 2:25PM a note from my steff in response to a question to be Melanne - sure this meno is shill current. It is Kesrey voted for the Nunn cap on entitlements, and was carrying around his own health care andt to the weket resolution that he scrapped related to financina. He has attended the Magazines/ Feder lunches with Den senators, and was complimentary at the second one. CONFIDENTIAL Memorandum To: HRC From: JDR Re: Senator Kerrey's Health Reform Plan Date: March 11, 1993 I had originally drafted this memo to you because of Bob Kerrey's repeatedly stated concerns about President Clinton's approach to health care reform. I wanted to give you a sense of the health care bill that Bob introduced a couple of years ago, and to let you know that the similarities between the two plans are more striking than their differences. But since WB drafted this, Bob and I had an exchange -- during yesterday's health care briefing for Democratic Senators by Ira and Judy -- in which he said in a note that he "likes what he is hearing" from the White House on health care. With that more hopeful comment, I pass these thoughts on in order to assist you in forging a partnership with Bob on health reform that we all want. Both President Clinton's approach and Boh Kerrey's plan rely on the private insurance market to provide insurance coverage through pooling arrangements. Kerrey's bill would require everyone to buy coverage through purchasing pools versus only businesses of a certain size (yet to be determined by your Task Force). Instead of quasi-public or private entities acting as purchasing agents (HIPCs), Kerrey's bill relies on the states to act as purchasing agents. Very confidentially, my health staff has spoken with a former aide to Kerrey, and she agreed that the approaches are compatible. She thought the Clinton managed competition framework with a global budget and the Kerrey bill were amazingly consistent with each other. (She even acknowledged that she wished they would have added the HIPC as the purchasing agent instead of the state.) While Senator Kerrey's bill explicitly "breaks" the job- based link for health insurance, he does go to the workplace for financing health care through an employer and employee payroll tax. Kerrey has specifically made financing a key issue -- to make himself distinct from others -- and it is also a point other "modified" single payers like Tom Daschle frequently make to point out that individual taxpayers are already footing the bill for our private health care system. DETERMINED TO BE AN ADMINSTRATIVE Initials: MARKING SDB Per E.O. 12958 as amended, Sec. 3.3 (c) Date 5/19/14 Under their modified single payer bills, they are only recapturing current health care spending by taxpayers and funneling it through the federal government. The net increase in taxpayer spending is only minimal. For some it may even be less. Daschle, as you have probably already heard, uses the term "fiscal clarity." Other factors may explain Kerrey's discontent, and I am hopeful they can be overcome with the proper attention to his concerns and need for involvement. Summary of "Health USA" In July 1991 Senator Kerrey introduced his "Health USA" plan (S.1446). The major provisions of the proposal are: A federal commission appointed by the President and confirmed by Congress would oversee the plan. The Federal Government would collect mcst health care funds, combining current federal health care spending (Medicare, Medicaid, Federal Employees Health Benefits Program, CHAMPUS), a new payroll tax of 4% on employers and 1% on employees, and a series of new taxes on liquor and cigarettes, taxes on Social Security benefits, higher top personal income tax rates, and a rise in the amount of income subject to taxation. These funds would be channeled to new state health agencies. Federal dollars could be supplemented with state dollars. States would certify private managed care and other private networks of insurers and providers who offer a mandated benefit package, including some mental health, substance abuse, prescription drug, preventive, hospice, and long-term care coverage. Residents would choose from among these certified plans. Plans could charge enrollees extra premiums for more generous benefits. Plans would receive from the state a capitated payment based on the number of enrollees in each plan. Plans would have to accept all who apply. Enrollees could only change plans during an annual "open enrollment" period. The plan would replace Medicare, Medicaid, the Federal Employees Health Benefits plan, and CHAMPUS. States would operate or contract for a separate plan which could be a fee-for-service plan. Physician fees would be state set using an RBRVS-like mechanism. Resource Development Accounts would be set up in each state to fund access in underserved areas. Outcomes research and practice guidelines would be funded by the federal commission. The VA Health Care System would be preserved, with arrangements for the Department of Veterans Administration to be reimbursed for care provided in VA facilities. Under Kerrey's bill, costs would be controlled by states having a predetermined allocation of federal funds and the authority to set rates and capitation fees. As I said above, the concept is actually very similar to HIPCS, but instead of the state government, managed competition envisions state- designated agencies would be the purchasing pools. Access is provided through universal enrollment. Consumer choice of private plans is expected to maintain quality. It is apparent that there are many similarities to the basic framework of managed competition within the discipline of a national health care budget: A federal commission overseeing the program; state-designated agencies negotiating with private health care systems; the possible use of a capitation (as opposed to a federal rate-setting) mechanism to control costs; elimination of current insurance practices such as exclusions for pre-existing conditions. Again, one difference is that the Kerrey plan would be financed by federal revenue collections, primarily employer and employee payroll taxes, as opposed to employers and employees sharing in the payment of premiums. A payroll tax is viewed by Kerrey as a source of financing, rather than building on our job-based system. Queie keep COPY youselt TO: Patty Solis of let line will FROM: Cindy Dwyer Kerrey Scheduler RE: Mrs. Clinton's visit to Lincoln, NE X you'll ido Patty, as we talked yesterday, I am faxing you the article on the Lancaster County Medical Society. It would be a tremendous favor to Senator Kerrey if Mrs. Clinton would meet briefly with a small group representing this effort for the purposes of presenting Mrs. Clinton with a copy of their report, brief introductions and a photograph. There would be 7 people representing the group and I will give you their names and their social security numbers. This is also a good news story for both Mrs. Clinton and Senator Kerrey and we'd like to have our Nebraska AP reporter attend but not allow him to interrupt or ask questions-- simply to cover the story. I have spoken about this event with both Steve Graham and Pat Hally. The time frame and location for this would be roughly 12:20-12:35 p.m. in the holding room after Mrs. Clinton and Bob have met privately. Call me when you can, Patty. Thanks, Cindy ( 202) 224-4425 direct) (202) 224-7645 fax) ADL ACTIVITIES OF DAILY LIVING INCOLN. Neb. - In early 1 also was concerned about 2 990, the leadership of the MAKING what the state legislature photo Lancaster County Medical migh: do. I really felt that the Society was shaken when a medical community was in 04 survey revealed that virtually none of the the best position to solve the John community's primary care physicians ac- How physician initiative problem. Roilendor cepted new Medicaid patients. This view may have seemed unrealisted The society had commissioned the SLT. MEDICAID since physician dissatisfaction with Med- yey. suspecting a problem. Medicaid ac. card was a: the root of the CTISIS. But Dr. less had been madequate for years in this Caudill was right. as 18 turned Jul. community or 213.000 residents of whom The Lancaster County Medical Society about 15,000 are Medicard cligible. But formed an ad hoc Medicaid committee. the results confirmed the physicians' worst solved the Medicaid problem chaired by Dr Caudill. It joined with the fears. Lincoln-Lancaster County Health Dept. "There were a couple of things 1 was and the Nebraska Dept. of Social Services concerned about after It his me." recalls Chris Caudill. MD. 1 WORK to fashion a Medicaid referral system that remecied the access problem almost as story by Lincoln cardiologist soon as i: was implemented in February ШаупеНеаго who was chairman of 1991. the Nebraska Medical Asso.'s Medicaid Ccm- in one U.S. community Since the program's inception. more than 90% of about 100 primary care physi- millee at the time. clans in the county have agreed es partier- "One was the absolute reality of pate - 1 180-degree shift in their the situation. with so many patients lovel of commitment 10 serving Med- out incre without physicians and icard patients. without knowing what they were NO- Because Medicaid varies from mg 10 do for medical care. Many he state 10 state. 11's difficult to measure says. were seeking care in emergency the degree of physician carticipation departments J: the equity's three nationally. However hospitals or at a county clinic for 15- of sentemployed physicians digent patients. Physicians treated a AMA's Center for Health Policy R.:- handful : charity cases whout fil. search found that 65.50 343 pr:- mg for retmoursement was clear mary care purchased in 1031 quality of care was susfering Medicate in 1991. Dr. Caudill's ciner concern as the Last September. the Diancaster public-relations cliemina posed by the Lincoin. Neb. physician willingness to County Medical Society and the Linco-n- finding participate in Medicaid has teen transformed. Landaster County Health Deptinwere non- "! wondered how DOB it would te DC- thanks to the CC3 mes 03: society. cred by inc U.S. Health Care Financing are " became known to the puoite in gen- Administration with 2 Reneficiary Ser- crai, and what INC reaction might be. And See INITIATIVE next case MERICAN MEDICAL NEWS/MARCH 22/29. 1693 ADL Initiative transportation and assigns a prima- ventive-medicine orientation that aged physicians to call with com- ry care physician. benefits both patients and physicians. plaints DT reimbursement questions. Assignments rolate among partic'- the providers say. Dr. Wright adds that the new sys. Continued from preceding page pating internists. pediatricians. family "We stress to the physicians the :Em also provided her department with rices Certificate of Meru for im- physicians and obsielfician-gynecol- importance of the preventive services J forum for updating physicians on provide health care delivery 10 Medic- agists. Each physician's name 15 kept in and tell them 10 make sure they bill Medicaid reforms they bad missed be- 3:0 recipients. One of four local of. 1 card file. New patients are as- for Lopez explains. "The physi- cause iney weren't participating For Forts honored, this was the only one signed to the doctor whose card 13 in cians are getting inc maximum ben- example. fees for primary care and ob targeted 10 Medicaid patients. front: the card is then moved to the efit for billing purposes and at the same stetries had been increased, and red The system IS simple in concept: back. Easy. Efficient. Equitable. time. the patients are setting the tape had been reduced through the :n- any Modicaid-eiigible natient who But best of all. it enables Medic- maximum benefit from having contin- troduction of a universal billing needs care but has no regular physi- and patients to break the fragmented- JOUS care. The kids are getting the form. "This helped us overcome a iot con calls the referral line at the county care cycle that erodes quality and well-child check-ups. and the women of the old history, she says. health department. Within minutes. wastes health care resources. are getting their Pap smears when The medical-society surveys a public health nurse confirms the call- By Jan. 31. nurses had assigned they should." helped prove that the Medicaid access er eligibility VIB computer. assesses more than 5,655 patients 10 participat- The system is successful because problem was real, Dr. Michels says. the patient's medical needs, screens for ing physicians. and had distributed 11 was built on the problem-sciving " forced heads out of the sand. Many access barriers" such DV jack of 4.305 vouchers for free cab rides 10 and model. its proponents say. Through doctors "assumed someone eise was from appointments. Since the Dro- follow-up surveys. the committee taking care of things. Once we look fram began. the family physicians have learned why physicians did not want care of that. we could start talking accepted an average of 71 new D3- to treat Medicard patients. about fairness and making (patient dis- tients each: pediatricians. 52 each: in- "That meant the basic compo- inbution) equal - or at least close termists. 27: and obstetricians. 22. nents of the system were the solutions :0 equal because things hadn't been The University of Nebraska Med- to the problems the doctors cited," very equal before.' ical Center's family practice residency Dr. Caudill says. "It ziso showed the Previously, Lancaster physicians program also participates. exercising physicians that we listened to what say, when word got our that a practice Overwhelmed a "right of first refusal" to help it main- they had to say." was accepting Medicaid patients. it tain an adequate case mix. If it de- The complaints were familiar. low by medical created a deluge. clines. the intake nurse reiers the pa. reumbursement. too much paperwork. "Periodically, the medical society license or treat to the next physician LN line. 100 many claims denied on techni- would go to a couple of groups and ask The residency program. with 15 to 20 calities and long celays in receiving them to help us out and see some privilege prtysicians, had accepted 809 refor- payment. Physicians also criticized Medicaid patients. and they get mun- applications? rais as at Jan. 31. Medicaid patients for missing appoint- used because they were the only "When we started this. I think we ments and being noncomplisnt group doing it." Dr. Caudill says. really put together # new medical sys- Such problems are addressed by Eugene Schwenke. MD, was in 3 Let the experts handle tem. Dr. Caudill says. "Between the state Social Services Dept. and the group family practice when the cro- them for you. the physicians and the patients and the participation of the public health Turn the (edious work of applicable nurses. it approaches some people's DO- for medical licensure of hospital tion of an ideal situation. in terms The system is successful because it was built on the privileges over 10 the American of delivery of care. we have something problem-solving model, supporters say. Through sur- that may not be available in the best Medical Association's National private-pay coverage situations. veys, the committee learned directly from physicians Physician Credentials Verification "!! may not be the: you can just why they did not want to treat Medicaid patients. Service* (AMA/NCVS*). take this plan and plunk it cown any- where and have 11 work. but 1 think It's easy Simply complete your the way it evolved could be useful in city-county Health Dept. Intake gram began. "There were three in AMA/NCVS application. We 11 are cutting together a program that nurses stress the importance of compli- my group at the time, and I think we'd it is create & partfolio of verified could work somewhere eise." once and keeping appointments. always done our fair share." he re- carr and perfessional Under 2 contract between the Social calls. "but you' open the door for one he plans founders acknowl- information on you. Services Dent. and the Health or two (Medicaid recipients). and T edge that there are drawbacks, Dept., federal money IS earmsrked for presty SOUTH it would just be overa Then when you want w apply for such as the lack of choice cab vouchers for patients without whelming medical accnoure. hospital privinges, for patients. who must accept transportation and for other adminis- Once the referral program was im- employment and professiona: mem- the assigned physicians unless both grative case-management services. plemented. "everybody else started patient and physician agree they can- Physicians are encouraged 10 se contributing and taking some of the terships. it submit your periods not for together. port patients who miss appointments. load. and it did make things much for you. Offsetting this restriction. howev- so that Health Dept. nurses can fol- smoother." says Dr. Schwenke. who AMA/NCVS saves ame houstais. CT. is the access that Medicaid patients low up with home visits. if neces- now practices emergency medicine at a sometimes gain 10 pracuees clused sary. Occasionally. the nurses 00- local hospital. scensure and group practices, 10 private-pay patients. Pat Lapez. RN, serve evidence of other problems. such The progra also offers Acxibility 100. Came this service. they need district public health supervisor and as domestic violence or substance 10 participating physicians. who may never reventy your AMA/NCVS coordinator of the referral program. re- abuse. and communicate it to the ap- withdraw temporarily as needed. redencials. calls asking a collesgue 10 follow up propriate agencies. Patients who 10- such 35 when a practice partner 15 sick on one of the Medicaid patients. peatedly abuse the referral program are or on maternity leave or the practice Rid yoursed of A ume-consuming "When she saw who the doctor was, simply dropped: it's happened to is at full capacity. Their cards are kept 1358 by retting AMANOVS do the the said. My god. I've been trying to about 35 over the first two years. out of the rulation until they return. *OTE. To request your AMA/NCTS 8" in to see aim for :wo years!" "All of us have leverage with CUT It's all based on good faith. Another drawback is that the pro- private patients." says family physician Physician Sign-up NC or w - NOW Peggy Barbee says the referral sys- gram excludes non-primary care spe Date Micnels, MD. who was Dress- tem nas made it much easter 10 deal NOVS can verify your applicants claimsts. so consultations and refer- dent of the county medical SOCIETY with Medicaid pasicats at Smith and for your organization. rals largery depeno on the strength of when the program began. "If they Reed Clinic. the four-physician IM call 800 877-NCVS. the relationships between primary continually fail 10 keep appointme its. procuse where she's the office man- care physicians and the specialists with we can do something about " ager. whom :ney regularly work. we'll threaten 10 charge them for :1. Bu: "it the referral system culls, at "1:'s hoped that the support of the with Medicaid you can't do that it's least we know the patient 13 qualified referrer would send , message to the considered traud. So we didn't have , or Medicaid coverage because the physician being referred 10 that at mechanism for (noncompliant) public health nurses have already they chior the patient flow, " would be Medicaid patients. and now do." screened for eligibility. she says. appreciated if they would lake care Says Dr. Caudill: "When we TODE Plus, people are much less likely to 01 this person." Dr Caudill says. Sub- this plan back to the physicians for cuse inc system when they know specialists rarely have refused 10 JL- their approval and plained why It someone's keeping track on things cept Medicaid referrals. was necessary and what the rules ere The referral system has redefined Vier two years. the organizers are we were trying 10 extract from them the Medicaid problem for the commu- analyzing hospital emergency depart- an obligation 10 participate. in return new. Dr. Caudill says. ment records for signs that the pro- they wanted assurances from Us that What :: boiled down to was that American Medical Assoc fram has reduced unnecessary visits by there would be accountability within here was this ACCESS problem for a long Medicain patients. Preliminary re- the patient population and fairness Time. and It looked like physicians su'ts show emergency visits increased within the relational system. comply wouldn't like Medicaid pa- 700 since :989. while the number of ments. But that really wasn the 150 Medicaid eligibles jumped by 120. the referral system also a:- sue. in the end there was a spirt of co- from 9,000 to 3.000. "That has 10 T tempts to ease the nassics. operation and a willingness 10 do speak positively of the program some- Chris Wright. MD. the yes their fair share. Once this system was how, Dr. Caudiil says, clai Services Dept. medical di- in place. the good will of the physi- The involvement 01 public health rector. made 1: known her office "as cians could manniest statif. 