<DOC> [107th Congress House Hearings] [From the U.S. Government Printing Office via GPO Access] [DOCID: f:79433.wais] HEALTH CARE INFLATION AND ITS IMPACT ON THE FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM ======================================================================= HEARING before the SUBCOMMITTEE ON THE CIVIL SERVICE AND AGENCY ORGANIZATION of the COMMITTEE ON GOVERNMENT REFORM HOUSE OF REPRESENTATIVES ONE HUNDRED SEVENTH CONGRESS FIRST SESSION __________ OCTOBER 16, 2001 __________ Serial No. 107-63 __________ Printed for the use of the Committee on Government Reform Available via the World Wide Web: http://www.gpo.gov/congress/house http://www.house.gov/reform U. S. GOVERNMENT PRINTING OFFICE 79-433 WASHINGTON : 2002 ___________________________________________________________________________ For Sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512-1800 Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001 COMMITTEE ON GOVERNMENT REFORM DAN BURTON, Indiana, Chairman BENJAMIN A. GILMAN, New York HENRY A. WAXMAN, California CONSTANCE A. MORELLA, Maryland TOM LANTOS, California CHRISTOPHER SHAYS, Connecticut MAJOR R. OWENS, New York ILEANA ROS-LEHTINEN, Florida EDOLPHUS TOWNS, New York JOHN M. McHUGH, New York PAUL E. KANJORSKI, Pennsylvania STEPHEN HORN, California PATSY T. MINK, Hawaii JOHN L. MICA, Florida CAROLYN B. MALONEY, New York THOMAS M. DAVIS, Virginia ELEANOR HOLMES NORTON, Washington, MARK E. SOUDER, Indiana DC STEVEN C. LaTOURETTE, Ohio ELIJAH E. CUMMINGS, Maryland BOB BARR, Georgia DENNIS J. KUCINICH, Ohio DAN MILLER, Florida ROD R. BLAGOJEVICH, Illinois DOUG OSE, California DANNY K. DAVIS, Illinois RON LEWIS, Kentucky JOHN F. TIERNEY, Massachusetts JO ANN DAVIS, Virginia JIM TURNER, Texas TODD RUSSELL PLATTS, Pennsylvania THOMAS H. ALLEN, Maine DAVE WELDON, Florida JANICE D. SCHAKOWSKY, Illinois CHRIS CANNON, Utah WM. LACY CLAY, Missouri ADAM H. PUTNAM, Florida DIANE E. WATSON, California C.L. ``BUTCH'' OTTER, Idaho ------ ------ EDWARD L. SCHROCK, Virginia ------ JOHN J. DUNCAN, Jr., Tennessee BERNARD SANDERS, Vermont ------ ------ (Independent) Kevin Binger, Staff Director Daniel R. Moll, Deputy Staff Director James C. Wilson, Chief Counsel Robert A. Briggs, Chief Clerk Phil Schiliro, Minority Staff Director Subcommittee on the Civil Service and Agency Organization DAVE WELDON, Florida Chairman CONSTANCE A. MORELLA, Maryland DANNY K. DAVIS, Illinois JOHN L. MICA, Florida MAJOR R. OWENS, New York MARK E. SOUDER, Indiana ELEANOR HOLMES NORTON, Washington, C.L. ``BUTCH'' OTTER, Idaho DC ------ ------ ELIJAH E. CUMMINGS, Maryland Ex Officio DAN BURTON, Indiana HENRY A. WAXMAN, California Garry Ewing, Staff Director Scott Sadler, Clerk Tania Shand, Minority Professional Staff Member C O N T E N T S ---------- Page Hearing held on October 16, 2001................................. 1 Statement of: Coburn, Dr. Tom A., M.D., a former Representative in Congress from the State of Oklahoma................................. 41 Flynn, William E., III, Associate Director, Retirement and Insurance Services, Office of Personnel Management; Stephen W. Gammarino, senior vice president, Blue Cross Blue Shield Association; Colleen M. Kelley, president, National Treasury Employees Union; Lawrence Mirel, commissioner, District of Columbia, Department of Insurance and Securities Regulation; and Robert E. Moffitt, director, domestic policy studies, the Heritage Foundation........... 58 Letters, statements, etc., submitted for the record by: Coburn, Dr. Tom A., M.D., a former Representative in Congress from the State of Oklahoma, prepared statement of.......... 45 Flynn, William E., III, Associate Director, Retirement and Insurance Services, Office of Personnel Management, prepared statement of...................................... 61 Gammarino, Stephen W., senior vice president, Blue Cross Blue Shield Association, prepared statement of.................. 67 Mirel, Lawrence, commissioner, District of Columbia, Department of Insurance and Securities Regulation, prepared statement of............................................... 79 Moffitt, Robert E., director, domestic policy studies, the Heritage Foundation, prepared statement of................. 87 Morella, Hon. Constance A., a Representative in Congress from the State of Maryland, prepared statement of............... 9 Weldon, Hon. Dave, a Representative in Congress from the State of Florida: Prepared statement of.................................... 3 Prepared statements of Mr. Atwater and Mr. Harnage....... 11 HEALTH CARE INFLATION AND ITS IMPACT ON THE FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM ---------- TUESDAY, OCTOBER 16, 2001 House of Representatives, Subcommittee on Civil Service and Agency Organization, Committee on Government Reform, Washington, DC. The subcommittee met, pursuant to notice, at 1:23 p.m., in room 2247, Rayburn House Office Building, Hon. Dave Weldon (chairman of the subcommittee) presiding. Present: Representatives Weldon, Morella, Souder, Davis of Illinois, and Norton. Staff present: Garry Ewing, staff director; Scott Sadler, clerk; Tania Shand, minority professional staff member; Earley Green, minority assistant clerk; and Teresa Coufal, minority staff assistant. Mr. Weldon. Good afternoon. The meeting will come to order. We will begin the hearing of the subcommittee. I certainly want to welcome everyone to this hearing on the Federal