S. Hrg. 103-216, Pr. 4 HEALTH SECURITY ACT OF 1993 Y4.L 11/4: S. HRG. 103-216/ PT.4 Health Security Act of 1993, S.Hrj.... EAKINGS BEFORE THE COMMITTEE ON LABOR AND HUMAN RESOURCES UNITED STATES SENATE ONE HUNDRED THIRD CONGRESS SECOND SESSION ON EXAMINING THE ADMINISTRATIONS PROPOSED HEALTH SECURITY ACT, TO ESTABLISH COMPREHENSIVE HEALTH CARE FOR EVERY AMERICAN JANUARY 26, FEBRUARY 2, 4, 22, MARCH 2 AND 8, 1993 PART 4 Printed for the use of the Committee on Labor and Human Resources AUG /f S3* S. HRG. 103-216, Pr. 4 HEALTH SECURITY ACT OF 1993 HEARINGS BEFORE THE COMMITTEE ON LABOR AND HUMAN RESOURCES UNITED STATES SENATE ONE HUNDRED THIRD CONGRESS SECOND SESSION ON EXAMINING THE ADMINISTRATION'S PROPOSED HEALTH SECURITY ACT, TO ESTABLISH COMPREHENSIVE HEALTH CARE FOR EVERY AMERICAN JANUARY 26, FEBRUARY 2, 4, 22, MARCH 2 AND 8, 1993 PART 4 Printed for the use of the Committee on Labor and Human Resources U.S. GOVERNMENT PRINTING OFFICE 78-569CC WASHINGTON 1994 : ForsalebytheU.S.GovernmentPrintingOffice SuperintendentofDocuments,CongressionalSalesOffice,Washington,DC 20402 ISBN 0-16-044565-5 COMMITTEE ON LABOR AND HUMAN RESOURCES EDWARD M. KENNEDY, Massachusetts, Chairman CLAIBORNE PELL, Rhode Island NANCY LANDON KASSEBAUM, Kansas HOWARD M. METZENBAUM, Ohio JAMES M. JEFFORDS, Vermont CHRISTOPHER J. DODD, Connecticut DAN COATS, Indiana PAUL SIMON, Illinois JUDD GREGG, New Hampshire TOM HARKIN, Iowa STROM THURMOND, South Carolina BARBARA A. MIKULSKI, Maryland ORRIN G. HATCH, Utah JEFF BINGAMAN, New Mexico DAVE DURENBERGER, Minnesota PAUL D. WELLSTONE, Minnesota HARRIS WOFFORD, Pennsylvania NlCK LlTTLEFlELD, StaffDirectorand ChiefCounsel SUSAN K. HATTAN, Minority StaffDirector (ID CONTENTS STATEMENTS Wednesday, January 26, 1994 Page Kennedy, Hon. Edward M., aU.S. Senator from the StateofMassachusetts ... 1 Kassehaum, Hon. Nancy Landon, a U.S. Senator from the State ofKansas 4 Dodd, Hon. ChristopherJ., a U.S. Senator from the StateofConnecticut 4 Thurmond, Hon. Strom, aU.S. Senator from the State ofSouth Carolina 5 Hatch, Hon. Orrin G., a U.S. Senator from the State ofUtah 6 Lee, Dr. Philip R., Assistant Secretary ofHealth, U.S. Department ofHealth andHuman Services, Washington, DC 6 Pell, Hon. Claiborne, a U.S. Senator from the StateofRhode Island 18 Wellstone, Hon. Paul D., a U.S. Senator from the State ofMinnesota 22 Naughton, Dr. John, dean, School ofMedicine, State University ofNew York at Buffalo, Buffalo, NY; Dr. H. Richard Nesson, president, Brigham and Women's Hospital, Boston, MA, on behalf of Coalition of Massachusetts Teaching Hospitals; and Dr. Stuart Bondurant, dean, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, on behalf ofAssociation ofAmerican Medical Colleges 27 Tuckson, Dr. Reed, president, Charles Drew University of Medicine and Science, Los Angeles, CA, on behalf of the Association of Minority Health Professions Schools, Washington, DC; Eli Ginzberg, director, Eisenhower Center for the Conservation of Human Resources, Columbia University, New York, NY; Dr. Jack M. Colwill, professor and chair, Department of Family and Community Medicine, University ofMissouri at Columbia, MO, on behalf of Council on Graduate Medical Education; Ann L. Elderkin, president, American Academy of Physician Assistants, Washington, DC; and Edward H. O'Neil, executive director, Pew Health Professions Commis- sion, San Frnacisco, CA 41 Appendix Article, letters, publications, etc.: Statements: Dr. Lee 54 Dr. Nesson 57 Dr. Tuckson 61 Mr. O'Neil 64 Ms. Gardner and Love 65 Dr. Bondurant 66 Dr. Naughton 85 Mr. Ginzberg 95 Dr. Colwill 96 MsElderkin 101 Ms. Betts 109 STATEMENTS Wednesday, February 2, 1994 Kennedy, Hon. Edward M., aU.S. Senatorfrom the StateofMassachusetts ... 