HEALTH CARE REFORM Y 4. SM 1:103-46 Health Care Reform Serial Ho. 103-. HEARING BEFORE THE SUBCOMMITTEE ON REGULATION, BUSINESS OPPORTUNITIES, AND TECHNOLOGY OF THE COMMITTEE ON SMALL BUSINESS HOUSE OF REPRESENTATIVES ONE HUNDRED THIRD CONGRESS FIRST SESSION PORTLAND, OR, SEPTEMBER 1, 1993 Printed for the use of the Committee on Small Business Serial No. 103-46 JUN2? 1994 "* Sft 1 S U.S. GOVERNMENT PRINTING OFFICE WASHINGTON 1994 : ForsalebytheU.S.GovernmentPrintingOffice SuperintendentofDocuments,CongressionalSalesOffice.Washington,DC 20402 ISBN 0-16-044079-3 HEALTH CARE REFORM y 4. SM 1:103-46 Health Care Reform Serial No. 103-. HEARING BEFORE THE SUBCOMMITTEE ON REGULATION, BUSINESS OPPORTUNITIES, AND TECHNOLOGY OF THE COMMITTEE ON SMALL BUSINESS HOUSE OP REPRESENTATIVES ONE HUNDRED THIRD CONGRESS FIRST SESSION PORTLAND, OR, SEPTEMBER 1, 1993 Printed for the use of the Committee on Small Business Serial No. 103-46 *m S8&&m m JliH2 ? -sastea^ U.S. GOVERNMENT PRINTING OFFICE WASHINGTON 1994 : ForsalebytheU.S.GovernmentPrintingOffice SuperintendentofDocuments,CongressionalSalesOffice.Washington.DC 20402 ISBN 0-16-044079-3 COMMITTEE ON SMALL BUSINESS JOHN J. LaFALCE, New York, Chairman NEAL SMITH, Iowa JAN MEYERS, Kansas IKE SKELTON, Missouri LARRY COMBEST, Texas ROMANO L. MAZZOLI, Kentucky RICHARD H. BAKER, Louisiana RON WYDEN, Oregon JOEL HEFLEY, Colorado NORMAN SISISKY, Virginia RONALD K. MACHTLEY, Rhode Island JOHN CONYERS, Jr., Michigan JIM RAMSTAD, Minnesota JAMES H. BILBRAY, Nevada SAM JOHNSON, Texas KWEISI MFUME, Maryland WILLIAM H. ZELIFF, Jr., New Hampshire FLOYD H. FLAKE, New York MICHAEL A. "MAC" COLLINS, Georgia BILL SARPALIUS, Texas SCOTT McINNIS, Colorado GLENN POSHARD, Illinois MICHAEL HUFFINGTON, California EVA M. CLAYTON, North Carolina JAMES M. TALENT, Missouri MARTIN T. MEEHAN, Massachusetts JOE KNOLLENBERG, Michigan PAT DANNER, Missouri JAY DICKEY, Arkansas TED STRICKLAND, Ohio JAY KIM, California NYDIA M. VELAZQUEZ, New York DONALD A. MANZULLO, Illinois CLEO FIELDS, Louisiana PETER G. TORKILDSEN, Massachusetts MARJORIE MARGOLIES-MEZVINSKY, ROB PORTMAN, Ohio Pennsylvania WALTER R. TUCKER III, California RON KLINK, Pennsylvania LUCILLE ROYBAL-ALLARD, California EARL F. HILLIARD, Alabama H. MARTIN LANCASTER, North Carolina THOMAS H. ANDREWS, Maine MAXINE WATERS, California BENNIE G. THOMPSON, Mississippi Jeanne M. Roslanowick, StaffDirector Stephen P. Lynch, Minority StaffDirector Subcommittee on Regulation, Business Opportunities, and Technology RON WYDEN, Oregon, Chairman IKE SKELTON, Missouri LARRY COMBEST, Texas TED STRICKLAND, Ohio SAM JOHNSON, Texas NORMAN SISISKY, Virginia JAY DICKEY, Arkansas JAMES H. BILBRAY, Nevada JAY KIM, California MARTIN T. MEEHAN, Massachusetts PETER G. TORKILDSEN, Massachusetts WALTER R. TUCKER III, California MICHAEL HUFFINGTON, California THOMAS H. ANDREWS, Maine Steve Jenning, Subcommittee StaffDirector Robert Lehman, Minority Subcommittee Professional StaffMember (II) CONTENTS Hearingheld on September 1, 1993 WITNESSES Wednesday, September 1, 1993 Brooks, Margaret, BrooksTemporaryServices 30 Cheriel, Chad, director, Oregon Office ofHealth Policy 5 Earls, Kevin, Associated Oregon Industries 18 Gilliam, Joe, National Federation ofIndependent Businesses 13 Laney, Scott, President, Griffith Rubber Mills 33 Sayler, Gene, Sayler's Old Country Kitchens '31 Selby, Miriam, Micro One 29 Wigglesworth, Gene, Midas Muffler& Brake Franchise 15 APPENDIX Openingstatements: Kopetski, Hon. MichaelJ 48 Wyden, Hon. Ron 46 Prepared statements: Cheriel, Chad 50 Charts 54 Gilliam, Joe 65 Sayler, Gene 86 AttachmentA 92 Selby, Miriam 84 Wigglesworth, Gen 66 Statement ofU.S. ChamberofCommerce 72 (HI) HEALTH CARE REFORM WEDNESDAY, SEPTEMBER 1, 1993 House of Representatives, Subcommittee on Regulation, Business Opportunities, and Technology, Committee on Small Business, Washington, DC. The subcommittee met, pursuant to notice, at 10:15 a.m., at Port- land Metro Council Chambers, 600 Northeast Grand, Portland, OR, Hon. Ron Wyden (chairman ofthe subcommittee) presiding. Chairman Wyden. The Subcommittee on Regulation, Business Opportunities, and Technology will come to order, and we want to welcome all our guests, particularly Congressman Kopetski. Congressman Kopetski serves on the House Ways and Means Committee, which is a committee of enormous importance to our State. It has been a full decade since we have had someone on that im- portant committee, and we are very pleased that Congressman Ko- petski is here today as well, because the Ways and Means Commit- tee, along with the other committee that I sit on, the Energy and Commerce Committee, will be the committees that will be handling the bulk ofthe health care reform legislation. Congressman Kopetski and I are convening today's hearing be- cause developing workable solutions to the health care crisis for small business is key to enacting effective health care reform in this Congress. We believe that this issue is a top economic