Employees Health Program. The purposes of this hearing are to examine the causes of the steep rise in health insurance premiums under the FEHBP program for 2002, to also examine the continuing exodus of HMOs from the program, and to examine any limitations in current law or practice that might restrict competition and innovation in the program. There have also been other important developments in the FEHBP that are of interest to the subcommittee. In particular, the merger of the Blue Cross/Blue Shield High Option and Standard Option plans and the creation of a new, lower-cost option is a matter of great interest to many. For the 5th straight year, premiums in the program will increase sharply. According to the Office of Personnel Management, on average those premiums will rise by 13.9 percent. Fortunately, the FEHBP is a market-oriented program. Employees and retirees have the opportunity to choose among competing plans during an open season in the fall of each year. The Office of Personnel Management estimates that consumer choice will reduce the average increase from 13.9 percent to 13.3 percent. The FEHBP is one of the most important programs this subcommittee oversees. As a physician myself and the Representative of Florida's 15th District, I am keenly aware of the importance of the FEHBP. Approximately 9 million Federal employees, retirees, and dependents rely on it for high-quality health care options at affordable prices. And I share their concern with the continued escalation of FEHBP premiums, which have risen by 46 percent since 1997. I believe that it is imperative that Congress understand the forces driving up health care premiums in the FEHBP and private plans. We must, however, avoid legislative actions or other heavy-handed governmental intervention to satisfy short-term political goals at the expense of the long-run health of the program. I look to our witnesses today for a clear explanation of the causes of these premium increases. I will also ask them to recommend ways to address those causes while we work to preserve competition and consumer choice. These key features have made the FEHBP a widely admired model employer-sponsored health care program. I am also concerned about the continuing decline in the number of HMOs participating in the program. Since 1996, many HMOS have left the program or withdrawn from specific service areas. That trend continues. At the end of this year, 28 HMOs will leave the program, and HMOs are withdrawing from 20 service areas. The loss of these HMOs reduces the choices available to Federal employees and retirees. In some cases, this reduction is severe. No HMO in Delaware will participate in the FEHBP. In North Carolina the number of participating HMOS will drop from five to one, and in West Virginia the number of HMOs will go from three to one. I will ask our witnesses, particularly the Office of Personnel Management, to recommend ways to make the FEHBP more attractive to HMOs. In addition, I am also concerned that current law and practices may unduly restrict competition and innovation in the program. Today, for example, the Office of Personnel Management has only limited authority to contract with fee-for-service plans. Plans are also restricted to offering two levels of benefits only. Mandates, whether imposed by Congress or the Office of Personnel Management, also restrict competition and limit innovation. They drive up costs and reduce the ability of carriers to design affordable benefit packages that will be attractive to Federal employees and retirees. I will ask our witnesses for recommendations that this subcommittee and the administration should consider to foster competition and innovation in the FEHBP. I look forward to hearing the testimony of our distinguished witnesses today, and I thank them for appearing. [The prepared statement of Hon. Dave Weldon follows:] [GRAPHIC] [TIFF OMITTED] 79433.001 [GRAPHIC] [TIFF OMITTED] 79433.002 [GRAPHIC] [TIFF OMITTED] 79433.003 [GRAPHIC] [TIFF OMITTED] 79433.004 [GRAPHIC] [TIFF OMITTED] 79433.005 Mr. Weldon. I would like to now ask unanimous consent that all members of the subcommittee be permitted to place any opening statement in the record. Without objection, so ordered. [The prepared statement of Hon. Constance A. Morella follows:] [GRAPHIC] [TIFF OMITTED] 79433.006 Mr. Weldon. I ask further unanimous consent that all witnesses be permitted to include their written statements in the record. Without objection, so ordered. We will hear the opening statement from the ranking member when he arrives. As I understand it, his plane just touched down a little while ago. This morning the subcommittee received a letter from Mr. Charles W. Jarvis, chairman and chief executive officer of the United Seniors Association, and written statements from Frank G. Atwater, president and chief executive officer of the National Association of Retired Federal Employees, and Bobby Harnage, national president of the American Federation of Government Employees. I ask unanimous consent that these items be entered into the record. Without objection, so ordered. 