11 enabled nurses gives the program a strong pre- fully behind the system and encour- them to 11. 24 MERIC NEWS/MARCH 22/29. 1993 Withdrawal/Redaction Marker Clinton Library DOCUMENT NO. SUBJECT/TITLE DATE RESTRICTION AND TYPE 003. fax From: Cindy Dwyer, To: Patty Solis, Re: Meeting with Lancaster Co. 4/14/93 b(6) Medical Society [partial] (1 page) COLLECTION: Clinton Presidential Records First Lady's Office Liz Bowyer OA/Box Number: 5432 FOLDER TITLE: [HRC Daily File] Friday, April 16 [1993] 2014-0483-S sb334 RESTRICTION CODES Presidential Records Act - |44 U.S.C. 2204(a)] Freedom of Information Act - 15 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 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 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. h(9) Release would disclose geological or geophysical information 2201(3). concerning wells [(b)(9) of the FOIA] RR. Document will be reviewed upon request. 04-14-93 10:05PM FROM SENATOR KERREY TO 94562317 P002/002 TO: Patty Solis FROM: Cindy Dwyer Kerrey Scheduler RE: Meeting with Lancaster Co. Medical Society Patty: This is a nearly complete list of the people Senator Kerrey would like Mrs. Clinton to meet on Friday in the Green Room at the Lied Center prior to Mrs. Clinton's speech. Previously, I had sent the article on the Medical Society and their efforts to work on solving the medicaid problem in their community. During the meeting, the Society would like to present Mrs. Clinton with a detailed report on how they proceeded and how it's working. The attendees would include: Natalie Clark, Lancaster County Medical Society SS# (b)(6) 003 Jane Ford. Director, Lincoln/Lancaster County Health Dept. SS# (b)(6) 003 Mary Dean Harvey, Director, Neb. Dept. of Health SS# (b)(6) 003 Pat Lopez, Neb. Dept. of Public Health Nurse SS# (b)(6) 003 Dr. Chris Caudill, Cardiologist SS# (b)(6) 003 Dr. Chris Wright, Medical Director for Medicaid SS# (still waiting for this one) David Buntain, Attorney, Nat'l. Dem. Committeeman SS# (b)(6) 003 Lucy Buntain, University of Neb. Foundation SS# (b)(6) 003 *We also would like to include a medicaid patient who has benefitted from this effort. We have one identified and whose name I will forward to you shortly along with their social security number. Thanks, please call. Cindy 4/14/93 6:45 p.m. BETH M. GONZALES Press Secretary United States Senate Senator J. Robert Kerrey Washington, DC 20510 Nebraska (202) 224-6551 PEGGY A. JOHANNSEN Deputy Press Secretary United States Senate Senator J. Robert Kerrey Washington, D.C. 20510 Nebraska (202) 224-6551 04/13/93 17:11 918007363297551 1 03 SEN. KERREY/OMA +++ WASHINGTON DC I 001 TH CLIPS, AM DATE 4/13/93 THIS IS CLIP PAGE / CONTINUED FROM CLIP PAGE PM X PAGE 1+2 CONTINUED ON CLIP PAGE Senators Reject Effort to Alter Senators Reject Abortion Bill Effort to Alter "To bring a woman in and indicate BY JASON GERTZEN Abortion Bill that child support from the father will be WORLD-HERALDBUREAU there to assist her is misleading and Lincoln Lawmakers grossly unfair," Sen. Bobike said. favoring a 24-hour waiting Continued from Page 1 Sen. Rasmossen said the way the two period for women seeking assistant to tell women that medical provisions were worded to provide only abortions in Nebraska held assistance benefits may be available partial information led her to question from Tuesday against efforts before and after the birth of the child the motives for including them in the to dismantle parts of Legis- Another provision explains that the fa- bill. lative Bill 110. ther is fiable to help support the child "By only giving pieces of information, "We ought to move the even if he offered to pay for the abortion. we are trying to persuade one way or the 1993 Legislature bill as SOOD as possible" to Senators last week rejected the amend- other." Sen Rasumesen said. "That is second-round debate, said ment to remove the two provisions. but not good policy." State Sen. John Lindsay of Omaha, the Sen. Emie Chambers of Omaha asked Sen ML "Cap" Dierks of Ewing chief sponsor of LB 110. his colleagnes Tuesday to reconsider that spoke against Chambers' motion that the In addition to imposing a 24-hour decision. Legislature reconsider its action of last Chambers said it didn't make sense to week in not removing the two provisions. State Sen. John Lindsay says women require physicians to provide informa- The Legislature rejected Chambers' need more Information about abertion: tion on child support because it was motion Tuesday, 20-9. State Sen. Emie Chambers plans to fight beyond their expertise as medical profes- Dierks said be thought it made good Lindsay's abortion bill Page 5. sionals. medical sense to make sure that doctors Sen. Jessie Resmussen of Omaha said discuss the information with women waiting period, LB 110 would require the information is misleading because it seeking abortions. that a doctor or his assistant discuss doesn't help the women determine Lindsay said the bill was needed with the woman such things as the whether they are actually eligible for medical risks of abortion and carrying a because he questioned whether doctors medical assistance benefits performing abortions voluntarily pro- pregnancy to term "I don't object to giving good infor- vide the information The bill also would require that mation to a woman," Sen. Rasmussen "Once they are inside the clinic, there women be given the opportunity to said. "If should be honest and it should is a financial incentive to withhold infor- review written information that de- be accurate You may be eligible for mation," Lindsay said. scribed and showed pictures or drawings these services, but you may not be" Sen DiAnna Schimek of Lincoln said of the fetus at the stage of development Sen. Andyee Boblke of Hastings said she questioned the need for the bill when the abortion would be performed she had similar objections to the child- "Any woman making such an awe- : Senators supporting a woman's right support information requirement as it is some decision will have thought about it to an abortion renewed an effort Tues- worded in the bill long and hard and have asked for as day to remove from the bill a provision Well over half of the child-support much information as she can get," Sen. that would require the physician or orders issued in the state are not fol- Schimek said. Please tunt to Page 2, Col. 3 lowed, Sen. Bohlke said. R=95% 918007383297551 03 04-13-93 P001 #20 002 Day-Care Frustrat on Erup S THIS IS CLIP PAGE CONTINUED FROM CLIP PAGE ON CLIP CONTINUED PAGE Grant Procedure Leads Some Omahans to Write to Nelson tions for obtaining grants were "ambigu- process and the information they (pro: for "& very good proposal" and urged her BY JAMES ALLEN FLANERY ous, repetitive and overlapping." viders) received. There was some ambl- to tighten it and resubmit It. She did and WORLD-HERALDSTAFF WRITER guity.' scored 64. She is unsure whether she will WASHINGTON DC Some Omaha day-care providers have Nebraska is expected to award a total Questions about the grant process apply a third time. complained to Gov. Nelson that the state of $750,000 in fiscal years 1992-94 to prose from these cases examined by The has treated them Inconsistently and un- day-care providers as part of 8 national Robert Bock's corporation applied World-Herald: fairly in rejecting their applications for push authorized by Congress to Increase for D grant to transform an old house in the quality and availability of day care. Elizabeth Stiles scored 80 of a Allen, Neb., Into the town's only day- federal grants to expand day care. Nelson has ordered a review of appll- "The grant solections that have been possible 100 points on her grant proposal care facility. The corporation received made so for in Nebraska were probably last year to increase the size of the $10,000 for what Bock describes as a cation procedures, and some changes fair," Ed Schulenberg, the governor's klichen in her day-care home In the 6100 major renovation and start-up costs) already have been made. The governor wrote one oritic that he tended to agree adviser on children and family policy, block of Florence Boulevard. She didn't State rules say the federal grants maybe 03 sald Monday. "But what was not was the Bct the money, but the state praised her Please turn to Page 15, Col. 6 with the critic's complaints that instruc- SEN KERREY/OMA T918007363297551 1 03 4/13/93 PAGE 9415 The grants are supposed to help pro- viders serving low-income areas. They also are supposed to increase day care for infants, disabled and ill youngsters and school-age children. A special citizens advisory committee has been appointed by the governor to coordinate the effort. It is working with the State Department of Social Services and the Department of Education. Dr. Raikes directs one of five subcommittees involved in the effort. The Department of Social Services awards the grant Pain Brown of Omaha. co-chairwo- man of the citizens advisory committee, said about 500 Nebraska day-care pro- viders applied for federal funds during the first round of grant applications early last year. More than 100 applied in the second round. So far, 79 providers have received grants for a total of $265,000. Ms. Stiles said the grant program for. day-care providers is confusing She said that eligibility standards keep changing and that scoring is difficult to under- In a Feb. 26 letter to an Omahan who was critical of the program, Nelson said that he was asking for a review of the "We need to be clear regarding the cause confusion for those providing this very important service to our children money. stand. application process. purpose of the funding, so as not to and families," the governor said DATE 17:11 X PM 04/13/93 OWH CLIPS, AM Anger Heard Over Day Care Continued fromPoge 9 used for "minor building modifica- Helen Raikes, chairman of a sub- committee that decides on the day-care grants and co-director of a day-care facility in Lincoln, is eligible - along with other subcommittee members to apply for the grants. Dr. Raikes, who has a PhD, said some committee members had applied. She said none had received a grant. If any came close to receiving one, she said, "procedures are there to avoid a conflict of interest." Ms. Stiles and other Omaha day-care providers have appealed for help to State Sen. Dan Lynch of Omaha. They are scheduled to meet with him at 7 tonight at the Midwest Child Care Association office. 5015 Dodge SL "My concern is we treat everybody in all areas even-handedly." Lynch said. In 1991. Congress passed legislation to increase the quality and availability of day care. More than $2 billion was authorized over a three-year period. Most of the money is being spent to help low-income people afford day care. More than $9 million has been re- ceived so far in Nebraska. The Legisla- ture authorized $250,000 of that money to be spent each year for three years on grants to day-care providers to finance new programs and increase the capacity tions." of existing operations. 03/31/93 10:55 402 137 5109 SEN KERREY/LING & 003 PAPER Jincoln gurral THIS IS CLIP PAGE 3 DATE 3-30-93 PAGE 1,7 FROM CLIP PAGE CONTINUED ON PAGE Short-term health cost controls likely LOS ANGELES TIMES and Journal Writers' The White House on Monday sent its strongest signal yet that it intends to impose short-term price controls on doctors. hospitals and other pri- vale sector medical providers as part of national health care reform. In the first public meeting of the White House Task Force on National Health Care Reform. Vice President AI Gore Jr., who chaired the meeting, Doctors make how much? Page 2. said short-term cost controls are nec- essary to put a lid on the cost of insur- ance premiums. making it easier for businesses to furnish workers with health coverage under a government mandate. Sen. Don Wesely of Lincoln chair- man of the Legislature's Health and Human Services Committee. said today price controls are something that need to be examined, but he would want to know how they would affect Nebraska before deciding whether to endorse them "Admittedly. they are extreme steps. but at the same time we have a Prices crisis that in the short term we may need to put a brake on" he said Generally. health care costs are too high. but compared with other states Nebraska has lower average costs for some services, Wesely said Be said (10f2.) be would not want certain rates in Ne- braska increased as a way to impose across-the-board price controls na- tionally. Wesely said be will travel to Wash- ington. D.C. on Friday to meet with the health care reform task force. Wesely said he will be one of about a dozen legislators from around the country invited to the meeting. Anne Nation of Friend a board member of a non-profit association See PRICES on page 7 402 437 5109 03-31-93 03/31/93 13:16 402 437 5109 SEN KERREY/LINC 001 DATE PAPER Lincoen Joumal 7 3-30-93 THIS IS CLIP PAGE 4 PAGE FROM CLIP PAGE CONTINUED ON PAGE that monitors legislation for 3,200 peo- price controls; and small businesses care. mental health and prescription ple enrolled in a health insurance pool opposed a government requirement drugs, all of which are costly. for high-risk individuals, said she does that all employers pay a major por- Gore presided over much of the not oppose short-term price controls, tion of every worker's health insur- meeting. sitting in for Hillary Rod- ance premiums. ham Clinton. who heads the task but added that "any health care re- form has to be comprehensive." Other elements of the proposed re- force The first lady was still in Little "Rate limits and global budgets can form package disclosed Monday in- Rock. Ark. with her father, who suf- be a key ingredient to making health cluded plans to provide coverage for fered a stroke nearly two weeks ago. care available and affordable." she long-term care and to give nurses and A number of small businesses vehe- said in a telephone interview this physician-assistants greater roles in mently argued against a government morning "But unless you have other health care as a way to hold down requirement that they pay for the controls - such as an all-payer sys- costs. Senior administration officials health insurance of all workers, say- tem, loss ratios for insurance compa- also pledged to minimize disruptions ing that would be a burden many nies and insurance coverage for all in- in doctor-patient relationships. small firms could not bear. dividuals - you are only dealing with In addition, to improve services to A government mandate to provide one aspect of an entire system that the underprivileged and others, the health coverage would cost small needs to be reworked" task force is exploring ways to elimi- businesses at least $40 billion, accord- Nation said she believes price con- nate Medicaid altogether. perhaps by ing to Margaret Smith of National gradually covering indigent persons Small Business United. trols are a good idea because they begin to bring some of the health care under the same large health care co- As an alternative, Gary F. Petty of costs under control by decreasing the ops being contemplated for much of the Small Business Legislative Coun- rate of inflation "But when you have the general population. cil urged the administration to insti- fee-for-service and you limit the rate Judging from the questions posed tute a wage and price freeze on by various administration officials, health care providers. for procedures, you risk telling people the task force apparently has not yet But G. Kirk Raab, president and simply to do more procedures," she said settled on some of the basic elements CEO of Genentech Inc. a pioneering More than 60 interest groups and of the reform agenda - including California-based high-tech firm, consumer representatives pleaded how to finance coverage for the 37 warned that such controls would their case before the task force Mon- million uninsured Americans and the "strangle investment" in the biotech- day- The only points of agreement extent of coverage for long-term nology industry. were the need to cut down on insur- ance red tape and to place greater emphasis on preventive care Many who testified harshly criti- cized likely elements of the reform plan. Insurers argued against caps on premiums; doctors, hospitals and other providers resisted mandatory Prices. (2062) 918007363297551 1 03 SEN. KERREY/OMA ALL 002 03/21/93 14:14 WE CLIPS, AM DATE 3/21/93 THIS IS CLIP PAGE: 2 CONTINUED FROM CLIP PAGE PM PAGE CONTINUED ON CLIP PAGE 3 BK Clinton Health-Care Proposal Could Cut Benefits, Hike Taxes BY PAUL GOODSELL WORLD-HERALD BUREAU Washington - President Chinton's Managed competition carries with it a ticking time health-care proposal could force the 700 bomb. What you're probably going to have to do to employees at the Kellogg's plant in Omaha to pay more for their health get access to everybody is to provide fewer services benefits. Instead of paying no deductibles or for more money.' co-payments for doctor and hospital - Rep. Fred Grandy bills, Kellogg's employees - and other workers across America with relatively generous benefits - could wind up with new out-of-pocket medical costs or packages, either negotiated by unions or is difficult to determine how people will health-insurance premium increases. offered by employers, would have to be be affected. And if the benefit package doesn't pared back." But it is clear to Grandy and others, change, the Clinton plan could result in A White House task force headed by both in and out of Congress, that the higher taxes for companies like Kellogg's the president's wife, Hillary Rodham Clinton plan eventually will prompt or possibly the employees. Clinton, is developing the adminis- changes in some of the most generous "The whole notion of managed com- tration's health-care proposal. benefit packages, including those nego- petition is that there will be a standard The administration wants to restrain tiated in labor union contracts. As a benefit package which will enjoy a tax health-care spending and provide bene- result, the plan could face opposition subsidy, but anything above that will be fits to an estimated 37 million Americans from unions, which have been among the paid with after-tax dollars," said Rep. who lack coverage. Key decisions on most vocal advocates of health-care re- Fred Grandy, R-Iowa. "Some benefit taxing benefits have not been made, so it Please turn to Page 5, Col 1 PODE 03/21/93 14:15 918007363297551 1 03 SEN. KERREY/OMA ALL 003 OWF THIS IS CLIP PAGE OWH CLIPS, AM PM * DATE 3/21/93 3 CONTINUED FROM CLIP PAGE 2 PAGE 5-A CONTINUED ON CLIP PAGE Clinton Health-Care Proposal BK Could Cut Benefits, Hike Taxes Similar Plan Continued from Page 1 Some people who have generous cm- It would be a mistake to tax benefits form. ployer-paid benefits may have to pay that exceed a basic level, Stewart said "I don't believe that's a good move," something to obtain the same benefits "We think that's absolutely the wrong Terry Moore, head of the Omaha Feder- -under the Clinton plan, Kerrey said. But direction," be said. "You cannot fix the ation of Labor, said of reduced bene- be said Clinton's basic benefits package health-care problem by penalizing those fits. "I don't see us supporting something will be a comprehensive plan similar to who are the 100 percent payers." of that nature." Such & tax change would be "enor- Tax Law mously costly," Stewart said. He said be Although businesses have strained in what many people have. could not speculate on whether it would recent years to absorb growing health- "The base package will not be a prompt the company to scale back bene- care costs, companies and workers have low-ball health-care package," Kerrey fits in its next labor negotiations. said benefited from the way tax law treats But Moore said companies like Kel- health-care benefits. Employers can de- But Grandy said the size of the bene- logg's would refuse union demands to duct all of the health-care benefits fits package will pose a major problem. If continue generous benefits. the plan is too generous, he said, it will be they provide, while workers do not pay "I guarantee you it's a strike issue from too costly for the federal government to taxes on the benefits they receive. the get-go," he said. subsidize it for the uninsured. If the basic The Clinton plan, however, is based on In Omaha, be said, limits on health- the theory of managed competition, package is too restrictive, however, it will care benefits would affect unionized leave many Americans dissatisfied with which refies OR competitive market the change. telephone workers, electricians and food forces to restrain health-care costs. In- "Managed competition carries with it