development concern for Oregon, because our State has one of the largest concentrations ofsmall businesses in the country. According to the Department of State Economic Development, about half of our State's businesses employ under 50 people, and small business is the muscle and sinew of almost every main street in Oregon. For thousands of those small Oregon businesses, health costs are their fastest rising expense, and about 185,000 of Oregon's 479,000 uninsured citizens are small business employees or their depend- ents. Now, President Clinton has not yet announced his health reform proposal, but press reports that the President's plan will contain mandates that are costly, inflexible, and burdensome have been frightening to many Oregon business owners. Let me assure Oregon businesses right now: So-called health reform that cripples small business is going to mean Oregonians have fewer jobs and reduced prospects for health coverage, and I (1) will oppose them, but health reform that produces real cost con- tainment, which in my view is the number one issue for small busi- ness, and protects small business employees from unfairly being denied coverage by insurers and preserves choice of providers is going to make Oregon more productive, and I will pull out all the stops to see it enacted. Now, responsible health reform is going to require that the major economic forces in our society, such as insurance companies, medical providers, trial lawyers, and yes, business, will have to share responsibility and accept changes in the status quo. Insurance companies are not going to be allowed to cherry-pick any longer andjust take healthy people. Medical providers will face changes in reimbursement practices, particularly for procedures that were once difficult but are now more routine. Trial lawyers will be required to accept changes that can reduce medical malpractice costs and the expense of defensive medicine. We are especially interested in hearing today what small busi- ness owners and Oregon businesses think they ought to be asked to do as part ofthe health reform effort. I am convinced that, working together, this issue can be appro- priately dealt with. Already, there is strong bipartisan support in the Congress and significant support among businesses for many key features of health reform legislation for small business. For example, there is great support for cost containment through the establishment of purchasing cooperatives that would give small business the same kind of bargaining muscle that the big firms have. There is great interest in establishing a basic benefit package that focuses on health care prevention. There is significant support for expanding the tax deduction for the self-employed, Medicaid reform, special consideration for the needs of the smallest businesses, and phasing in the plan over a number ofyears. Congressman Kopetski and I are going to be asking about these and other ideas today. What is clear, however, is the cost of doing health care as usual is prohibitively high. Medical bills are gobbling up everything in sight and, like acid, are eating away at the survivability and profit- ability ofsmall businesses across Oregon. Health care reform is finally at the top of the congressional agenda, and Congressman Kopetski and I are here to get the views of Oregon's small businesses for one reason, and that is to do this job right. So, I am especially pleased to welcome Mike Kopetski today. We are going to be teaming up and working very closely on this issue throughout the Congress, through our committee assignments and our friendship, and I appreciate him coming and want to recognize him for any statement. [Chairman Wyden's statement may be found in the appendix.] Mr. Kopetski. Thank you, Mr. Chairman, and I think Oregonians know that Ron Wyden, in large part because of his work and knowledge on health care issues, put him in the Congress. We are very fortunate as a State and as a region to have some- one with Congressman Wyden's knowledge and expertise and com- mitment to this issue to serve in the House of Representatives and, importantly, to be serving on the subcommittee of the Energy and Commerce Committee which has jurisdiction over health care and health care reform matters. I should just note also that, in the budget reconciliation bill, in- cluded in that is a provision that reinstates the 25-percent tax credit for health care coverage for sole proprietorships, of which there are many in Oregon who make up a lot ofthe small business- es in our State. I am pleased to be invited to participate in today's hearing on small business and health care reform. Clearly, it is one of the thorniest aspects of health care reform. Small businesses are a cru- cial part of our economy, and their health is vital to a strong eco- nomic recovery. As we all know, our current health care system is employment- based and has been so since shortly after World War II. Approximately two-thirds of