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I will introduce our first witness. I would like to ask our first witness to come forward. Ms. Norton. Mr. Chairman? Mr. Weldon. Yes? Ms. Norton. I would like to offer an opening statement. Mr. Weldon. Well, go ahead. Ms. Norton. Thank you, Mr. Chairman. I have been on this committee for 11 years, and there has never been any reluctance to allow members to offer an opening statement. This is a very important hearing, and I appreciate your calling this hearing. I would like the opportunity to express my own concerns concerning what has happened to this very important program. Mr. Weldon. Would the gentlelady yield? Let me just share with you why I wanted to limit it to Mr. Davis and me. Ms. Norton. Yes, I would appreciate it. Mr. Weldon. This is a relatively small committee. You are the only person here, but I have been in the Congress for 7 years and I have gone to a lot of hearings where Member after Member makes an opening statement. Frequently, witnesses fly in from faraway places and sit and listen to Members. I personally prefer a policy where the chairman and the ranking member make their statement and the other Members submit them for the record. As I said, it is a small group. I would be happy to let you go ahead and make your opening statement. Ms. Norton. Yes, I would ask the chairman not to break the longstanding policy of this very small committee to allow Members to express their views in opening statements, particularly since on FEHBP there is usually only one hearing per year, and I assure you, Mr. Chairman, most of the witnesses here have flown in from OPM and other far-flung parts of the District of Columbia. If I may, I am very concerned and want to have the opportunity to express that concern because I think only when those concerns are expressed will there be the kind of response and pressure that we need when we see the kinds of costs we are seeing in the FEHBP program. I would not want to hide my disappointment at what has happened to this program since I have been a Member of Congress for 11 years. Today the last thing the Federal workers and other Americans need now are large increases in health care, but what FEHBP is offering is not only inflation, but hyperinflation. This really takes us back to the bad old days that we haven't seen in years now, where you have an almost 50 percent increase in FEHBP premiums over a period of 4 years. So that I just want to say that this Member who has been fond of calling FEHBP a model program for the country is going to cease doing so, because I think now FEHBP compares unfavorably to other plans in the country. For example, people in the Federal sector and elsewhere embraced HMOs in order to cut costs, and yet we see in our program that the HMOs have increased slightly more than the fee-for-service, 14 percent for HMOs, 13 percent for fee-for- service. We see HMOs fleeing FEHBP. So, clearly, they don't consider this a hospitable program. I am concerned that the usual suspects such as drug costs, while significant, are not even the main culprit. One of the things I want to ask the witnesses concerns this category called utilization technology and medical inflation, which apparently accounts today for the most important part of the increase. There is something called medical inflation which accounts for 60 percent of this category of increase. I will certainly want to know what in the world that is because it is undefined. When I look at what has happened to FEHBP over the years that I have watched this program, I am inclined to compare what is promoting increases to the usual suspects. Mandates, for example, are 1.5 percent of the additional cost. Well, that is more than I would like, but that doesn't compare to 9.5 percent, which is caused by utilization technology and medical inflation. You would think demographics, another of the usual suspects, would account for a greater part of the cost, of the increase in cost, because the average employee for the Federal Government is retiring age, ladies and gentlemen, at 58. That is why we are going to see an exodus of Federal employees in very large numbers in the next year or two. But you have a 0.7 percent for the average employee who is 58 and the average retiree is 71 percent. So that doesn't account for this large increase. I just want to say, Mr. Chairman, this is some model--with the FEHBP premium increase more than the average for all employers. So we are behind other employers who don't have this full range of competition in their plans. It is some model when almost half of all employers in the country pay 100 percent of the premium, almost half, for health insurance for their employees, and FEHBP still is stuck at 72 percent. The country is falling behind, not moving ahead in health care, and FEHBP is falling behind even further. A major problem may be that we do not manage administrative costs in the various health care plans. We simply proliferate administration. So one plan does costly administration and the next plan does costly administration, and we get to pay for all of that. Medicare administrative costs are 1.7 percent. Medicaid administrative costs are 4.4 percent. I am not sure what the average administrative cost is for a plan like Blue Cross/Blue Shield. That is something I would very much like to know. FEHBP, we know this, is a model of competition. It would be hard to find any plan that had 180 carriers. It has many cost- saving HMOs, so-called cost-saving HMOs, but the results are not what competition and cost-cutting plans are supposed to give us. Mr. Chairman, these annual hearings have had no effect whatsoever on the same problems. They go up each year. I believe that