processing employees, among others. surers would compete to offer the best Gary Denier, a spokesman for the quality and lowest-cost version of a basic a ticking time bomb," Grandy said. United Food and Commercial Workers benefits package, which would be avail- "What you're probably going to have to International Union, said the union able to everyone. do to get access to everybody is to opposes taxation of individual health As envisioned by Alain Enthoven, a provide fewer services for more money." benefits and limits on corporate deduc- Stanford University professor who is Average Plan tions. considered the father of managed com- Grandy said the Congressional Budget Bargaining petition, the federal government would Office told him that the average health- "It undermines the collective bargain- impose tax penalties on packages that insurance package is worth $1,350 for ing process," be said. exceed the basic level individuals and $3,230 for families. But Kerrey said an advantage of The business's tax deduction for bene- The typical plan offers comprehensive Chinton's plan is that it will help break fits might be limited to the cost of the benefits with a $50 deductible for indi- the link between employment and health basic benefits plan, encouraging com- viduals, $250 for families and a 20 care. He said be doubts that health-care panies to provide only the standard percent employee co-payment for medi- benefits would be on the bargaining package. cal bills up to $500 per person annually. table in labor negotiations if Clinton's Taxable Income A tax cap based on that average would Another option would count excess affect Kellogg's employees, said Joe plan is enacted "You will not get health care through benefits as taxable income for the Stewart, senior vice president for corpo- the negotiation process," be said. employee, although Mrs. Clinton ap- rate affairs in Battle Creek, Mich "What will happen is, Americans will peared to rule that out earlier this month "We' re well above that," he said. "Our employees have a very excellent health acquire a right to health care. They'll no by calling it an unfair tax increase on the middle class. care package- of the line" longer fear they won't have coverage." Enthoven, however, recently told the Stewart said hourly employees, in- Washington Post that it is essential touse cluding members of the American Feder- the tax code to deter unlimited health ation of Grain Millers, pay no premiums, benefits. He said it is crucial that workers deductibles or co-payments. White-col- have a financial stake in choosing be lar workers pay 1 percent of their salary tween health plans. up to a $600 maximum premium and a 10 Without incentives for individuals to percent co-payment contain costs, Enthoven told the Post, the Clinton administration's efforts to control costs would be undermined. Both Grandy and Sen Bob Kerrey, D-Neb., agree that individuals should be more aware of the cost of health care. ""Everybody's going to have some con- tribution that they have to make," Ker- rey said 03/22/93 11:31 402 437 5109 SEN KERREY/LINC 012 PAPER linceln d. Star THIS IS CLIP PAGE 12 DATE 3.21.93 PAGE 68 FROM CLIP PAGE CONTINUED ON CLIP PAGE Era of health care without limits is over Now will come a wave of reaction condition and- here's the big departure- against Oregon's unprecedented but also the likelibood of treatment improving the carefully crafted health care plan It won quality of a patient's life. The first 568 treat- the Clinton administration's conditional ment regimes would be federally-state Medicaid waiver approval last week funded under Medicaid; the remaining 120 At the heart of the experimental pro- would not. gram passed by Oregon's Legislature with Typical of the criticism is that made by broad, bipartisan support is this moral con- Joseph Tiang-Yau Liu, a senior health as- frontation and revolutionary tradeoff: sociate with the Children's Defense Fund. ? Some high-cost medical procedures, or He laments that Oregon's "prioritization others with minimal long-term benefits, system would replace the individualized would no longer be available to Medicaid judgment of experienced physicians with a participants so that resources thus saved computer-generated list Only the poor could be transferred and extended to the would be subjected to this rationing pro- uninsured working poor. cess. The state did not include state employ- With Washington's approval, an esti- ees in their prioritization scheme and the mated 120,000 additional Oregonians now Legislature voted down a proposal to ration living in poverty would be newly entitled to their own health care." Medicaid benefits. That isn't all Historically, rationing of health care in A high-risk pool for the medically unin- America has been most based on the money surable would be established, something of those wanting and needing services. Ore- Nebraska did several years ago. Medical gon moves in the direction of targeting pub- services would be delivered through a man- lic resources differently; the greatest good aged care protocol, something the Clinton for the greatest number. administration is weighing for the entire na- Yes, it's so that in Oregon, those who tion Small businesses which begin insuring might be most victimized by the change are workers would be eligible for state tax some Medicaid beneficiaries, those already credits. poor or elderly. But none should be so blind For the moment, let's suppose that Ore- as not to see the possibility of the same "out- gon can cough up the nearly $100 million in comes and effectiveness" criteria later ap- state matching funds required for the alt- plied to the Medicare program nationwide, ered Medicaid program to be implemented. together with cost controls. (This is nowhere near certain.) Alternative- Oregon's senior senator, Bob Packwood, ly, think about the plan's most celebrated is right around the bull's-eye: "Sooner or feature, selective rationing later, the rest of America is going to come Oregon's health care practitioners and to what Oregon is trying. The era of health vendors rated and ranked 688 procedures care with no limits" is over. If not yet, then and conditions, factoring the severity of a very soon 03/28/93 16:03 918007363297551 1 03 SEN. KERREY/OMA WASHINGTON DC 001 X 3/28/93 THIS IS CLIP PAGE 2 OWH CLIPS, AM DATE CONTINUED FROM CLIP PAGE PM PAGE 1-B CONTINUED ON CLIP PAGE 3 Senators Face Health-Care Tax Issues BY JASON GERTZEN have risen rapidly in recent years as more WORLD-HERALD BUREAU people have sought assistance and as Lincoln - Lawmakers this week will more services have been covered The begin trying to assemble a budget-bal- state's cost increases for the next two ancing package of new taxes that proba- years are expected to reach 572 million. bly will total $20 million to $25 million, The increases are largely responsible for the chairman of the Nebraska Legisla- a projected state budget shortfall of ture's Revenue Committee said last about $35 million over the next two week. years. "It has been a revenue issue from day Warner and other state senators said one." said the chairman, State Sen the Legislature plans to heed the public's Jerome Warner of Waverly. "We are call to get the state budget under control looking for a combination that is feasible by cutting spending. and reasonably acceptable tax policy." Senators' turned their attention to But many specific cuts that have been taxes last week as the Legislature's proposed so far have met with opposi- Health and Human Services Committee tion The extent of the spending reduc- killed most of the measures that had been tions that eventually are approved by the Legislature will depend on whether there proposed to ease the state's budget will be new revenue and, if so, how much problems by cutting the services covered Wamer said. by Medicaid Medicaid is a cooperative program "There is no point spending a lot of between the state and federal govern- time arguing about a cut that isn't going ment It helps pay for health-care serv- to be made because there will be some ices for the needy, aged, blind and revenue measures," be said. Warner disabled and for low-moome families served as chairman of the Legislature's with children: budget-writing Appropriations Commit The state's expenses for the program Please turn to Page &, CoL 1 918007363297551 1 03 03-28-93 03:54PM P001 #08 R=95% 83/28/ 03/28/93 16:03 918007363297551 1 03 SEN. KERREY/OMA WASHINGTON DC 002 OWH CLIPS, AM X DATE 3/28/93 THIS IS CLIP PAGE 3 own CONTINUED FROM CLIP PAGE 2 PM PAGE 8-B CONTINUED ON CLIP PAGE Legislature Weighs Health-Care Taxes Continued from Page 1 another approach to hit the hospitals tee from 1977 to 1991. again." Gov. Nelson's proposal in Legislative Options Bill 834. to raise an estimated $7 million Beside the health-care taxes. the Reve- a year by taxing the net income of hospitals and nursing homes. will be nue Committee has other tax options, considered Wednesday at a public hear- including raising general sales and in- ing. come tax rates or reviving the sales tax on food. The eight-member Revenue Commit- tee then will begin trying to fashion a tax Radcliffe said he considered general package to send to the full Legislature. sales and income tax increases and repeal Warner said. The committee will consid- of the sales tax exemption on food to be er LB 834 and at least three other bills among the proposals least likely to be that would directly tax the health-care adopted. "They face a certain veto," he said. industry. "I don't think the health-care industry Warner said most of the tax increases can escape some type of contribution," before the committee would get his said Lincoln lobbyist Walt Radcliffe, support only if they were limited to two who represents some of the interests that years. This would recognize that changes would be affected by the taxes. affecting health-care financing are likely Revenue Transfers to be implemented. he said. Warner said he initially thought the Two Views : health-care industry would face tax Two other committee members indi- measures totaling about $12 million to cated in interviews that the committee $15 million. The proposals have attract- would not be starting the week with a ed so much opposition. however. that he clear consensus on which steps to take. said he wasn't sure how realistic it was to assume that the health-care taxes would Sen. Ron Withem of Papillion said reach that level. that if tax increases are necessary. he The Nebraska Hospital Association would prefer to see them targeted to supports LB 815. which would raise an avoid general increases in sales or in- : come tax rates. estimated $6.3 million a year by having local hospital authorities tax Douglas "Because so much of our problem is and Lancaster County hospitals. The caused by problems within the medical hospital authorities, which are govern- cost arena, some of our budget cutting : mental bodies. would transfer the reve- and some of our revenue increases need : nue to the state, which would use the to be in that area," Withem said. "There money to leverage federal funding for the are people within the medical communi- Medicaid program. ty benefiting from the increase in expen- Hospital officials oppose taxing their ditures in the medical arena, and they industry in order to pay for problems for need to contribute to help solve the which they say all society should be problem." responsible, Sen Doug Kristensen of Minden pre- Taxing a hospital's gross receipts or sented a nearly opposite view. repealing its sales tax exemption would be disastrous. said Roger Keetle, a lob- "The Medicaid issues.are very broad- byist for the hospital association. based issues." he said. "This appears to : Hospital officials agreed early in the be 8 problem Nebraska as a whole has to process to support LB 815 as a good- shoulder." faith gesture that they were interested in Kristensen said be could support a helping find a solution to Nebraska's slight increase in income or sales taxes. health-care financing problems, Keetle Another option. be said. would be to said. make everybody pay something by im- "Unfortunately, it's kind of like, posing a combination of taxes that could 'What have you done for me lately,' he include higher levies on cigarettes and said "Now they have come up with alcohol. R=95% SEN. KERREY/OMA OWH CLIPS, AM X DATE 3/29/93 145 THIS IS CLIP PAGE CONTINUED FROM CLIP PAGE CONTINUED ON CLIP PAGE PM PAGE Doctors Board Calls for Change BY JAMES FLANERY the State Health Department and should the situation was worse than it actually WORLD-HERALD BUREAU have two or three additional members is," the board said in a three-page Lincoln - The board that oversees who have no ties to medicine statement made public Monday. Nebraska's doctors acknowledged Mon- At the same time, however, the board "The articles could be construed to be day that the regulatory system it serves is said a recent World-Herald series exag- a critical indictment of the efforts of the "cumbersome, fragmented and. ham- gerated shortcomings in Nebraska's sys- medical board and other components of strung with a paucity of investigative and tem of regulating doctors. the disciplinary mechanism," the board legal resources." Those who read "the exaggerated said. "On the contrary, Nebraska has To better protect Nebraskans, the quotes and dramatic case histories and been and continues to be served by Board of Examiners in Medicine and the speculation of the proper number of dedicated individuals at all levels of this Surgery said, it should be independent of disciplinary actions might conclude that Please turn to Page 5, CoL 1 Doctors Board Appoint two or three say represen- tatives to the board. A majority of similar boards in other states have more than The court's ruling means that "we've Issues a Call one lay member. Nebraska's board has got a major hole in the dike that's got to one. be plugged." said the board's vice chair- For Change Give the board the power to regu- man, Dr. Philip Metz. a Lincoln plastic late and define unprofessional conduct surgeon "The rest of these things (regu- A recent Nebraska Supreme Court deci- latory changes) can wait." Continued from Page 1 sion overturned the discipline of a Ne- At its Sunday meeting, the board endeavor." braska doctor on the grounds that the expressed little interest in changing the The statement marked the board's first doctor's reported action - prescribing official reaction to The World-Herald way it addresses the issue of doctors who drugs to undercover investigators - was are accused of medical malpractice. articles, published Feb. 28 and March 1. not specifically prohibited by state law. Helen Meeks. director of the State The board. whose current members are Give the board power to subpoena Health Department's Bureau of Examin- six doctors and a retired pharmacist, doctors' records and demand that doc- ing Boards, asked the medical board makes recommendations on the licensing tors appear before the board. members whether they wanted to consid- and investigation of doctors in the state. Grant the board authority to re- er written criteria for when to investigate Monday's statement follows action quire educational programs where neces- doctors accused of malpractice. earlier this month by Gov. Nelson and sary. other state officials to address possible Give the board power "to hire. train "It seems to me to be a redundancy." changes in the system that licenses, and direct its own investigators." Those said Dr. William Shiffermiller of Omaha investigates and disciplines 3,000 Ne- who investigate doctors now work for the a board member since 1986 and a past braska physicians. State Health Department They investi- chairman. Nelson and the State Board of Health gate doctors and practitioners in 23 other The World-Herald series indicated have appointed committees to recom- health professions. that between Sept. 1, 1990, and Jan 1, mend changes. A committee of the Allow the board to hire its own 1993. the board reviewed 82 Nebraska Legislature has embarked on a long-term attorney or obtain someone to represent doctors who had made malpractice pay- study of additional reforms. it regularly from the Nebraska Attorney ments to patients. It chose not to investi- Nelson is expected to introduce a bill General's Office. gate any of the 82 doctors. within the next few weeks that will The board's statement came one day incorporate some of the conclusions after the board met in Lincoln. At the reached by his committee, the State Sunday meeting, Dr. James Dunlap of Health Department and a variety of Norfolk, a former board chairman other interest groups. urged it to take many of the actions it In its statement Monday, the board supports in Monday's statement. said it desired a "more meaningful and comprehensive role in the whole disci- The board decided to appoint Dr. Dunlap and another former board mem- plinary process." It said it now is one of the six weakest ber, Dr. John Sage of Omaha, to assist Nelson's special committee. medical boards in the country. Final Some board members were hesitant decisions about disciplining doctors are about hasty action. made not by the board but by the state health director. "I'd hate to see us react to something written up in the newspapers and come "We fear, however, that the public out with a worse system than we have," believes that we have far more authority said Dr. Robert Harry, a Lexington and power" than the board has, the surgeon who has served on the board statement said. since January 1990. "As far as I can tell, At the same time, the board cautioned there aren't too many things that slip by against too much government interven- us." tion. The board said it favored the follow- Several board members said they were ing changes in the regulatory system: more concerned at the moment about the Make the board independent of the Nebraska Supreme Court decision State Health Department. March 5. 918007363297551 03 03-29-95 06:18PM POOD #08 R=96% 1 03/30/93 10:19 402 437 5109 SEN KERREY/LINC 004 DATE PAPER 3/29/93 Linciln fourral THIS IS CLIP PAGE 4 PAGE / FROM CLIP PAGE CONTINUED ON PAGE 5g Nebraska kids worse off Nebraska's overall ranking in the Kids Count kids survey dropped one spot to ninth best in the well- being of its children. count Percent change over time Work Better Percent low birth weight bables NW Infact mortality rate- (per 1,000 live births) 1990 14 Child death rate, ages I-14 (per 100,000 children) 1990 Percent of all births that are to single teens luvealle violent erime arreit rate, (10FZ) { ages 10-17 (per 100,000 youths) Percent graduali DR from high school Percent tecas not in school and 1985/ 1990 mail in labor force, ages 16.19 & Team violent death me 1985/1990 ages 15-19 (per $00,000 (clui) & Percent (Idren in poverty THE Sav 20 Percent children 4a single parent families 1983/ 1990 2 SOURCE: CENTER FOR THE STUDY OF SOCIAL POLICY State's high rank in child well-being also has signs of growing problems BY MARTHA STODDARD AND DAVID LYNCH Conditions have worsened on six of the 10 measures Lincoln Journal used in the report, including all of the five measures Nebraska's children rank among having to do with teen-agers. But even in two areas the best off in the nation but the state is slipping on several measures of where the state improved - infant mortality rate and child well-being, according to a state- the percent of children in poverty - a closer look at by-state report card released today. the numbers shows a different story. The fourth annual Kids Count Data Book, released by the Center for the Gail Flanery, Voices for Children of Nebraska Study of Social Policy and the Annie E. Casey Foundation, ranked Ne- deputy director of Voices for Children from 9.6 deaths per 1,000 Five births in braska ninth best among the 50 states of Nebraska. 