119 Hatch, Hon. Orrin G., a U.S. Senatorfrom the State ofUtah 122 (III) IV Page Leavitt, Michael, Governor of the State of Utah, on behalf of the National Governors' Association; John Waihee, Governor of the State of Hawaii, on behalfofthe National Governors' Association; and Carmen Buell, mem- ber of the Massachusetts House of Representatives, Greenfield, MA, on behalfoftheNational Conference ofState Legislatures 124 Mikulski, Hon. BarbaraA., a U.S. Senator fromthe State ofMaryland 130 Thorpe, Kenneth, Deputy Assistant Secretary for Planning and Evaluation, U.S. DepartmentofHealth andHuman Services, Washington, DC 143 Wellstone, Hon. Paul D., a U.S. Senator from the State ofMinnesota 162 Dodd, Hon. ChristopherJ., aU.S. Senatorfrom the StateofConnecticut 166 Jeffords, Hon.JamesM., a U.S. Senatorfrom the State ofVermont 167 Thurmond, Hon. Strom, aU.S. SenatorfromtheStateofSouth Carolina 167 Appendix Article, letters, publications, etc.: Statements: Dr. Waller 169 Governor Leavitt 172 GovernorWaihee 188 Ms. Buell 198 Mr. Thorpe 208 Mr. Wetzell 221 Mr. Curtis 228 Dr. Pearson 232 STATEMENTS Friday, February 4, 1994 Bingaman, Hon. Jeff, aU.S. Senator from the State ofNew Mexico 259 Kennedy, Hon. Edward M., aU.S. Senator from the StateofMassachusetts ... 259 Hustead, Edwin C, senior vice president, Hay/Huggins, Lac, Washington, DC; Margaret H. Jordan, vice president of Health Care and Employee Services, Southern California Edison Co., Rosemead, CA; and Dr. William H.Straub,Westport, CT, on behalfoftheJackson Hole Group 261 Kassebaum, Hon. Nancy Landon, a U.S. Senator from the State ofKansas 264 Mann, Cindy, Massachusetts Law Reform Institute, Boston, MA; Gail Shear- er, Consumers Union, Washington, DC; and Ronald Burd, president, DevereuxFoundation, Devon, PA 276 Dodd, Hon. ChristopherJ., a U.S. Senator fromthe StateofConnecticut 287 Jeffords, Hon. JamesM., a U.S. Senatorfrom the State ofVermont 288 Thurmond, Hon. Strom, a U.S. Senator fromtheStateofSouth Carolina 289 Appendix Article, letters, publications, etc.: Statements: Ms.Jordan 290 Ms. Mann 293 Ms. Shearer 296 Mr. Burd 299 Response to questions ofSenatorKassebaum fromRonaldBurd 306 Mr. Hustead 308 Dr. Straub 314 Mr. Peck 318 Mr. Schwartz 321 STATEMENTS Tuesday, February 22, 1994 Kennedy, Hon. Edward M., aU.S. Senator from the StateofMassachusetts ... 335 Harkin, Hon. Tom, a U.S. Senator from the State ofIowa 337 Durenberger, Hon. Dave, a U.S. Senator from theStateofMinnesota 341 Wellstone, Hon. Paul D., a U.S. Senatorfromthe State ofMinnesota 342 Jeffords, Hon.James M., a U.S. Senatorfrom the State ofVermont 343 V Page Thurmond, Hon. Strom, aU.S. Senator fromtheStateofSouth Carolina 344 Dodd, Hon. ChristopherJ., aU.S. Senatorfromthe StateofConnecticut 344 Feder, Judith, Principal DeputyAssistant Secretary forPlanning andEvalua- tion, U.S. DepartmentofHealth andHumanServices, Washington, DC 345 Johnson, Jr., Harry, Baltimore, MD; Marilyn and Tom Weisner, with son Thaddeus, Aurora, IL; Julianne O'Connell Beckett with daughter Katie, co-director, FamilyVoices, Cedar Rapids, LA; and Sandra Sulfaro, Marlboro, MA 362 Long, LindaM., co-chair, MassachusettsAd HocCommittee on Health Reform and Disability, Boston, MA; Gina McDonald, chairperson, Health Reform Committee, National Council on Independent Living, Topeka, KS; and Janet CKeeffe, co-chair, Health Task Force, Consortium for Citizens with Disabilities, Washington, DC 382 Appendix Article, letters, publications, etc.: Statements: Ms. Feder 396 Mrs. Weisner 398 Mrs. Beckett 403 Ms. McDonald 405 Ms. Long 411 Ms. CKeeffe 416 Massachusetts AssistiveTechnology Partnership Center 443 AIDSAction Council 447 Ms. Smith 451 American Orthotic and Prosthetic Association 452 American Therapeutic and Recreation Association and the National Therapeutic Recreation Society 454 NationalAssociation forMedical Equipment Services 457 NationalAssociation ofSchool Psychologists 463 MostReverendJohn H. Ricard 469 STATEMENTS Wednesday, March 2, 1994 Wofford, Hon. Harris, a U.S. Senatorfrom the State ofPennsylvania 477 Jeffords, Hon. James M., a U.S. Senator from the State ofVermont 479 Fitzwilliams, Georgia, Germantown, WI; Gerald E. Pickering, Warrington, PA; and Elizabeth deVries, Manchester, NH 480 Perkins, Joseph, Danvers MA, member, board ofdirectors, American Associa- tion ofRetired Persons; William H. Bywater, president, International