those with health care insurance under the age of 65 have insurance through an employment-based group, either because their own employer offered it or because they were insured as a result of their being a dependent of a worker whose employer offers group coverage. It's clear that any health care reform undertaken, whether in the direction of mandating employer coverage or contributions or in the direction of establishing a Government-run single-payer health care system will affect both the businesses that are paying for coverage now and those that are not. The President is expected to unveil his health care reform pro- posal by the end of this month, and reports are that the proposal will mandate that employers contribute to the cost of covering their workers. Indications are that employers will be required to contribute a portion of the market premium for their employees' health plan, but the contribution will be capped at a relatively low percentage for small firms and at a higher percentage for larger firms. Under the President's proposal, the requirement will be phased in, and assistance will be given to businesses will very low-wage workers and for very small businesses. Oregon is a particularly apt place to hold this hearing. Oregon has both a higher-than-average percentage of its population with- out health care insurance and a higher-than-average concentration ofsmall businesses. Oregon is a small business State. Small firms with 50 or fewer employees represent 96 percent of Oregon businesses and employ 47 percent ofits private-sector work force. Fifty-five percent of Oregon businesses employ between one and four workers, and Oregon has a higher-than-average percentage of agricultural workers, one of the sectors of the economy with a low rate ofworker health care. We must be very careful in working on health care reform to ensure the health of small businesses and family farms in Oregon while improving access to quality health care. 4 We cannot just enact mandates without addressing the reasons why many small businesses are not providing coverage. Small busi- nesses are at a severe disadvantage in providing health care com- pared to the large employers. Small businesses are not able to spread risks widely, are in a weaker bargaining position with the insurance companies than larger employers are, and are faced with much higher administra- tive costs. Administrative costs consume 40 percent of every dollar paid in total health premium for businesses with fewer than five employ- ees, compared to administrative costs of around 5 percent per dollar for the larger companies. We must also keep in mind that small businesses, like all busi- nesses, want to take care of their employees. Despite the steep costs involved, according to the Department of Labor, roughly 62 percent of American businesses with fewer than 100 employees do provide health care coverage to their employees. However, unless we act soon, this percentage will drop significantly. A recent survey found that 30 percent of small businesses are considering dropping health insurance benefits because of the cost, and 13 percent of respondents to the same questionnaire indicated that they had dropped coverage within the preceding 3 years. Health care reform, including employer mandates, will simply not work unless we get a handle on the reasons that our current employer-based system is not working now. I am looking forward to today's hearing and to the release of the President's proposal. Health care reform is going to be successful only ifeverybody gets into the act. We must have a full and open debate on the issues involved, and I am pleased to join my colleague, Congressman Wyden, in starting this dialog here in Oregon. [Mr. Kopetski's statement may be found in the appendix.] Chairman Wyden. I thank my friend for his kind comments and excellent statement, and this is going to be a long push, and it is going to be great to pursue it with you, and I think we have a chance to really kick it off today with a great group of witnesses. Our first panel is going to be Chad Cheriel, who is with the Oregon Office of Health Policy, who over the years has been the source in our State for good, accurate data about Oregonians as it relates to health. Chad, why don't you come forward? We do swear our witnesses. So, we have got a little bit of protocol here to follow, and I think we are going to get you the microphone here. Dr. Cheriel, do you have any objection to being sworn as a wit- ness this morning? Dr. Cheriel. None at all. Chairman Wyden. Please raise your right hand. [Witness sworn.] Chairman Wyden. Well, we welcome you and, again, appreciate all the work that you have done over these many years. We are going to make your prepared statement a part of the hearing record, and if you could take 5 minutes or so and highlight some of the principle concerns here, particularly to the extent that you can give us new information about the profile you have of