1985 to 8.3 per 1,000 in 1990 for Ne- and the District of Columbia on child Conditions have worsened on six of braska as a whole. But the rate is well-being. the 10 measures used in the report, in- "dramatically higher for minority Last year's report listed the state in cluding all of the five measures hav- race children," Flanery said. eighth place. ing to do with teen-agers Children in poverty dropped from New Hampshire was ranked as the But even in two areas where the 182 percent in 1985 to 14.5 percent in best state for the well-being of chil- state improved - infant mortality 1990, when looking at all ages. But the dren, and the District of Columbia rate and the percent of children in percent of children age 5 or younger was ranked the worst. poverty - a closer look at the num- in poverty increased 25 percent, ac- But the well-being of Nebraska bers shows a different story, Flanery cording to federal census statistics, children. especially those under 5 said. she said. years old, is falling. said Gail Flanery, The infant mortality rate dropped See KIDS on page 4 R=97% 402 437 5109 03-30-93 10 17AM P004 #27 10:20 SEN KERREY/LINC 005 03/30/93 PAPER Lincolne Sournal C402 437 5109 THIS IS CLIP PAGE 5 DATE 3/29/93 FROM CLIP PAGE PAGE CONTINUED ON PAGE 4 From page 1 Kids Nebraska earned a ranking of 32nd, first baby or 816 new families one of its lowest tankings on the mea- were vulnerable right from the start sures used in the report, for its child because the mother lacked a high death rate. The rate worsened by 25 school education. was teen-ager, and percent between 1985 and 1990. in- was single when her First baby was creasing from 25.4 per 100,000 children born. age 1 to 14 to 316 per 100,000. "Thirty-seven percent of new fami- The state's lowest ranking came on lies - or 3,294 families had at least the teen violent death rate - deaths one of these strikes against them," from homicide, suicide and accidents the report said for youths age 15 to 19. The rate wors- Forty-five percent of new families ened by 23 percent from 1985 to 1990, nationally started with at least of rising from 613 per 100,000 to 75.3 Ne- those three risks, which Kids Count braska ranks 33rd on this measure Coordinator Judith Weitz said In- Dr. David Schor, director of Mater- crease the chances that "families will nal and Child Health for the state, break up, be poor or be dependent on said year-to-year variations explain public assistance and that children some of the worsening in death rates. will be neglected and fall behind in But be also called for legislation that school" would set up child death review "The alarming number of vulner- teams to look at whether deaths could able new families is the tragic, but have been prevented. predictable, consequence of the de- On other teen-age measures: teriorating status of American teens," The proportion of teens age 16 to 19 said Douglas W. Nelson, executive di- who are not working or in school rose rector of the Annie E Casey Founda- tion. 48 percent from 1985 and 1990 in Ne- The state has several projects braska. But nationally, the percent- under way to address problems iden- age of teens in this category de creased tified in today's report, said Kathie Osterman, spokeswoman for the state Births to teen-age mothers in- Department of Social Services. creased 33 percent over the same Five Among the efforts are a Commis- years, rising from 5 percent of all sion for the Protection of Children, es- births in 1985 to 7 percent in 1990 The tablished in 1991 by Gov. Ben Nelson percentage rose faster than the na- to improve the ways the state re- tional average. sponds to and supports children and High school graduation rates, while families. fifth best in the country, slipped 5 per- One commission effort, called cent The number of teens graduating Good Beginnings, is still being de- within four years dropped from 88 veloped but will focus on improving percent in 1985 to 84 percent in 1990. health. education and social services The violent crime arrest rate for for children. Plans call for the pro- youths age 10 to 17 worsened by 26 gram to include parent education, a percent in Nebraska from 1986 to 199L family visitation program for parents But the state still fared better than of newborns and young children and the rest of the nation early childhood education The report also showed that Ne- The Social Services Department braska had a sizable number of new has job support programs targeting families at risk, although the state did teen parents, Osterman said. The better than most other states. Health Department is hiring an ado- "In 1990, almost one out of ten new lescent health coordinator, Schor families that began with the birth of a said. (2of2) R=96% 402 437 5109 03-30-93 10 7AM P005 #27 03/31/93 12:15 8918007363297551 1 03 SEN. KERREY/OMA WASHINGTON DC 002 OWE CLIPS, AM X DATE 3/31/93 THIS IS CLIP PAGE CONTINUED FROM CLIP PAGE PM PAGE 11 CONTINUED ON CLIP PAGE Creighton Ethicist on Task Force Professor Helping to Weigh Pros, Cons of Health-Care Provisions named David who was paralyzed from BY ROBERT DORR the neck down after breaking his neck in WORLD-HERALD STAFF WRITER 'It gets very intense.' a diving accident. For an Omaha woman on Hillary Dr. Purtilo was present when David's Rodham Clinton's task force. helping to Ruth Purtilo former girlfriend and his older brother forge a national health-care reform plan Task force member told David they were getting married. means taking part in spirited small- She groped for words and felt inade- group discussions that span 13-hour quate. She decided she needed something work days. more than her physical therapy skills. "It gets very intense," said Ruth Purti- ment be discontinued? And why? After earning a doctorate in ethics to. whose national reputation as an About 30 times last year she became from Harvard University. she taught and expert in medical ethics won her a seat on involved in such discussions. worked as an ethicist at the University of the White House task force. "That's high stress," said Dr. Purtilo, a Nebraska College of Medicine, at Mas- The Creighton University professor friendly, smiling person who relaxes by sachusetts General Hospital, at the Uni- has been assigned to a working group reading T.S. Eliot's poetry, tending her versity of Massachusetts Medical School that is weighing ethical pros and cons of garden and taking walks. and as a visiting scholar at Karolinska provisions being considered for the She seldom expresses her opinions Institute in Stockholm, Sweden. health-care measure. about what should be done in medical She never returned to physical thera- Her work on the task force encom- cases, she said, preferring to ask ques- PY. passes many ideas. she said during an tions that help focus the thinking of Dr. Purtilo's marriage to Omaha law- interview in Omaha last week after her physicians, nurses and family members. yer Vard Johnson brought her back to first three days of meetings. She has Those meetings should serve her well Omaha The two knew each other when as one of 15 members of the Clinton task returned to Washington this week and she lived in Omaha Johnson then was a will every week until the health-care force's ethical considerations group. state senator who worked with her on package is ready to go to Congress in Her group and 33 others. meeting legislation affecting the N.U. Medical May. separately in the Old Executive Office Center. Some ideas come from stacks of mail Building next to the White House, report She moved from Omaha to Boston in sent by Americans who have their own once a week to a panel called Tollgate. 1987. When Johnson attended his Har- suggestions about how to change the Mrs. Clinton sits on that panel To make vard Law School class reunion in 1989, nation's health-care system Vice Presi- it into the fmal health-care bill. an idea they had dinner together. That began a dent Al Gore said this week that 50,000 must be accepted by Tollgate, Dr. Purtilo yearlong. long-distance romance that led Americans have sent suggestions to the said. to marriage in 1990. the second marriage Sometimes an idea starts with the task force. for both. Dr. Purtilo said the stacks of letters ethics group and goes to Tollgate. At Ethicists typically are called in for the seem unending other times, Tollgate sends an idea to the most difficult cases, she said. As an The letters are directed to the ethics ethics panel for discussion. example. she recalled an infant girl who committee and to other small working Although the Clinton administration had a rare and complicated intestinal groups within the Clinton cask force. The is committed to giving greater access to disease that kept her from digesting groups mine the mail to find good ideas health care, Dr. Purtilo said, "there's no food. and to learn trends in the public's preconceived plan." Doctors at the N.U. Medical Center concerns about health care, she said. Dr. Purtilo, 50, daughter of a Method- performed several surgeries in the first ist minister, grew up in Duluth and St. days after birth The infant was fed "I haven't read the mail, but we're all Paul, Minn., in a family that believed it through injections into blood vessels. taking our turns, and my turn will come," should feed and take care of people who Future medical care was estimated to she said. had no other place to go. cost $1 million a year, and success wasn't At Creighton University's Center for Her father once brought home a teen- certain. Health Policy and Ethics, Dr. Purtilo age boy who had completed a prison But the infant's family favored taking teaches and writes in her specialty of sentence for stealing The youth lived every lifesaving measure. Moreover, the medical ethics, a relatively new field with her family for several months until baby was normal except for the intestinal spawned by high-tech, high-expense he got a job, Dr. Purtilo said. disease. medicine, Wanting to enter some helping pro- Other factors that were considered: She also serves on St. Joseph Hospi- fession, she picked physical therapy and The family had enough insurance cover- tal's ethics committee. graduated summa cum laude from the age to pay the cost for about a year, An attending physician usually brings University of Minnesota. continued treatment wouldn't cause se- in members of the ethics committee - Several years later she made a deci- vere pain and without treatment death including a doctor, nurse, chaplain and sion that became a career turning point, was certain. ethicist - to help the family and the although she didn't know it then Work- The medical team and family ultimate- medical team deal with such questions ing at a Grand Forks, N.D., clinic, she ly decided to indefinitely continue the as: When, if ever, should medical treat- gave therapy to a 19-year-old youth treatment, she said. P002 #19 918007363297551 1 03 03-31-93 THIS IS CLIP PAGE FROM CLIP PAGE CONTINUED ON PAGE Omahan: Health discussions intense Creighton professor on small group weighing ethical issues SEN KERREY/LINC OMAHA (AP)- An Omnha woman seem unending. about what should be done in medical tion is committed to giving greater on Hillary Rodham Clinton's task The ethics committee and other cases, she said, preferring to ask access to health care, PurtHo sald, force trying to develop a national small working groups within the task questions that help fooms the thinking "there's no preconcelved plan." health-care plan says spirited small- force sift through the mail to find of physicians, nurses and family She is one of several people with group discussions are taking place as good Ideas and to learn trends in the members. Nebraska connections helping the the Issues and options are reviewed. public's concerns about health care, Those meetings should serve her Clinton administration develop its "It gets very Intense,". said Ruth she said. well as one of 15 members of the Clin- health-care plan. Purtilo, who is known nationally as an At Creighton University's Center. ton task force's ethical considerations Others are Roger. Blauwel, a for- expert In medical othles. for Health Policy and Ethics, Purtilo group, mer partner in the Kutak Rock law 15 The Creighton University professor teaches and writes In her specialty of Her group and 33 others, meeting firm In Omaha who is tax counsel to has been assigned to a group weigh- medical ethics, a relatively new fleld separately in the Old Executive Of- Rep. Peter Hoagland, D-2nd District; ing ethical pros and cons of provisions spawned by high-tech, bigh-expense fice Building next to the White House, Shella Nix, a Creighton University for the health-care measure. medicine. report once a week to a panel called graduate and former Washington lob- She went to Washington this week She also serves on St. Joseph Hospi- Tollgate, Mrs. Clinton sits on that bylst who works for Sen. Bob Kerrey, C402 437 5109 PAGE and will every week until the package tal's ethics committee, which helps panel. D-Neb.; Karen Davenport, 20, a led- is ready to go to Congress in May. families and medical teams deal with To make it into the final health- eral government intern assigned to Citizens have provided some sug- such. questions as: When, If ever, care bill. an idea must be accepted by Kerrey's Senate staff; and Nicole gestions about how to change the na- should medical treatment be discon- Tollgate, Purtilo sald. Simmons, a former Omaha World- Lion's health-care system, she said. tinued? And why? Sometimes an idea starts with the Herald reporter who now works for APER Lincoln Janual Vice President Al Gore said this week About 30 times last year she be- ethics group and goes to Tollgate. At the federal Health Care Financing that 50,000 Americans have sent sug- came involved in such discussions. other times, Tollgate sends an idea to Administration gestions to the task force. "That's high stress," Purtilo said. the ethics panel for discussion. More than 500 people serve on the Purtilo sald the stacks of letters She seldom expresses her opinions Although the Clinton administra- task force. 10:30 3:31:93 04/01/93 DATE 03/31/93 11:59 3918007363297551 1 03 SEN. KERREY/OMA WASHINGTON DC 002 DATE 3/31/93 THIS IS CLIP PAGE 2 WH CLIPS, AM X CONTINUED FROM CLIP PAGE 11 CONTINUED ON CLIP PAGE PM PAGE BK 2 Link Kerrey to Health-Care Group BY GOODSELL WORLD-HERALDBUREAU Washington Sheila Nix was a 'We bring Bob's viewpoint (to the task force). He's college student at Creighton University braska. when Bob Kerrey was governor of No- concerned that there's a comprehensive package of Now a member of Kerrey's Senate benefits, and he's concerned about eligibility for all staff, Ms. Nix and fellow aide Karen Americans.' Davenport are his main links to the White House health-care task force. -Shells Nix "We bring Bob's viewpoint (to the task Senate staff member force)." Ms. Nix said. "He's concerned that there's a comprehensive package of benefits, and he's concerned about eligi- providers. She took a leave of absence from the fits and the plan for providing health bility for all Americans." À Chicago native, Ms. Nix graduated law firm to serve as legal counsel for families. care to low-income and nonworking from Creighton in 1983 and worked in Kerrey's presidential campaign, which Omaha for Coopers & Lybrand account- began in September 1991, returned to Ms. Nix is married to a Washington ing firm from 1983 to 1986. After earning Arnold & Porter for a few months after Kerrey dropped out of the race in March patent attorney. They are expecting their a law degree at the University of Chicago first child in three weeks in 1989, she became a lobbyist with a 1992 and was hired for his Senate staff last November. Ms. Davenport, 26, is in Kerrey's Washington law firm, Amold & Porter. Ms. Nix, 31, said she lobbied for both On the health-care task force, both office temporarily as part of the Presi- insurance companies and health-care women serve on the working groups dential Management Internship pro- handling the standard package of bene- gram, a federal program that provides a two-year stint in government. 918007363297551 1 03 03-31-93 11:49AM P002 #17 03/31/93 11:57 5918007363297551 ! 03 SEN. KERREY/OMA WASHINGTON DC 001 X DATE 3/31/93 THIS IS CLIP PAGE own CLIPS, AM CONTINUED FROM CLIP PAGE CONTINUED ON CLIP PAGE PM PAGE / BK RICH JANDA/THE WORLD-HERALD THEASSOCIATED PRESS CREIGHTON PROFESSOR: Task STAFF MEMBERS: Roger Blauwet, tax counsel for Rep. Peter Hoagland, force member Ruth Purtilo is on the D-Neb., and Shella Nix, who works for Sen Bob Kerrey, D-Neb, are among faculty of Creighton University's Cen- a number of congressional staffers and government agency employees on ter for Health Policy and Ethics the health-care task force. Midlands Voices Heard on Health BY ROBERT DORR Market forces already are lobbyist who works for Sen. Bob and PAUL GOODSELL transforming the health insurance Kerrey, D-Neb. WORLD-HERALD STAFF WRITERS industry. Focus, Page 10. Karen Davenport, 26, a federal At least seven people with Nebraska government intern assigned to Ker- or Iowa connections are helping to force members include: rey's Senate staff. develop the Clinton administration's Ruth B. Partilo of Omaha, pro- Peter Rewecke, legislative direc- proposal for changing the nation's fessor of clinical ethics at Creighton tor for Sen. Tom Harkin, D-lowa health-care system. University's Center for Health Policy Dr. Stephen Gleason, a Des A task force headed by Hillary and Ethics. Moines physician. Rodham Clinton has a May 3 deadline Roger Blauwet, a former partner Nicole Simmons, a former to complete the proposal, which is in the Kutak Rock law firm in Omaha Omaha World-Herald reporter who intended to restrain health-care costs who is tax counsel to Rep. Peter now works for the federal Health Care and guarantee insurance coverage. Hoagland, D-Neb. Financing Administration More than 500 people serve on the Sheila Nix, a Creighton Universi- For profiles of Nebraskans on the task force. Nebraska and Iowa task ty graduate and former Washington task force, see Page IL 918007363297551 03 03-31-93 11:49AM P001 #17 03/31/93 12:13 918007363297551 1 03 SEN. KERREY/OMA WASHINGTON DC 001 CLIPS, AM X DATE 3/31/93 THIS IS CLIP PAGE 8 CONTINUED FROM CLIP PAGE PM PAGE CONTINUED ON CLIP PAGE Omahan Caught Up in Health Project best combination of service, choice and BY PAUL GOODSELL price for a standard health benefit pack- WORLO-HERALOBLREAU 'The staffers are there, in age. They would have to provide cover- Washington Roger Blauwet, a age for anyone who selects their plan, member of the White House health-care a sense, to keep a politi- regardless of current or potential health reform task force, hasn't had much time cal eye on the process. condition. to settle in since be moved here from Individuals would choose between the Omaha in mid-January. -Roger Blauwet competing plans and will not be limited, "I'm unpacking clothes out of the Member of health-care task force as many are now, to a single plan offered boxes as I need them." Blauwet said. by their employer. But the Clinton plan A former partner in the Kutak Rock is likely to increase the use of "managed- law firm in Omaha, Blauwet moved to care" plans such as health maintenance Washington to be tax counsel to Rep. health care four years ago. organizations (HMOs), which place re- Peter Hoagland. D-Neb. Hoagland re- Passed by Congress with near-unani- strictions on individual choice of doc- cently won a seat on the tax-writing mous support and signed into law in tors. House Ways and Means Committee. 