Union of Electronic, Electrical, Salaried, Machine and Furniture Workers, AFL- CIO, Washington, DC; Mel Bass, director, Health and Benefit Policy, Amer- ican Automobile Manufacturers Association, Washington, DC; Anna M. Rappaport, managng director, William M. Mercer, Inc., Chicago, IL; and Sylvester J. Schieber, vice president, The Wyatt Company Research and Information Center, Washington, DC 493 Appendix Article, letters, publications, etc.: Statements: Mr. Perkins 514 Mr. Bywater 525 Ms. Rappaport 532 Mr. Schieber 536 STATEMENTS Tuesday, March 8, 1994 Kennedy, Hon. Edward M., aU.S. Senator from the State ofMassachusetts ... 547 Jeffords, Hon.JamesM., a U.S. Senatorfrom the State ofVermont 549 Wellstone, Hon. Paul D., a U.S. Senator from the State ofMinnesota 550 VI Page Coats, Hon. Dan, aU.S. Senator from the State ofIndiana 555 Pell, Hon. Claiborne, aU.S. SenatorfromtheStateofRhode Island 555 Thurmond, Hon. Strom, aU.S.Senator fromtheStateofSouth Carolina 555 Metzenbaum, Hon. HowardM., a U.S. Senator fromtheState ofOhio 556 Simon, Hon. Paul, aU.S. Senator fromtheState ofIllinois 557 Mikulski, Hon. BarbaraA., a U.S. Senator from the StateofMaryland 557 Dodd, Hon. ChristopherJ., aU.S. Senator fromthe StateofConnecticut 558 Wofford, Hon. Harris, a U.S. Senatorfrom the State ofPennsylvania 559 Hatch, Hon. Orrin G., a U.S. Senatorfrom the State ofUtah 561 Ford, Betty, and Rosalynn Carter formerFirst Ladies 562 Hughes, Hon. Harold E., formerU.S. Senator; founder and chairman, Society of Americans for Recovery; and chairman of the board, Harold Hughes Centers, Inc., DesMoines, IA 582 Geraty, Dr. Ronald, executive vice president, Medco Behavioral Care, Bur- lington, MA; Cynthia Turnure, executive director, Department of Human Services, Chemical Dependency Program Division, State of Minnesota, St. Paul, MN; Henrick J. Harwood, senior manager, Lewin-VHI, Inc., Fairfax, VA; Lenore Behar, head, Child and Family Service Branch, North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, Department ofHuman Resources, State ofNorth Carolina, Raleigh, NC; and Edwin C. Hustead, senior vice president, Hay/Huggins Co., Washington, DC 595 Appendix Article, letters, publications, etc.: Statements: Mrs. Carter 609 Ms. Behar 610 Mr. Hustead 612 Mrs. Ford 614 Mr. Hughes 621 Dr. Geraty 627 Ms. Turnure 633 Mr. Harwood 639 Letters: Representative J.J. Pickle, U.S. Congress, 10th District, Austin, TX, from Genevieve Tarlton Hearon, dated, February 23, 1994 643 Andrew Cuomo, Assistant Secretary, Community Planning and Develop- ment, U.S. Department ofHousing and Urban Development, from Jon- athan D. Ezekiel and Genevieve Tarlton Hearon, dated, February 23, 1994 644 Henry Cisneros, Secretary, U.S. Department ofHousing and Urban De- velopment, from Jonathan D. Ezekiel and Genevieve Tarlton Hearon, dated, February 25, 1994 646 HEALTH SECURITY ACT: TRAINING HEALTH PERSONNEL WEDNESDAY, JANUARY 26, 1994 U.S. Senate, Committee on Labor and Human Resources, Washington, DC. The committee met, pursuant to notice, at 10:43 a.m., in room SD-430, Dirksen Senate Office Building, Senator Edward M. Ken- nedy (chairman ofthe committee) presiding. Present: Senators Kennedy, Pell, Metzenbaum, Simon, Wellstone, WofFord, Kassebaum, Jeffords, Gregg, and Durenberger. Opening Statement of Senator Kennedy The CHAmMAN. The committee will come to order, and I apolo- gize first ofall to our witnesses and also to our colleagues. The vote at 10:30 was not expected and put us in a dilemma about com- mencing the hearing. I think we are probably as far along as we would be otherwise, since I think everyone will restrict their opening comments. I will put my full statement in the record. [The prepared statement ofSenator Kennedy follows:] Prepared Statement of Senator Kennedy Today as the new session of Congress begins, we resume our Committee hearings on President Clinton's proposal for health re- form. Our topic this morning is the size and composition of the workforce in the health care systems and their role in the spiraling cost ofhealth