1988 by then-President Ronald Reagan, Blauwet said the managed-comipeti- But Blauwet soon was asked to take on the legislation was intended to provide tion approach must be modified in rural an unpaid second job as a member of the additional Medicare coverage for cata- areas, however, where there are not health-care task force headed by Hillary strophic illnesses. The benefits were to be enough health providers to generate Rodham Clinton. He serves on a work- financed through higher premiums, competition. Rural areas have other ing group concentrating on insurance based on income, of up to $600 per problems that some task force members issues. person for the most affluent retirees. initially did not fully understand, he Blauwet, 46, is one of many congres- Although most retirees would have said. sional staffers working 10 to 12 hours a paid far less, the premium plan caused an Blauwet said be objected when some week on the task force. Unlike adminis- uproar that led Congress to repeal the members spoke of rural residents per- tration officials assigned from various entire bill in 1989. haps having to drive 30 minutes to reach federal agencies to develop details of the "If it could happen with a little thing, a hospital. He said he told the group that plan, the Capitol Hill aides have the think of what could happen with com- it takes more than an hour to get to a added responsibility of screening the prehensive health-care reform." Blauwet hospital in many rural areas. proposal for political and logistical land said. "People who have lived in New York mines. As a result, he said, It is important to all their lives don't have a concept of "The staffers are there, in a sense, to consider how individuals will be affected what rural really means," he said. keep a political eye on the process," by health-care changes. The son of farmers who still live in Blauwet said. Clinton officials "don't Blauwet declined to discuss details of Larchwood, Iowa, Blauwet graduated want to second-guess Congress on this the task force's work or give his opinion from Creighton University and Creigh- issue." about how the health-care system should ton School of Law. He served in the Blauwet had relatively little direct be reformed But be said a key challenge Army from 1969 to 1972, living in experience in insurance operations or the is to control costs without squeezing the Washington, D.C. theory of health-care reform before his system so much that doctors do not have Blauwet was a clerk for Associate assignment to the task force, although he enough incentive to deliver good services Justice Lawrence M. Clinton of the had done legal work for Mutual of and individuals lose the ability to make Nebraska Supreme Court and worked at Omaha, Prudential Insurance Corp. and their own health-care choices. & law firm in Superior, Neb., before other insurers. "You can't wring so much excess out moving to Kutak Rock in 1980. He But Blauwet participated in meetings of the system that you don't have innova- specialized in corporate finance and that Hoagland held this winter with tion," he said. regulatory matters. Omaha insurance companies and area At the same time, he said, most people Hlauwet, who is single, said he hopes hospitals and said he has continued to realize that health-care costs are spiral- to eventually have time to go sailing on meet with those groups. Hoagland said ing out of control and that some changes the Chesapeake Bay. For a while, howev- Blauwet is a quick study who has worked must be made. er, he expects to remain busy with long "seven days a week" to master health- The Clinton plan is expected to build days and weekend task force meetings care issues. on the theory of "managed competition" a schedule that he said is not too Blauwet said all the task force partici- establishing a better health-care mar- different from his days at Kntak Rock. pants - but especially those working for ketplace where competition will restrain "My office hours in Omaha tended to members of Congress- are conscious of cost increases. be 9 in the morning to 8 or 9 at night," he the debacle over catastrophic-illness Insurers would compete to offer the said. R=95% 918007363297551 1 03 03-31-93 SEN. KERREY/OMA WASHINGTON DC 001 04/01/93 18:10 918007363297551 1 03 AM 4/1/93 THIS IS CLIP PAGE 3 & OWH CLIPS, DATE CONTINUED FROM CLIP PAGE PM X PAGE CONTINUED ON CLIP PAGE Wesely to Weigh In On Health Proposal BY JASON GERTZEN "It doesn't make sense to do a lot of WORLD-HERALD BUREAU things." Byars said. "I am going to be a Lincoln - State Sen. Don Wesely of foot dragger. How much time should we Eincoln is going to Washington Friday spend developing something that will to advise the Clinton administration on become part of the junk heap before it's what Nebraska legislators want in a implemented?" national health-care plan. Byars said he questioned the value of "My focus is that they should listen to pushing for significant Medicaid change the states and not shut us out of the in Nebraska until the federal plan is planning." said Wesely, chairman of the made public because "everything 1 hear is there won't be a Medicaid in the Legislature's Health and Human Serv- ices Committee. Clinton plan." "One size fits all is not going to work Medicaid is a state-federal cooperative well for all 50 states," Wesely said. program that helps pay for health-care "Nebraska is not New York, Florida or for the needy. aged, blind and disabled, California." and for low-income families with chil- dren. Wesely is one of about 25 legislative leaders on health-care issues from across Wesely said there is a possibility that the nation who have been invited to meet the plan will feature one basic package of with members of the health-care task benefits for all citizens instead of a force headed by Hillary Rodham Clin- separate package for the poor. wn, said Susan Seladones. director of Sen. Jessie Rasmussen of Omaha, vice public affairs for the National Confer- chairman of the health committee. said ence of State Legislatures. she was concerned that such a plan The meeting will be conducted at the would not take into account the unique White House. differences and needs of the poor. espe- States are not sitting back and waiting cially those with more serious medical for the federal government to bring & needs. health-carc reform plan to their door- "I hope they would not ignore the steps, Wesely said. But some states have philosophical direction we have gone been hindered in their efforts to make toward promoting independence rather changes because a number of such initia- than requiring them to live in institu- tives require federal approval that is tions," Sen. Rasmussen said. difficult to receive, he said. Byars said state legislators have tried "The federal government is part of the to see that poor, disabled Nebraskans barrier," Wesely said. have access to personal aides and other Sen. Dennis Byars of Beatrice, a mem- services that allow them to live indepen- ber of the health committee, said he dently in their home, rather than being believes that Nebraska should wait for forced into a more expensive nursing the national health-care plan proposal to home or other institution. be made public next month before ap- Although this approach is more cost proving major changes to the state's effective, "we become portrayed as big system. spenders," Byars said. 918007363297551 ] 03 04-01-93 P001 #02 R=95% 04/05/93 08:33 308 632 3291 SEN. KERREY/EXON +++ KERREY DC X 003 scottsbluff Star-HeraLD Transmitting Page 3 of ? 4-3-93 Page Page 2 of 3 Cydney Janssen of Gordon, chairwoman of the Rural Health Task Force of the Nebraska Rural Development Commission, said Panhandle hospitals need to cooperate to keep prices down and give the best care. Nebraska's per-capita health care cost was $2,452 in 1990 and is expected to be $5,576 by 2000, Janssen said. Those numbers mean Nebraskans have less disposable income, higher insurance premiums and rising prices in other sectors as employers pass on the cost of insuring their workers. Phemister said a Panhandle cooperative might be like Wisconsin's. "I think it could look a great deal like that," she said. Gordon and other small rural hospitals already have been discussing the idea for months. The hospitals are looking at ways to share services, share an auditing firm and perhaps purchase supplies together, Phemister said. Steve Hetzel, senior vice president of Regional Care Inc., an affiliate corporation of Regional West Medical Center, said his group has been talking with other hospitals about cooperation since last fall. The corporation was formed to develop a health plan for the Panhandle. But for such informal efforts to develop into an organized coop- erative, smaller hospitals and Regional West need to work to- gether on an equal level, Ruff said. "Come with the thought you're going to create something to- gether, not buy into something hat's structured already," she ;aid. The conference was sponsored y the University of Nebraska Panhandle Education Center. B.J. Peters, spokesman for the center, said it was a way to get the Panhandle hospitals together R=95% 308 632 3291 04-05-93 10:41AM P003 #25 08/1 04/05/93 08:33 308 632 3291 SEN KERREY/EXON KERREY DC 1 002 = Scottsbluff Star HeRaLD Transmitting Page 2 ot / 5-3-93 Page I Page 1 of 3 Area hospitals ponder. ways to cooperate By JAN TREFFER Staff Reporter SCOTTSBLUFF Health care soon could look much dif- ferent to Panhandle patients. Cooperative medicine is on the way. Representatives of Panhandle hospitals say they're eager to form a consortium to keep care affordable and their hospitals open. "I think there are enough of us in the Panhandle that think it's necessary for survival. It's a go." said Gladys Phemister, administrator of Gordon Memorial Hospital. Sixty-six people came to Scottsbluff Friday for a rural health care conference featuring Patricia Ruff, who outlined the role of the Rural Wisconsin "I Hospital Cooperative. think there Ruff, deputy director of are enough of us the cooperative, said it was started in 1980 and in the Panhandle offers services to 20 that think it's member hospitals. Members contract for necessary for only the services they survival. It's a go." need, such as purchasing and staff. Gladys Phemister, Gordon Memorial The cooperative also established HMO Wis- Hospital administrator consin, a health main- tenance organization that sells insurance to residents. The 30,000 subscribers pay into a pool, and the HMO pays physicians and hospitals at a con- tracted rate. If money is left over at year end, policy-holders get a refund. E=95% 308 632 3291 04-05-93 10:41AM P002 #25 WASHINGTON DC 014 04/04/93 14:55 918007363297551 1 03 SEN. KERREY/OMA DATE 4/3/93 THIS IS CLIP PAGE 2 OWH CLIPS, AM CONTINUED FROM CLIP PAGE CONTINUED ON CLIP PAGE PM PAGE 6 6 OMAHAWORLD-HERALD Health Plan to Allow Choice Of Doctor, Preventive Services THE LOS ANGEL tion will unvell next month Among tives would certify a variety of acceptable them: health networks. Washington President Clinton's health-reform plan will allow Americans - The government would create spe- The plans might include a health the freedom to "follow their own doc- cial incentives to get doctors and nurses maintenance organization. with a re- "ors" into new provider networks. the to work in poor city neighborhoods and stricted list of doctors and hospitals. a administration's chief health-care ad- in rural areas. to "make it attractive to go preferred provider organization with a viser disclosed Friday. And the basic there and stay there." somewhat broader list of doctors. or a Anti-trust laws would be eased to benefits package will include preventive traditional fee-for-service plan allowing services rarely covered by current insur- allow local groups of doctors and hospi- the patient to choose any physician. The ance programs. he said. tals to join together in the creation of fee-for-service plan, which allows unres- health-care networks. tricted selection of doctors, would be "There should be a choice of physi- cians you shouldn't herd people into - The popular Medicare program more expensive for those who choose to one plan or another," Ira Magaziner, would be largely untouched by the re- join. who is directing the administration's form package. other than the addition of All Americans "should be able to 500-member health-care task force, told some new benefits that will be part of the follow (their) own doctor" into the kind a gathering of consumer groups. universal package. The administration is of plan the physician chooses to join, Addressing an issue that many ad- very "conscious of not wanting to break Magaziner said. "Americans don't want visers consider critical to the success of something most elderly people feel is to be told they can't stay with their own the reform effort. he emphasized the working pretty well," Magaziner said. doctors," Magaziner told the meeting, president's desire to allow people to "be The administration's package will which was organized by Families. USA, able to choose their own doctor." have a basic set of health benefits an advocacy group active in the health- The administration is eager to assure guaranteed for all Americans. The cover- reform campaign The audience included consumers who now have relatively good age will be universal and portable, fot representatives from more than 200 or- health-insurance coverage that they can lowing each American, regardless of ganizations, including women's groups, continue their current relationships with health status or employment, Magaziner labor organizations and health groups. their family doctors or specialists. said. Care will be delivered under a "man- All the plans would have to offer at In a two-hour question-and-answer aged competition system," with residents least the basic benefits package, provid- session. Magaziner provided other sig- of a geographic area choosing among ing hospital and doctors services, includ- nificant new details on the form of the several health plans meeting government ing mental health care and some health-reform package the administra- standards. Local purchasing coopera- prescription drug coverage. P014 #17 918007363297551 I 03 04-04-93 is 04/05/93 12:36 402 437 5109 SEN KERREY/LINC 018 PAPER 4-4-93 Luncoln Germal-Dtar THIS IS CLIP PAGE 18 FROM CLIP PAGE DATE CONTINUED ON PAGE From page 1A Hospitals payers and advancements in treat- with their own measures to keep ment have contributed to the new ebb down costs by shortening stays where in inpatient numbers. possible "What we didn't count on to the de- For example, Lincoln General has gree that it occurred were the used the MEDIS system to make sure changes in technology," said Arian patients stay no longer than neces- Stromberg, administrator at Lincoln sary. St. Elizabeth has turned to home General health nurses to provide some of the He cited a new technique for pre- and post-admission care. AU removing gallbladders as an exam- three hospitals have worked to com- ple. With the new procedure, most press the same amount of patient gallhladders can be removed through education, tests and care into shorter small incisions instead of requiring periods of time. major abdominal surgery. Patients can go home within a day or two in- "As payers have changed the way stead of 10. they pay, it has changed practice pat- Bob Lamk, president and chief ex- terns," Frye said. ecutive officer of St. Elizabeth, As a result, average lengths of stay pointed to aggressive efforts by insur- for acute care patients dropped at ance companies and other payers to Bryan from a peak of 67 days in 1989 control health-care costs by manag- to 6.1 days last year, from 5.9 days in ing care. Such efforts typically in- 1987 at Lincoln General to 4.5. days clude requiring approval for patients last year and from 52 days in 1988 at to be admitted to the hospital and re- St. Elizabeth to 4.6 days last year. views during their stay to be sure hos- With the increases in outpatient pital care is still needed services, the shorter inpatient stays Lincoln's hospitals have responded have not slowed the pace of activity. "We're still seeing the same num- "We're really going hospital with- bers of people throughout or even out walls. Our focus here is patient strengthening (the numbers)," Strom- services versus a lot of bricks and berg said. mortar," said Charlotte Liggett, vice At St. Elizabeth, for example, beds president at St. Elizabeth not used by inpatients often are filled But the decline in daily impatient by "extended outpatients." Those are censuses has affected the hospitals' patients who stay overnight but less bottom Ines. than the 24 hours that would classify Last year, St. Elizabeth responded them as inpatients. to the drop in its impatient numbers "We don't have that many empty by asking all employees to take a 5 beds because we've got them filled percent cut in hours or a 5 percent cut with these guys and gals," Lanik said in salary- Lincoln General restruc- Outpatient surgery has grown from tured its staff to eliminate several un- less than a third of all surgery in 1984 filled positions. Bryan has used a to nearly half last year at Bryan and "considerable amount" of flex-staff- Lincoln General ing - calling in staff only when they SL Elizabeth has seen the greatest are needed. change People getting outpatient Lincoln General also dropped its surgeries there accounted for 71 per- licensed bed capacity from 307 in 1992 cent of all surgery patients last year, to 268 this year. Bryan plans to deli- up from only 24 percent in 1984 cense 32 beds when its current expan- The shift to outpatient care has sion project is completed some health-care futurists pointing to a new type of hospital as a place "We are delicensing beds because (Hospitals) where people go for treatment but we know we will have plenty of beds not to stay. left," Frye said. (30f3) R=96% 402 437 5109 04-05-93 22PM P018 #28 4 017 04/05/93 12:35 402 437 5109 SEN KERREY/LINC APER Luncoln Journal Dtar THIS IS CLIP PAGE 17 FROM CLIP PAGE DATE 4-4-93 PAGE CoA CONTINUED ON PAGE Hospital useage Outpatient surgery has accounted for. a growing proportion of Lincoin hospital business while the number of inpatients on an average day has slipped. Bryan Lincoln General St. Elizabeth 12000 Surgery 10000 Outpatient Inpatient 8000 6000 4000 2000 0- 1984 1992 984 661 1984 992 250 Average dally Inpatient census 200 150 0 100 Bryan 50 Lincoln General St. Elizabeth 0 Hospi tab 98 1985 986 987 988 1989 1990 1991 1992 SHEILA STORY KEYSER/LINCOLN JOURNAL- STAR SOURCE: NE DEPT. OF HEALTH (20f) 402 437 5109 04-05-93 01:22PM P017 #28 R=96% 04/05/93 12:34 402 437 5109 SEN KERREY/LINC 016 PAPER Luncoln gremal-Atar THIS IS CLIP PAGE 16 DATE 4-4-93 I FROM CLIP PAGE PAGE CONTINUED ON PAGE New services keep hospitals in black Facilities shift to outpatient care BY MARTHA STODDARD Lincoln Journal Star Mounting pressures to control SUND costs, along with advancements in health care, emptied Lincoln hospital beds at a quickening pace last year. SPECIA Figures collected by the state De- partment of Health show sharp drops dive in the mid-1980s after Medicare in the mumber of inpatients filling : changed its payment system Before beds on an average day last year at 1983, Medicare paid hospitals based all three general hospitals. on their charges' After that date, the The decreases were the largest federal health-care program for the since Medicare shifted to a new hos- elderly and disabled paid hospitals a pital payment system in 1983. fixed amount for each diagnosis, no "All of us in the industry have been matter how long the patient stayed working harder to get patients out of Many private insurance companies the system faster." explained Sue followed suit Frye. vice president at Bryan Me- While Inpatient mumbers planged morial Hospital. outpatient services went through ex- Having fewer inpatients has forced plosive growth Lincoln General Hospital. Bryan Me- A "new normal" pattern appeared mortal Hospital and St. Elizabeth to be emerging by the late 1980s. Out- Community Health Center to take patient services grew more slowly. some cost-saving measures, but Inpatient admissions stabilized or growth in outpatient and other ser- even grew, and the average patient vices has kept them busy and in the stayed longer. black, of ficials said. Hospital officials said the new pat- Statistical reports from the three term resulted from shifting almost all since 1984 show that: possible patients to the outpatient Numbers of inpatients headed back down last year after increasing side and having only very sick people left as inpatients slightly during the late 1980s. But after reaching a peak near the The average acute care patient end of the 1980s, the average length of stayed an ever shorter time during Hospitals stay for inpatients started down in the the past few years. 1990s. Hospital admissions also Outpatient operations continue dropped at St. Elizabeth and Lincoln to account for a growing proportion General of all surgeries. Hospital officials said pressure Traditional hospital utilization from insurance companies and other numbers - inpatient admissions and Inpatient surgeries - took a dramatic See HOSPITALS on page 6A (1063) R=96% 402 437 5109 04-05-93 01 22PM P016 #28 04/05/93 12:29 402 437 5109 SEN KERREY/LINC 008 04/C PAPER Juncoln 8 THIS IS CLIP PAGE AA DATE 4-5-93 FROM CLIP PAGE PAGE CONTINUED ON PAGE Optional services not Medicaid's problem All the talk during the legislative ses- move into nursing homes and Medicaid sion about cutting Medicald services was would be paying more dollars. mostly an educational exercise aimed at Of course, eliminating some of the op- helping the rest of us understand how the tionals really would save tax dollars. Medicaid program works. The state could refuse to pay for den- After all the sound and fury, the Health tures for poor older residents. Or for and Human Services Committee wisely glasses. The state could stop buying hear- dropped the balk of the cutting proposals. ing aids, pacemakers, or providing wheel- Medicaid, the federal-state partnership chairs or oxygen program that provides health care for The state could stop speech therapy for some low-income Americans- very poor poor stroke victims. children and their parents, disabled These are all options, rather heartless adults and very poor seniors - is a defi- options in a state where most families nite financial headache for the states, own several cars, many are able to buy which pay about half the costs. personal computers for home use and But then, cost is a headache common to take the family out to dinner once in a the entire health care issue. while The truth is, we can only eat around the It's very easy for those of US who have edges of the state's Medicaid problem employee health benefits - often par- with cuts in programs. unless we are will- tially or completely subsidized by the ing to tell very poor Nebraskans that they company - to forget how vulnerable we cannot get some of the basics of medical would be, poor and sick care. The Health and Human Services Com- The whole talk of optional services was mostly silliness. In fact, "optional" was mittee has dropped the cutting proposals sometimes synonymous with "least ex- that would save no money and the ones that would be beartless. pensive." These are optional only because the SOME VALID changes remain on the federal government puts them on a list table called "optional." Some services states The state should make it very diffi- must provide to be part of the Medicaid cult for older residents to put their assets program. Other services are listed as op- and money into trusts or give it outright tional. to children, then turn to Medicaid to pay But many are not optional in the world for nursing home care. The Legislature is of reality. seriously considering several bills that Let's just look at a few of them. will make this paper impoverishment much more difficult Medicaid's most ex- PODIATRISTS ARE an optional ser- vice. However, Medicaid reimburses for pensive clients are the elderly. Taxpayers all physician services. So the folks who should be helping only those who are truly now use podiatrists for foot problems can poor. simply go to a doctor with an MD title for The state should move into a man- the same problems and Medicaid will pay aged care system if that kind of system those bills, generally higher bills. No sav- will actually curb rising costs. ings here. The state also is looking at building Hiring aides to help people with physi- co-payments and deductibles into the cal handicaps eat, dress, cook, allows Medicaid system where feasible. these people to live in their own home or Hopefully, the Legislature put the use- apartment rather than in a nursing home. less "optional services" debate to bed. Usually it is far cheaper to pay for these That does not mean, however, that aid services than to pay nursing home state leaders should not continue to ex- costs. amine the Medicaid system, looking for Nursing home costs are covered by savings. Cost of services should be a fac- Medicaid. Personal care services are on tor in deciding what services are appro- the optional list. priate. The least expensive option, with- So what would happen if these optional out greatly sacrificing quality, should be services were cut? Folks would have to a guiding principle. R=96% 402 437 5109 04-05-93 01 22PM P008 #28 09:52 918007363297551 1 03 SEN. KERREY/OMA WASHINGTON DC 003 10 FACE AM X DATE 4/6/93 THIS IS CLIP PAGE CONTINUED FROM CLIP PAGE PM PAGE 2 CONTINUED ON CLIP PAGE 2 Costs of Health Care Run High on the Farm Continued from Page 1 Union lobbyist. Food, Health Care The Donnellys make $12,000 a year Spending by Americans from their family farming corporation and $6,500 from Mrs. Donnelly's part- Average Heatth time job. Year Income Food Care Until last year. the Donnellys paid 1991 $33,901 $4,271 $1,554 $160 a month for insurance that re- 1990 31,889 4,296 1,480 quired them to pay the first $5.000 of 1989 31,308 4,152 1,407 medical costs for each family member. 1988 28,540 3,748 1,298 An increase to $180 a month was the 1987 27,326 3,664 1,135 final straw. Mrs. Donnelly said. 1986 25,481 3,363 1,062 She quit as a classroom aide and 1985 25,127 3,394 1,037 took a $5.25-an-hour job in the Burt 1984 24,578 3,391 899 County Attorney's Office, largely be- 1983 23,186 3,198 839 1982 cause the county government would 22,702 3,137 822 1981 pay half the cost of group medical 19,989 3,224 746 insurance for her family. Source: U.S. Department of Labor Mrs. Donnelly's half-share amounts to $2,760 a year for her family's health insurance, more than the family paid RISING COSTS: Health-care expenses under the old policy. But the new doubled over 10 years for the average policy carries a $100-a-person annual consumer spending unit families and deductible, in contrast to the $5,000-a- singles while food costs Increased person deductible in the old insurance one-third. Food costs include restaurant plan. meals. Health-care charges exclude em- Donnelly said what his family pays ployer-paid insurance. for medical insurance is "outrageous." But he is grateful his family is covered. residents tend to be middle-aged and "I'm just lucky my wife has a job," elderty people, who are more likely to he said. need health services. Kathy Chatt. a nurse in the Teka- The Farmers Union supports a sin- mah-Herman Schools. said she sees gle-payer system in which everyone children who need medical care but chooses his or her own doctor and don't always getit hospital, and all the bills go to the "Health insurance is a luxury a lot of federal government. The cost would be people can't afford," she said. paid by increased income taxes and Ms. Danielson of the Farmers Union employer-payroll taxes, she said. contends that managed competition. Ms. Danielson said she worries that which is expected to become part of a the Clinton task force on health care new national health-care plan, isn't likely won't give enough attention to the to work in rural areas. problems of rural areas. Just one of the Under managed competition, resi- 34 working groups is assigned to rural dents of a geographic area would choose health care, she said. among several health insurance plans A health-care reform plan must deal that compete for their business. Those with the problems that small common- plans, including hospital and doctor ities have in keeping hospitals open care, would have to meet government and in attracting doctors, she said. standards. A recent study determined that the But rural areas won't attract compe- average rural physician is 60 years old, tition, Ms. Danielson said Farming Ms. Danielson said. "This is even older areas are thinly populated. and the than the average farmer." R=96% 918007363297551 - 03 04-06-93 10:41AM P003 #04 09:51 G918007363297551 1 03 SEN. KERREY/OMA WASHINGTON DC 002 04/06/93 OWH CLIPS, AM X DATE 4/6/93 THIS IS CLIP PAGE CONTINUED FROM CLIP PAGE CONTINUED ON CLIP PAGE PM PAGE 16.1% Health Insurance Can Food 12.6% Percent of BY ROBERT DOER that is studying national health-care Income WORLD-HERALD STAFF WRITER reform. Reedland A Tekamah, Neb., farm wife Out-of-pocket health-care costs Health Care changed jobs last year, mainly, she medical and drug charges, plus health Spending,by/ said, to get medical insurance that her insurance paid by the average family could afford. American household doubled between Americana "Basically, I-work for insurance," 1981 and 1991. rising to $1,554 a year, said Terri Donnelly, 39, who lives with U.S. Labor Department figures show. 37% her husband, Dale, and their two That excludes health insurance costs children northeast of Teksmah. paid by employers. Mrs. Donnelly is among a growing For many farm families, the cost of number of farm wives seeking work in health care runs much higher. town to put their families under an Health insurance takes 15 percent of affordable medical insurance umbrel- the Donnellys' $18,500 before-tax in- 1981 1981 Source us Department of Lator la Health-care experts contend that come. rural areas pose special problems for By comparison. the average U.S. MKEDRUMMY/THE WORLD-HERALD the Clinton administration task force household spent less than 5 percent of Be Costly for Farm Families its income for medical insurance and insurance as individuals," be said. hold paid just 12.6 percent of its other pocket health-care ex- Farmers might pay as much as income for food in 1991 compared penses in 1991, U.S. Labor Depart- $4,000 1 year for health insurance that with 43 percent in 1901, 35 percent in ment figures show. carries a deductible of up to $5,000 per the mid-1930s, 27 percent in 1960 and The lower national average partly family member, Mueller said. 16 percent in 1981, federal figures reflects the fact that nearly two-thirds Farmers are at a disadvantage for show. of Americans younger than 65 receive another reason: Many large employers While the costs of health care paid their health-care coverage through the have joined insurance plans that bar- by the average U.S. household doubled workplace. For them rising medical gain with groups of doctors and hospi- during the 10 years ending in 1991, costs are partly or fully paid by their tals to reduce charges. That doesn't food costs went up one-third employers. help self-employed farmers. "Perhaps the ultimate irony is the Self-employed people, such as farm- There is irony in farmers being farm family that is forced to drop ers, must pay the entire cost them- among the primary victims of rising health insurance so that it can afford acives, said Keith Mueller, rural health health-care costs, rural health special- the crop insurance required by the specialist at the University of Nebras- ists say. bank for its operating loan," said ka Medical Center. The success of farmers is a Large Nancy Danielson, a National Farmers "They are out there trying to buy reason the average American house- Please turn to Page 2, Col. 1 918007363297551 03 04-06-93 10:41AM P002 #04 R-95% 04/07 17:28 918007363297551 1 03 SEN. KERREY/OMA WASHINGTON DC 006 04/07/93 B OWH CLIPS, AM DATE 4/7/93 THIS IS CLIP PAGE 8 CONTINUED FROM CLIP PAGE PM X PAGE 11 CONTINUED ON CLIP PAGE Van to Carry Health Services Across State A 34-foot motor home has been con- verted into a mobile nursing center to take diabetes education and services into Nebraska communities. The mobile unit is a project of the University of Nebraska College of Nurs- ing and the Combelt Federation of Cosmopolitan International. The van's first trip was Tuesday, when it was taken to Southroads Mall to offer services to Health Hikers. a group of 300 men and women who walk at the mall. Cosmopolitan provided $100,000 and volunteer services to provide the unit, said Jim Sauer, chairman of the West Omaha Cosmopolitan Club. The mobile unit, staffed by nurses, offers services such as risk-factor ap- praisals, nutritional assessments, blood testing and screenings for high blood pressure, obesity, vision and foot abnor- malities. Catherine Todero, associate nursing dean and project coordinator, said the unit will concentrate on assisting under- served groups who are at high risk for diabetes: blacks, Hispanics, American Indians and the elderly. JA/07/ 04/07/93 17:27 918007363297551 1 03 SEN. KERREY/OMA WASHINGTON DC 004 OWH CLIPS, AM DATE 4/7/93 THIS IS CLIP PAGE 6 CONTINUED FROM CLIP PAGE PM X PAGE 8 CONTINUED ON CLIP PAGE Co-Payments Can Help Control Medicaid Costs The Nebraska Legislature indicated it require financial participation by Medic- won't remove all the extra recipients it has aid recipients. allowed to go onto the Medicaid rolls or Introduced by Sen. Tim Hall and all the extra services it has added to others, LB 808 would require that Medic- Medicaid. But options for partially.cc aid patients pay $3 for physician services trolling costs remain. or home health aides, $2 for a clinic visit One is Legislative Bill 808. It would and $1 for prescription drugs. The fee require Medicaid patients to make atoken would be waived for the truly needy. payment for each prescription or visit to a Under federal law, children, pregnant doctor's office. The co-payments could women and some institutionalized per- raise $1.3 million a year for the state's sons would be excused from the pay- Medicaid program. ments. More important, co-payments tend to The idea has opposition. There are make for more intelligent consumers. people who view the attempt to control When an insurer provides first-dollar Medicaid spending as a cruel assault on protection, some people see the benefits as the poor. free. They are more likely to go to a But no one has proposed denying basic specialist, for example, for a cold. Even a care to people who have no other way to token co-payment can cause them to take pay for it The purpose is to raise revenue a second look. More than half the states and discourage overuse. 04/08/93 09:31 1918007363297551 1 03 SEN. KERREY/OMA WASHINGTON DC 003 OWH CLIFS, AM X DATE 4/8/93 THIS IS CLIP PAGE 6 CONTINUED FROM CLIP PAGE PM PAGE 11414 CONTINUED ON CLIP PAGE Medicaid Cost Controls BY JASON GERTZEN Continued from Page 11 ers. WORLDHERALD BUREAU Committee agreed it would try to revive Wesely filed a motion to revive bills Lincoln - The Legislature's Health the proposal in LB 794 that would killed in the Revenue Committee that and Human Services Committee offered eliminate Medicaid coverage for 10 serv- would tax the gross revenue of hospitals ices. Committee members said they were a counterproposal Wednesday in the bid and nursing homes, remove the sales tax angry and frustrated that the health exemptions given to hospitals and nurs- to gain control over the state's rapidly committee had not made more of an increasing Medicaid costs. ing homes and change a capital-gains effort to reduce spending on Medicaid, a deduction provision of the Employment, "We are moving forward on signifi- health-care program for the poor that is and Investment Growth Act cant changes to the system," said State expected to cost the state an additional Gov. Nelson said Wednesday during a Sen. Don Wesdy of Lincoln, committee 572 million over the next two years press conference that he thought legisla- chairman. "When they are evaluated alone. tors should rely more heavily on health- they will ace these are significant cost- The health committee's cost-contain- care industry temporary tax increases to containment initiatives that will improve ment approach was more sensible than help cope with the high Medicaid cost the system, reduce waste and minimize the "mean-spirited and hard-hearted" increases. the harm to the truly needy." approach of LB 794, Wesely said. "It's appropriate to go back to the The committee voted to send to the LB 794 would eliminate coverage for industry to get their help in solving the full Legislature bills that would require 10 services the federal government gives problem." Nelson said. Medicaid recipients to pay 1 few dollars states the option of providing with their The Legislature's Revenue Committee Proposed Medicaid programs. is preparing a $27 million package that when they get services 808), increase "The optional services have become a so far includes a beverage tax, a higher the licensing fees doctors pay (LB 805), symbolic thing for making Medicaid cigarette tax and a $6 million tax on make it more difficult for people to shift recipients pay for the high cost of health-care providers. their assets so they are judged poor Medicaid," Wesely said. "I don't think it Nelson said he wanted the package to ultimately saves money." also include his Legislative Bill 834, When coverage for certain services is which would raise $7 million in taxes on enough for Medicaid (LB 800), require eliminated, Medicaid recipients will seek hospitals and nursing homes. Those prescreening for nursing home patients care from other, possibly more expen- taxes would be in addition to the $6 (LB 801) and require Medicaid recipients to go through a doctor who would serve sive, health-care service providers, he million in health-provider taxes that are said. part of the Revenue Committee's pack- 816). as a gatekeeper for medical services (LB Sen. Scott Moore of Seward, appro- age. LB 805 was amended so that instead of priations committee chairman, said he "If you don't do that, tell me what $1,000 license fees, doctors would pay would consider pulling back on the drive incentive there is for health-care provid- to revive LB 794. $150 a year. The money raised would be ers to be part of the long-term solution," "We are just saying you have to curb Nelson said. used to increase payments to primary the growth," Moore said. "If they have The governor said he opposed the care tients. doctors who treat Medicaid pa- another way to do that, we will warm to beverage tax, was still considering the that." cigarette tax increase and was consider- The committee still is considering a Wesely served notice Wednesday that ing proposed spending cuts. bill, LB 804, that would allow the State he would push for health-care industry "If they go back to the budget we Department of Social Services to reduce tax increases or other measures over deep presented, there indeed is a balanced Medicaid costs by eliminating coverage cuts in Medicaid if the cost-containment budget without increasing any of these for certain services. proposals failed to satisfy other lawmak- taxes," Nelson said. On Tuesday, the Appropriations Please turn to Page 14, Col. I 918007363297551 1 03 04-08-93 10:21AM P003 #23 002 6308 632 3291 SEN. KERREY/EXON KERREY DC 04/08/93 n8:41 TICKOLL Transmitting Page 6 of 4-8-93 Page 4B Page of 2 OUR VIEW Scottsbluff WNCC turning good idea Star Herald into affordable child care Western Nebraska Community College has taken a significant step in showing what can be done with a good idea - in the process, demonstrating the value of forming partnerships. The Child Development Center, now beginning construction, is a cooperative venture between the college, the city of Scottsbluff, the WNCC Foundation and Panhandle Community Services. The $680,000 facility should be completed by mid-August and will be- come operational shortly afterwards. It will be owned by the foundation, built on college land, adminis- tered and operated by Panhandle Community Services and financed partly by a block grant administered through the city. The day-care center will serve 125 children mainly children of WNCC students and young- sters enrolled in Head Start. A The center's goal is two- t least half of the pronged. It will provide af- privately run day-care fordable day care for parents centers in the Twin Cities who are studying at WNCC. It also will serve as a training are at capacity and have facility for students in the a waiting list. college's early childhood ed- ucation program, allowing them to gain hands-on ex- perience dealing with children. 308 632 3291 04-08-93 10:47AM P002 #25 R=96% 003 SEN.KERREY/EXON KERREY DC 04/08/93 08:41 6308 632 3291 HeRaLD Transmitting Page 7of7 4.8.93 Page 4B Page 20£2 In our ever-changing, high-tech society, community colleges play a key role in retraining people for new careers. Not all students Scottsbluff enrolled at WNCC are recent high-school graduates preparing for a Star four-year institution. A significant proportion are adults seeking Herald fresh educational opportunities as they change the direction of their lives. For this latter group, which includes many single parents, the lack of affordable and convenient child care often has held them back. Not so now. Some have faulted WNCC for competing with the private sector when it comes to child care. But a quick survey of privately run day-care centers in the Twin Cities reveals that at least half are at capacity and have a waiting list. In fact, WNCC and its partners would not have been able to secure funding for the new child-care facility if a need for such services had not been demonstrated. This region will be well served by the day-care center and the training it provides. 308 632 3291 04-08-93 10:47AM P003 #25 04/08/93 17:28 918007363297551 1 03 SEN. KERREY/OMA WASHINGTON DC 006 OWE CLIPS, AM DATE 4/8/93 THIS IS CLIP PAGE b PM X PAGE b CONTINUED FROM CLIP PAGE CONTINUED ON CLIP PAGE Study Finds Lack of Health Insurance BY ROBERT DORR He said the study shows the need for a without insurance. The Families USA WORLD-HERALDSTAFFWRITER national plan extending medical care to study counted families with at least one in 30 percent of Nebraska families and all Americans and for "getting health member lacking insurance coverage. 27 percent of Lowa families, at least one costs under control." The NEU. Medical Center survey was person lacks health-care insurance or Earlier this week, a University of based ou a telephone survey of 1,500 Nebraska Medical Center researcher re- expects to lose it this year, according to a adults. The Families USA study used study released Thursday. ported that 10 percent of Nebraskans data obtained in the U.S. Census Bu- lacked medical insurance in 1991. That reau's monthly surveys of 60,000 house- Nationally. 