care. There are many aspects of this issue. It involves the quality of physicians, nurses, and other health care wofflers, health services, uneven geographic distribution ofthe inadequate numbers ofracial and ethnic minorities among health providers, the excessive num- ber ofspecialists and the lack offamily doctors. In 1961, halfofall U.S. physicians were generalists. By 1990, the ratio had dropped to one-third as the number of specialties has soared. All projections indicate that the ratio will continue to de- cline as smaller and smaller numbers of medical school graduates plan careers as family doctors. The increasing imbalance undermines our ability to provide ac- cess to universal health care. It also limits our ability to meet the demands of managed care and the needs ofunder-served rural and urban communities. (1) The uneven geographic distribution of physicians remains an in- tractable problem despite a doubling in the physician supply dur- ing the past 25 years. The number of areas with inadequate num- bers of family doctors rose between 1980 and 1992, despite a na- tion-wide increase of 150,000 physicians. An estimated 35 million Americans reside in these under-served areas. An expanded role for nurses in health reform is a key part of President Clinton's plan. Nurses can fill many of the current gaps In access and availability of primary and preventive health serv- ices. Nurse practitioners continue to play a central role in improv- ing access to health care and providing quality and cost-effective care for millions of Americans living in rural and medically under- served areas. Academic health centers are the jewel in the crown of the na- tion's health care system. They train the physicians of the future. They conduct much of the medical research that holds the best hope for preventing, treating, and curing the diseases that shorten the lives and blight the hopes of millions of our fellow citizens. They are the source ofthe most advanced and complex care for the sickest patients. The increasingly competitive health market-place we have today is already challenging the viability of these essential institutions. Because of their special role in training, research, and advanced care, academic health centers are inherently higher cost facilities than other hospitals. In a competitive market place, no—individual health plan will be willing to pay these additional costs even though the health care system as a whole depends on these high-quality academic health centers. These competitive forces will exist with or without health reform, in fact, health reform is our best chance to assure that aca- demic health centers continue to make their indispensable con- tributions to the nation and the world. In Massachusetts, and many others states, these health centers are also key components of the local economy, because they are centers of excellence for medical research, training, and advanced care. The Committee has been working closely with the Administra- tion to assure that the importance and special needs of academic health centers are recognized. The President's plan contains a number of important provisions to deal with the problems that managed competition may pose, and I look forward to the discus- sion ofthese issues today. The more competitive health marketplace oftoday also poses spe- cial challenges to a broad range of other health care workers, and these challenges will be i—ntensified by h—ealth reform. As we will hear today, we can expect and we need down-sizing of our hos- pital system and a shift in emphasis from specialty, inpatient care to outpatient primary care and preventive services. At the same time, health care spending will continue to increase under health reform, and new jobs will be created in biomedical research, out- patient and primary care, and home care. But to assure that current health care workers are not the inno- cent victims of reform, we need a clear national policy for retrain- ing dislocated wofflers and providing other forms ofassistance. The