35 percent of American survey reported numbers of residents holds. families have an immediate family mem- ber who has no health insurance or expects to lose it this year, according to the study by Families USA The organi- zation is a national consumer group that advocates health-care reform. "Hard-working Americans are losing their health insurance because business- es, and especially small businesses, sim- ply can't afford to protect their workers any more." Ron Pollack, executive direc- tor of Families USA, said in a statement in Washington, D.C. 04/11/93 14:54 918007363297551 1 03 SEN. KERREY/OMA WASHINGTON DC 010 OWH CLIPS, AM PM X DATE 4/10/93 THIS IS CLIP PAGE 3 CONTINUED FROM CLIP PAGE PAGE 7 CONTINUED ON CLIP PAGE Views on Health, Medicine Proposals The following are excerpts from recent essays care in the Midlands and in the nation. The writers submitted to The World-Herald concerning health are Omaha health professionals. Managed Competition Prescription for Failure' BY FRANCES MENDENHALL, D.D.S. Most of as had never heard of managed competition until last December when the Jackson Hole Group, composed of It was terrible news when the Clinton task force appeared business school professors and insurance industry CEO's, to slam the door on the one solution that has successfully conceived of it The plan would force Americans into cul-rate addressed problems particular to America, the Canadian HMO's. These would offer & minimum care package that model. everyone would be encouraged to accept. Those desiring Canada has done an end run around the bureaucracy and higher standards would be penalized by higher taxes. paperwork of multiple insurance companies by having a Insurance companies would practice "managed care," dictat- single payer, its federal government. ing what doctor a patient may see and what procedures he or The Clinton administration is offering managed competi- she may perform. It is the worst of several worlds: some tion, an idea doomed to fail. rationing, control taken from patients and doctors and put In Canada every resident is insured through the province. into the hands of the insurance industry, more paperwork for Canadians enjoy unrestricted choice of doctors. Their care is doctors and their staffs. high quality. they live longer than we do, and fewer of their The architect of the plan, Alain Enthoven of the Jackson babies die. Their health plan is more popular than our Social Hole Group. says it would eliminate small practices. Ironical- Security. ly, there is more "competition" - at least from the providers - in Canada where patients are free to choose their own Health care costs Canadian taxpayers 30 percent less per doctor. How eliminating choice and forcing small practices to person than we now spend. The Canadian government close could satisfy anyone's desire for freedom in the collects the insurance premiums in the form of taxes and pays marketplace is beyond me. doctors and hospitals directly on a fee-for-service basis. Managed competition. furthermore. could never control Paperwork is simple. billing is easy. Most offices are able to costs. Just look at the last decade: While HMO's and other collect fees within three weeks. Hospitals' billing departments "managed care" programs have grown at an unprecedented need a tiny fraction of the payrolls and bureaucracy found in rate, so have costs. A key problem has been and will continue hospitals here. to be administrative overhead, currently 24 cents of every Stndies show that a billing system like Canada's would health care dollar. Adding another layer of bureaucracy to the eliminate between $80 billion and $140 billion in waste on system will not lower this expense. paperwork in the United States - enough to cover every If the president's group won't change its mind, Congress insured American. must change it 04/11/93 14:55 918007363297551 1 03 SEN. KERREY/OMA WASHINGTON DC 011 CLIPS, AM X DATE 4/10/93 THIS IS CLIP PAGE # CONTINUED FROM CLIP PAGE PM PAGE 7 CONTINUED ON CLIP PAGE 'Cooperative Health Efforts Should Get Priority' BY EDWARD 1. TAYLOR, M.D. Inpatient and outpatient dialysis. Outpatient care facilities. Outpatient care is cheaper than hospitalization, but the Medical information management systems (computers). shift of health care to the outpatient setting has not been In order to foster a spirit of cooperation in Omaha without cost. Hospitals and physicians groups have invested medicine, I suggest the following: large amounts of money in special now outpatient care Do not place a moratorium on new project development. facilities. If outpatient care is to be safe and effective, we need new A less obvious cost is the decline is quality of care facilities that bring doctors, laboratories and radiology caused by an inadequate system for communication among services together in the outpatient setting. Some degree of care givers. In the old system, a patient in a hospital updating of inpatient services is also essential. would have a complete chart with laboratory, radiology, Empower the state certificate of need board to consider nursing and physician inputs in one place almost immedia- only those projects proposed by cooperating networks of tely. Now. since patients undergo tests or treatments at hospitals and physician organizations that provide unified different locations, it is difficult to assemble the information and comprehensive health care. needed to care for them properly. Most area hospitals have chosen individually to make Lower the dollar limit above which a certificate of need is investments in new facilities. Each project requires the required. approval of Nebraska's certificate of need board. and the Encourage development of cooperative groups of Omaha board seems to be rubber-stamping most of the requests. This businesses to negotiate directly for insurance contracts with is an expensive way for us to proceed. Omaha would save on comprehensive physician hospital organizations. In this health costs if hospital systems worked together in these model, physicians and hospitals organized together ARE the enterprises to share such facilities as: insurance company. The care institution would have a vested Expensive and underutilized equipment: MRI units. CT interest in operating efficiently and avoiding duplication. scanners. lithotripsy machines, etc. Costs would be driven down by eliminating the outside New operating rooms. insurance company as the middle man. Urgent care and emergency services. With or without the Clinton health care reforms, these Rehabilitation and psychiatric units. suggestions make sense. NAME OF PAPER Record DATE 3/19/93 CITY, STATE Chadron, NE PAGE / OF On panel with Hillary- CSC dean speaks on health care By LINDA STOTTS held Monday. Other panel members included the The nation's health care problems Davis' invitation was initiated president's wife, Hillary Rodham are every bit as complex as might through Sen. Bob Kerrey's office. Clinton, who heads a national task be suspected, according to the dean The day-long meetings were spon- force working to produce a health- of the School of Science and Math- sored by the Robert Wood Johnson care reform plan, and Donna Shalala, ematics at Chad- Foundation. Dr. Steve Schroeder, secretary of health and human ser- ron State College president of the foundation, served vices. after he had par- as moderator. (Continued on Page 2) ticipated in a pub- lic forum on the situation in Des Moines, Iowa, this week. Dr. Ted Davis was one of two Dr. Ted Davis Nebraskans in- vited to participate on panels in the second in a series of public forums, "Conversations on Health: A Dia- logue with the American People," Health care panel- (Continued from Page 1) Opportunities Program at Chadron "I came away from the meetings State, a cooperative program with with a deepened awareness of the the University of Nebraska Medical complexity of our health care prob- Center. He told the forum partici- lem and the reform needed. Many pants that the program is an "effort concerns are, in fact. in conflict with to allow rural people to help solve one another," said Davis. the health care shortage." "I don't see an easy solution to He explained the RHOP process, the health care issue. The various which recruits students from rural needs must be addressed with dif- backgrounds and educates them in ferent unique solutions making up rural settings as much as possible, the system with compatable compo- with the intent for them to return to nents, he said. work in rural areas. Monday's meetings, targeting ru- "I observed a high level of energy ral health, were divided into three among the 300 to 400 people in at- sessions: controlling the costs of ru- tendance. They were all concerned ral health, peace of mind and rural with sharing their needs and ideas health needs. for change in our rural health care Davis was on the panel concerned systems," Davis said. with rural health needs and spoke "We must not sit back and wait on the topic of distance and distri- for a change. Hard work is needed bution of providers. He shared in- to construct a system that will be formation about the Rural Health successful." Davis concluded. Record 50 Chadron. NE CB Cir. 3,255 MAR. 9 1993 UNIVERSAL Press Choping Bursau CSC professors attend Clinton briefing Two Chadron State College pro- Senators James Exon and Bob position. Crouse said. munity colleges, technical institutes fessors. Dr. Margaret Crouse and Jim Kerrey and U.S. Repres ntatives Pe- The new administration will stress and secondary schools so vocational Stokey, attended a three-day brief- ter Hoagland and Bill Barrett to urge youth apprenticeships, in which high students can enter a three- or four- ing on the Clinton Administration's greater support for vocational edu- school students in their final two year technical program while in the proposals for vocational education cation in the upcoming federal bud- years or at graduation will be placed last two years of high school. and job training in Washington, get. in workplace learning situations. D.C., last week. During the visit, the :SC profes- Vocational educators working with The event was sponsored by the sors were briefed by representatives Crouse is Chadron State's voca- youth apprenticeship programs cur- American Vocational Association, and congressional staff currently en- rently being tested around the coun- tional coordinator and is responsible representing some 40,000 vocational gaged in reauthorizing the Elemen- try have found that the integration for in-service and pre-service pro- education leaders around the coun- tary and Secondary E lucation Act grams for vocational education of classroom instruction and appren- try. It was designed to provide in- and apprenticeship legi: lation. teachers. ticeships are effective in helping formation about vocational education Both Crouse and Stokey urged the youth understand the relevance and Stokey is an assistant professor of issues. Nebraska legislative assistants to necessity of academic skills as well electronics and power. He is the in- Topics discussed during the brief- look at the apprenticeship program as specific job skills, the CSC pro- structor for Principles of Technol- ing included the impact of trade carefully as it appears to fit within fessors were told. ogy. agreements with foreign countries on vocational education's kisting infra- Several sessions also were offered Chadron State offers graduate- local internship programs, charter structure. level courses designed to prepare to focus on how to more effectively schools and the role business and in- The Clinton Administration's plans administer "tech-prep" programs. teachers for tech-prep settings. They dustry must take in education. for education and job train- include Principles of Technology, CROUSE and Stokey also met ing represent a major policy TECH-PREP is a program that Applied Math and Administration of coordinates curricula between com- with legislative assistants of U.S. shift from the Re: gan-Bush Vocational Education Programs.j 04/13/93 09:01 308 632 3291 SEN. KERREY/EXON KERREY DC 008 DINNEY 1212GRAPH Transmitting Page 8 of 10 4-9-93 Pace A4 Page 1 of 2 Three major points on health care system It would help, we think, while Hillary Clinton and her hundreds of panel advisors are trying to put together a new form of national health care, if some- one would be bold enough to come out and say exactly what is bothering most Americans over the existing SIDNEY health care system. In plain words, those concerns are: (1) Most people think doctors' fees are too high; TELEGRAPH (2) Most people think hospitals charge too much; (3) Most people think the cost of prescription medicines is 4-9-93 outrageous. Come on, now, isn't that what it's all about? And if it is, why doesn't someone come out and say that we may put together a thick book filled with new health care policy, but nothing will be accomplished until someone addresses those three major points. We are not saying that doctors are overpaid, or hos- pitals are overcharging or prescription drugs are too expensive. We are not experts in that field and we would prefer to reserve such opinions for the experts. What we are saying is that most people think that those three points are the crux of the whole health care riddle, and until somebody addresses them, the rest of the rule book will be meaningless and hypocrit- ical. R=95% 308 632 3291 04-13-93 11:04AM P008 #45 40 04/13/93 09:02 in JIDNEY LICGRAPH 2308 632 3291 SEN. KERREY/EXON Transmitting KERREY DC Page 40t of 4-9-93 Page A4 Page 2 of 2 Sidney Telegraph What we read mostly is of the 30 million plus peo- ple who reportedly have no health insurance cover- age. What we need to address directly is what the other millions of people think about a system under which they are fully or partially covered by insurance, but still feel the costs are too great. Employees and employers are caught up in this because a sizable por- tion of the paycheck is now going for health protec- tion. Can they afford to continue this payment sched- ule? If not, who is going to pay it? And should the health care professionals help cut the costs S0 that we can get a handle on the overall problem? It's dirty work, but someone has to do it. 04-13-93 11:04AM P009 #45 308 632 3291 R=95% 04/12/93 10:22 402 437 5109 SEN KERREY/LINC PAPER Jincoln StaR THIS IS CLIP PAGE 9 FROM CLIP PAGE DATE 4.12.93 PAGE 6 CONTINUED ON PAGE Women leaders bring health to forefront The increasing role of women in public concerns into study and public policy. life has had a tangible benefit. Women's Healy was appointed in 1991, and im- health Issues are getting the attention - mediately the NIH under her leadership read: research dollars they deserve. launched a massive study of women's Women have been subservient to men health In recent weeks, the NIH has am- when it comes to medical matters. Dis- nounced another study targeting diseases -ease and drug studies rely heavily on that are major causes of death and disa- male participants, even when the studies billty in women. use animals. The asstruption has been that sex was not a significant factor. But MEANWHILE, THE Congressional the facts are otherwise. Caucus for Women was instrumental in For example, Creighton University getting more research dollars to women's neurologist Nancy Futrell studied the ap- health issues and urging an FDA probe propriateness of using male mice to study into the exclusion of women in studies aspirin as a stroke preventive. After not- performed by drug companies. ing that male and female mice age differ- It was wrong to believe that women's ently and respond differently to treat- presence would raise the nation's moral ments, she argued that stroke research discourse (as argued when women fought should recognize ser as a factor in for the vote), that women vote as one, or humans. Most of the stroke studies done that women in power- - in politics or busi- in the U.S. overwhelmingly use men, yet ness will necessarily lead to a more hn- women outmumber men in the population mane social agenda. most likely to suffer a stroke. But it is true that power held too IN ANOTHER example, the New Eng- closely by one generally homogenous land Journal of Medicine reported a sex group will distort the agenda It's true of bias in heart treatment. Men were more racial or ethnic groups, and it holds true likely to get aggressive treatment and to for gender. The presence of women fn be counseled for heart disease. Heart dis- Congress, in medical colleges and at the ease was viewed as a man's disease, yet NIH has brought a serious health inequity more women in the U.S. suffer from heart to the forefront. disease than do men At the trying of Democrats in Con- In an editorial accompanying that arti- gress, President Clinton asked for Healy's cle, Bernadine Healy, the outgoing direc- resignation. She was a Bush appointee, tor of the National Institutes of Health, who supported many of Bush's health warned that sex blas was leading doctors policies no longer in favor. Clinton would to underestimate the severity of coronary be wise to appoint someone - woman or disease in women man - who will continue in Healy's foot- Healy, the first woman to lead the NIH, steps. The path to a better understanding has done much to get women's health of women's health is a journey just begun. PAPER Lincen Journal THIS IS CLIP PAGE / FROM CLIP PAGE DATE 4-13-93 PAGE 9 CONTINUED ON PAGE RR First lady could attend UNL health meeting Organizers have received no tional Health Care Reform will word yet whether first lady Hil- speak. lary Rodham Clinton will join On the national side, the confer- some of the leading national and ence on Friday will feature Dr. Nebraska thinkers in health re- Paul Ellwood, one of the chief ar- form at a Friday and Saturday chitects of the managed competi- conference. tion model of health reform. and Sen. Bob Kerrev. D-Neb, and E Richard Brown, a professor at Gov. Ben Neison will co-chair the the University of California at Los conference. which was planned by Angeles. who helped draft Ker- the independent, bipartisan Co- rey's Health USA bill lumbia Institute. It will focus on The managed competition state-level solutions to national model is expected to be part of health care problems. President Clinton's health care Nearly 900 people have regis- proposals. Kerrey's proposal is a tered for the conference, accord- variation on a single-payer model ing to a Columbia Institute spokes- of reform. woman Others have been put on a Other national speakers sched- waiting list uled include Janet Shikles, direc- The conference will be 8:30 tor of health financing and policy am.4:15 pm Friday and 8 am- for the U.S. General Accounting noon Saturday. Due to the larger Office. than expected registration, the On the local level. the confer- conference site was changed to ence schedule for Saturday will Kimball Recital Hall, 11th and R feature reports from the gover- streets on the University of Ne- nor's Blue Ribbon Coalition and a braska-Lincoln campus. Parking committee of state agency direc- will be available at State Fair tors. The two groups have been Park one block north of Military studying Nebraska health prob- Road on 14th Street. lems and possible state-level solu- Mrs. Clinton had said she would tions appear at the event, but that could Representatives from Vermont, not be confirmed this morning. She Minnesota and Colorado also will is scheduled to speak at 12:45 p.m. talk about their states' experi- Friday. which could change to ac- ences in developing plans for commodate her. If she does not ap- health care reform The states are pear, another representative from at various points along the road to the president's Task Force on Na- creating their own solutions. 04/14/93 08:40 918007363297551 1 03 SEN. KERREY/OMA WASHINGTON DC 001 OWH CLIPS, AM X DATE 4/14/93 THIS IS CLIP PAGE / CONTINUED FROM CLIP PAGE PM PAGE 142 CONTINUED ON CLIP PAGE BK Mrs. Clinton, Health-Care Planner First Lady to Discuss Task Force's Work BY ROBERT DORR "We are very excited that she is TARRWRITER coming" Ms. Kilgarin said. Hillary Rodham Chnton will come The task force Mrs. CImton heads is to Nebraska Friday for a health-care expected to complete its work and conference in Lincoln, the Governor's issue a report next month. The task Office said Tuesday. force's recommended national health- Mrs. Chaton heads the national care plan will go to the president and task force on health-care reform. She then to Congress Final action by will speak about the task force's work Congress might not come until 1994. at 12:45 p.m. Friday at Kmball Hall The Lincoln trip will be Mrs. Cim- on the University of Nebraska-I incoln ton's second visit to the Midlands campos. said Karen Kilgarin, spokes- related to health care Last month in woman for Gov. Nelson Ankeny. Iowa, she listened and asked Her appearance had been tentatively questions of health-care experts and THEASSOCIATED PRESS scheduled and was confirmed Tuesday consumers who have had experiences HILLARY RODHAM CLINTON: afternoon Please turn to Page2, Col. She will speak Friday. Confinued from Page I co-chairman. the Fasht Several national health-care emerts About 880 people have registered to will speak Friday and will appear as attend the Lincoln conference which members of panels. will last all day Friday and until They include Dr. Panl Ellwood, noon Saturday. Ms. Kilgarin said she chief executive of the Jackson Hole didn't know how much of the two-day Group, a Wyoming organization that event Mrs. Clinton would attend is given credit for the concept of No room remains for members of managed competition, which is expect- the general public. said Jennifer Belles, ed to be part of the Chuton health-care a project associate for the conference plan to Speak Friday in Lincoln coordinator. the Columbia Institute. Vermont Gov. Howard Dean will Those attending will be business execu- deliver Friday's keynote speech. tives, civic leaders, health professionals All meetings will be at UNL's and consumer advocates. Kimball Hall except the Friday lun- Some people were invited to attend, cheon, which will be at the student and others contacted the institute for union on UNL's City Campus. The reservations, Ms. Belles said. The insti- entire conference had been scheduled tute is an independent. bipartisan or- for the student union, but Kumball ganization based in Washington Hall has larger seating capacity and Some of those attending probably better accomunodations for news ar- will have to stand. Kunball Hall sears ganizations. 850. The Saurday meeting will focus on Sen. Bob Kerrey, D-Neb, is chair- health-care actions that have been man of the conference. Gov. Nelson is taken by Nebraska and other states. 04/05/93 17:48 C'402 437 5109 SEN KERREY/LINC PAPER Xincotn Kaurn THIS IS CLIP PAGE 7 4 FROM CLIP PAGE DATE 4/5/93 PAGE 8 ATE CONTINUED ON PAGE Reform must address case of the uncovered midwife In pursuit of health care reform Hillary of shortsightedness, the insurer ends up Rodham Clinton and her crew need to pay paying more when a patient is forced, for attention to the plight of people like Joanne reasons of reimbursement, to forego a mid- Bronson and her patients wife's services in favor of an MD's. But of Bronson is Lincoln's only utrse-midwife. course the insurance company can compen- Midwives have been recognized in Nebras- sate by charging all its policyholders a little ka's law since 1984, and Bronson is fully more qualified She attended midwife school in Exactly what shape health care reform Caltfornia, passed our state's certification in this country will take is not yet certain examination and practices with a group of But clearly it has two goals One is holding doctors specializing in obstetrics and gyne- down costs. Midwife services can help do cology. And yes. she has delivered babies. this. Another is retaining for patients as In the eyes of some health insurance much choice among providers as is feasible companies, however, Bronson has no Some patients prefer entrusting their care standing. They refuse to cover her services. to a qualified midwife A patient whose medical insurance is car- The insurance companies themselves ried by one of those firms is out of luck if have it in their power to correct this situa- she wants to avail herself of Bronson's care. tion. If they don't- and if federal mandates So is Bronson don't address the problem- - then it's up to And so are all of us. A midwife's fees are Nebraska's Legislature: Spell out in law less than those charged by an ob-gyn practi- that qualified midwife services are to be in- tioner. In what seems like an extreme case cluded in health insurance coverage. 402 5109 04-05-93 06 P007 #47 Howard Dean, M.D. Governor State of Vermont Office of the Governor Pavilion Office Building Montpelier, Vermont 05609 (802) 828-3333 March 11, 1993 Ira Magaziner Senior Domestic Policy Advisor White House 1600 Pennsylvania Avenue Washington, DC 20500 Dear Ira: In our meeting last week, I expressed serious concerns about the proposals under consideration by the administration for achieving health care cost savings during the next two years. In response to my protest, you suggested that I write- down my thoughts about better methods for meeting your short-term cost control goals. Accordingly, I have outlined below two cost control options which I believe are preferable to the options currently under consideration. However, I feel it is important to state that I remain concerned about any attempt to impose strict controls on health care expenditures in the absence of universal access and health care delivery system reforms. All options are inherently problematic, will have unintended consequences, and may very well run counter to your long term reform goals. i am operating under the assumption that you are serious about maintaining a key role for the states in administering a national health care reform plan. I also assume you recognize that none of us really knows how to do such things as global budgeting, and that we have much to learn before that system is perfected. It is my belief that the federal government can learn much from the current cost control efforts of some states, including the attempts of states such as Vermont, Minnesota and Colorado to develop a workable global budgeting process. My first suggestion is an interim cost containment scheme that allows states three program options. Option one would be to fall under a national scheme of all-payor ratesetting or price controls, administered directly by the federal government. Option two would be to develop a state-specific ratesetting system. Maryland and New York are good examples of Printed on recycled paper produced without chlorine. Ira Magaziner March 11, 1993 states that would likely prefer their own, well-developed ratesetting system to a national system, and likely could meet national standards using those systems. Option three would be imposition of all-payer premium controls, administered by the state. For states that have significant managed care penetration, or have well-developed plans for global budgeting, this approach would be preferred, as it allows for budgeting on a per-capita basis. Vermont and Minnesota would probably prefer this approach because it is not inconsistent with their long term plans for systemic health care reform. Regardless of the cost control option chosen by a state, a state would be held to the same standards of accountability for achieving savings as those choosing other options. This presumes a level of data availability regarding state-by-state expenditures which may not exist, but you will face that problem in implementing any of the options currently under consideration. The ability of states to meet your short term goals would be greatly enhanced through passage this year of statutory changes to Medicaid law and ERISA. Greater flexibility to implement Medicaid managed care and to include self-insured firms in our system designs will increase significantly our ability, and hence the federal government's ability, to control health care costs. My second suggestion is simply a variation on your price control proposal. My most serious concerns about price controls are, 1. that they will inhibit, during the next two years, the type of delivery system reform and resource reallocation that is so essential to health care cost containment in the long run, and 2. that they will become permanent, rather than temporary, and that attempts to control costs the right way will be abandoned in favor of flawed regulatory approaches. Therefore, I suggest that, if you impose price controls, you exempt from those controls any plans that reimburse on a fully-capitated basis. Further, I suggest that you allow states to "come out from under" price controls on a state-by-state basis when a state can demonstrate the existence of at least one viable HIPC within its borders with a given percentage of the population being served by the HIPC. These suggestions represent my own personal opinions and do not represent official policy of the National Governors' Association. I believe most of my colleagues are equally concerned by the interim cost control options that are on the table, though I suspect that most of them would see the suggested refinements outlined above as at least an improvement over nationwide ratesetting, price controls or premium caps. -2- Printed on receveled paper produced without chlorine. Ira Magaziner March 11, 1993 I hope this is useful to you. I appreciate the opportunity to offer my thoughts. Please let me know if you have questions or comments. Sincerely, Howard Howard Dean, M.D. Governor HD/ar cc: Hillary Rodham Clinton Governor Roy Romer Governor Carroll Campbell Governor George Mickelson -3- Printed on recveled paper produce without chlorine. Howard Dean, M.D. Governor State of Vermont Office of the Governor Pavilion Office Building Montpelier, Vermont 05609 (802) 828-3333 March 30, 1993 Ira C. Magaziner Senior Domestic Policy Advisor 216 Old Executive Office Building Washington, DC 20500 Dear Ira: Per your request, I have outlined in the attached paper the "global targeting" option for short term cost control which I advanced at our meeting last week. While it is certainly not perfect, I believe this method is far preferable to some of the other options under consideration. I would like to make it absolutely clear that this paper represents my own thoughts and not those of Governors in general. Many Governors remain very concerned about global budgets, and would probably see the timeline I have outlined as overly-ambitious. Please let me know if you have questions or comments about the attached. Sincerely, HowardDeam/Aire Howard Dean, M.D. Governor HD/ar cc: Governor Roy Romer Governor Carroll Campbell Governor George Mickelson Printed on recvcled paper produced without chlorine. GLOBAL TARGETS AS SHORT TERM COST CONTROLS If one of the long term goals of health reform is to develop the capacity to construct and enforce global budgets on a state-by state basis, then it makes sense to takes steps in the short run to achieve this goal. Short term cost controls should enhance the ability of states to monitor and control total system costs. However, some suggested interim cost controls will require significant investment of time and resources during the next several years, but will not ultimately complement national reform objectives. A voluntary "dry-run" of a global budgeting or expenditure targeting process could be implemented during the period between passage of national health care reform legislation and full implementation of reforms. Targeting could result in significant cost control and would contribute to the development of the infrastructure for the new system. By requiring states to gather the information necessary for targeting, and engaging them in the technical process of targeting, you will be preparing for future reforms. Global targets are essentially a challenge to providers and payers to live within budgetary restraints on a voluntary basis. Providers and payers could be compelled to cooperate in achieving the targets through the threat of imposing more regulatory cost control regimes. If voluntary limits were exceeded, cost controls could be imposed directly from the federal government or states to providers. These controls could take the form of all-payor rates, price controls, or premium caps. To make this threat stick, it is essential that data systems be put in place to track compliance with the voluntary limits. Precursors to Development of Targets Implementation of expenditure targets should be combined with three mandates at the national level. The first is a requirement that all insurers use a common claims form as defined by the federal government. At the outset, mandated use of a standard HCFA form would probably make sense. However, use of a form that does not capture information about out-of-pocket expenditures will significantly limit our ability to track total costs. Second, each state should be required to establish an insurance claims database that is capable of collecting all of the claims data from all payers in the state. This claims database can form the foundation for a much more comprehensive database that serves a variety of purposes in the reformed system. With the common claims form in use, and mandated collection of the information from those forms, states can at least begin to track expenditures and utilization with some accuracy. Third, insurance rating reforms should be mandated at the federal level prior to implementation of global targets. Implementation of some form of modified community rating will make it easier for states to comply with a global target by controlling insurance premiums, the enforcement mechanism that will probably be favored in the long run. Greater uniformity in insurance rating practices would facilitate across-the-board control of insurance premiums, something that would be very difficult in some states at this time. In addition, insurance reforms will likely cause some insurers to cease doing business and the resulting consolidation of the insurance marketplace will aid the imposition of cost controls. The three of these measures should be implemented as rapidly as possible, as they are essential precursors to the development and enforcement of global targets. Given the proper tools, states will be better able to control health care costs both short term and long term. However, federal laws and regulations currently inhibit our ability to control some costs. States should be given the ability to implement, in an expedited manner, Medicaid managed care and to include self-insured firms and Medicare in their health care reform designs. Changes to Medicaid and Medicare law and regulation and ERISA are essential and will significantly enhance the ability of states to implement global targeting and, ultimately, global budgeting. The global targeting method should be combined with capitating Medicaid and Medicare payments to states to allow greater leverage and flexibility in meeting the targets. However, capitating these programs should not be expected to yield dramatic savings in the short run, given low current reimbursement rates. How to set the targets Using information available from the major payers (Medicare, Blue Cross and Blue Shield of America and Kaiser Permanente, for example), it should be possible to develop a per-person expenditure target for the average American. It would then be possible to adjust that number regionally based on the methodology utilized by Medicare to adjust payments to HMCs for Medicare enrollees. Further age/sex adjustment would be necessary, as would some adjustment to account for the fact that Medicare traditionally underpays rural primary care providers and hospitals. This regional per-person target would then be used to compute a state target, based on census bureau population data. This would constitute the first year target for states. Obviously, this methodology is crude and might result in targets that differ dramatically from actual expenditure levels. However, it would give the federal government a very rough measure of state-by-state performance at the same time that the new datasystem allows for tracking of actual expenditures. Once a year's worth of data had been collected through the state claims databases, the targeting process could be refined. An acceptable rate of increase in expenditures could be defined and serve as the target for the state for the coming year. The rate could be the same across all states or could vary from state to state. Various adjustments to the allowable rate of increase could be made to account for local factors affecting health care cost increases. In the third year, the targeting process would be further refined. An assessment of state performance could be made at the end of the third year, at which time the federal government could impose federal cost controls on insurers or providers in those states that are failing to meet the targets. By the fourth or fifth year, it might be possible to implement binding budgets in most states. Presumably the imposition of a binding budget would carry with it some incentives for the state in terms of increased matching funds to cover the uninsured or other enhanced resources. Hence, states would have an incentive to develop their budgeting and budget enforcement capacity as quickly as possible. Some states, such as Vermont, would likely be able to enforce a binding global budget in fewer than four years. Scorable Savings/Recapture A plan is necessary to convert current cost shift to employers to increased funding for people whose coverage is publicly-subsidized (low-income, Medicaid, Medicare). Payments to providers from payers must be equalized, but current payments from the private sector should not be lost as cost controls yield savings. The most logical method for "capturing" the cost shift is through imposition of a premium or provider tax. A premium tax is probably preferable in that it allows insurance plans some flexibility in spreading the cost of the tax among providers. Once the global budget becomes binding on a state, it can be assumed that the cost of the tax is not shifted to consumers and instead comes from foregone cost increases at the health plan and/or provider level. While this assumption can not be made if budgets are non-binding, the threatened federal controls can be used as a safeguard against cost shifting to consumers. For example, if Vermont did not comply with its target in years two and three, the federal government would apply some form of direct controls on health care providers or insurers. If the federal government wanted to "make up for" those over-runs, the federal controls could actually take the form of a price cut to insurers or providers. This method strengthens the threat of the federal controls, and provides some comfort for the federal government that cost savings will actually be achieved and recaptured. 02-17-93 01:59PM TO 94567739 P002/003 Howard Dean, M.D. Governor State of Vermont Office of the Governor Pavilion Office Building Montpelier, Vermont 05609 (802) 828-3333 February 16, 1993 Hillary Rodham Clinton Chair, White House Health Care Task Force White House 1600 Pennsylvania Ave. Washington, DC 20500 Dear Hillary: I read with interest, but also alarm, the article in the February 14 edition of the New York Times about the administration proposal to cut expenses in the Medicare program. While I, and the National Governors' Association, fully support taking steps to deal with the deficit, I believe that the methods reportedly chosen to cut Medicare are contrary to NGA policy and will undermine the credibility of the administration's attempts to reform the health care system. I personally believe that we need to deal with the expanding Medicare budget in order to cut the deficit. However, the methods described in the New York Times have basically been tried in the past and failed. I believe the effect of the proposals that I read about in the New York Times would be as follows: 1. As pertains to fee restrictions, enactment will result in subsequent rapid increases in the volume of services provided to Medicare patients, thus negating some of the expected savings. 2. Primary care providers will bear the brunt of the adverse effects of this policy. These physicians do not make the kind of money reported in the New York Times article and their office expenses rise with medical inflation. The effect of the policy outlined in the New York Times article will be, over a relatively short period of time, to cause primary care physicians to opt out of serving Medicare patients, because they will not be able to afford to do it. 02-17-93 01:59PM TO 94567739 P003/003 Hillary Rodham Clinton February 16, 1993 page two 3. Undoubtedly there will have to be a substantial increase in the already horrendous Health Care Financing Administration bureaucracy in order to attempt to discern whether physicians' price increases are in fact the result of a cost shift due to Medicare capping, or are due to some other cause. 4. Finally, and most seriously of all, a return to the old HCFA philosophy would signal a marked retreat from the aggressive, and very refreshing, approach that has been taken heretofore by the Clinton administration in dealing with overall health care reform. It is not possible to legislate against cost shifting without capping expenditures in the entire health care system. I have repeatedly tried to make the point that you cannot cap any aspect of the health care system without capping the entire system. My own view is that tremendous savings can be obtained in the Medicare system using a capitated care approach, which will limit both volume and price. I very much hope that the President will not be specific on Wednesday about the way in which he intends to save Medicar dollars. We need to deal with Medicare expenditures in the context of overall reform, and the nation's Governors remain committed to helping you with that task. I feel very strongly that to depart from a recognition that health care reform must be comprehensive and retreat to the failed formulas of the past will undercut our entire effort. Sincerely, Howard Deanfe Howard Dean, M.D. Governor HD/ar cc: President Bill Clinton Health and Human Services Secretary Donna Shalala Governor Roy Romer Governor Carroll Campbell Governor George Mickelson Ira Magaziner Mark Gearan

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[HRC Daily File] Friday April 16 [1993]

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