the time has come for thinking beyond the boundaries that Congress and the OPM have brought to the problem, that we ourselves have to take responsibility for allowing this to get out of control. Thank you, Mr. Chairman. Mr. Souder. Mr. Chairman? Mr. Weldon. Does the gentleman have an opening statement? Mr. Souder. I would like to submit my opening statement for the record and go on record as saying I believe it should be the chairman and the ranking member that generally do the statements. That is the way we do most of the Government Reform committees. There are exceptions that we can do, but that, combined with the late start, I have two other things I have to go to. I am not going to now be able to hear more of the witnesses, and I am frustrated. Ms. Norton. Because one member gave an opening statement? Mr. Weldon. No, we were delayed waiting for Mr. Davis. His plane arrived late. Mr. Souder. I basically agreed with your points, but I hear them all the time. Mr. Weldon. Well, I understand the gentleman's frustration and we will go ahead and proceed. I would like to introduce our first witness, Dr. Tom Coburn. Dr. Coburn is a distinguished former Member of the House, having represented the 2nd District of Oklahoma from the 104th Congress through the 106th. During that time he was an active and articulate spokesman on health care issues, and he is today a practicing physician. Dr. Coburn, I welcome you to this hearing and I look forward to hearing your testimony. If you could please stand and allow me to give you the oath? [Witness sworn.] Mr. Weldon. Note for the record that the witness responded in the affirmative. Dr. Coburn, you are recognized. If you could please try to summarize your statement to 5 minutes, we would appreciate it. STATEMENT OF DR. TOM A. COBURN, M.D., A FORMER REPRESENTATIVE IN CONGRESS FROM THE STATE OF OKLAHOMA Dr. Coburn. I would be happy to do that. First of all, let me thank you and say it is good to see Ms. Norton and Mr. Souder. I miss my times with you in the House, but I thoroughly enjoy myself in medical practice today. I think that it is important that this hearing not just concern itself with the increases that you are seeing in the FEHBP arena because it is only one symptom of what is actually occurring out there, and it is based on multiple factors. I also think that you ought to have a realistic perspective of what has happened in medicine. Medicine is no longer an altruistic, benevolent profession. It has been turned into a hard-core business, and decisions about people's lives and their health have more to do with dollars than they have to do with caring of the individuals, and that is unfortunate in this country. I think we ought to try to put incentives into place that would move us back to that of the science that is based on care of the individual. I also would say that many of the people who are participating in the field of medicine are not unbiased, as I am not myself. I am a purchaser of multiple plans of health care for businesses that I have. I also am biased in that I am one of the providers in health care. I tend to bias toward my own advantage. Therefore, everything that I say, as well as every other person who is giving testimony here, has a vested interest in their own perspective that makes their testimony somewhat suspect. But I do have the ability of having been in Congress, also having practiced medicine, also having been a purchaser, a large purchaser of health care benefits. I have seen what I think to be are multiple numbers of the problem. The first thing is it looks like this last year we spent $1.4 trillion on health care, of which about $400 billion of it had nothing to do with helping someone get well. That is a large number. It is somewhere estimated that the paperwork costs alone with medicine are around 19 percent. That is atrocious. When we quote what Medicare and Medicaid is, that has nothing to do with the real cost of the paperwork because that has all been shifted to the providers. Medicare and Medicaid are wonderfully efficient now that they don't have the responsibility of providing any of the documentation or paperwork associated with it. The Federal employees' program is a great program. It is one of the best in the country. It allows the most choice. It allows the greatest freedom of opportunity. It allows people to make decisions about their own lives. Ms. Norton noted that it is markedly increasing. The reason the private sector's prices are not increasing as much is because all the people who are providing those are cutting benefits to maintain and control costs. The reason that they are having trouble controlling the cost is because the government isn't funding the actual cost of Medicare and Medicaid. It is being tremendously cost-shifted to all the other sectors. So we can run around and look for the cost-drivers, and there's multiple cost-drivers, but one of the most important is the lack of proper funding for the health care programs that we provide for the elderly and indigent in this country. Therefore, we tax everybody else in this country indirectly through their health care premiums for providing those services. To deny that is to stick our head in the sand and say that we are not causing the prices to go up by what is happening in Washington the way they fund Medicare and Medicaid and at the States. The one criticism I would have of the Federal employees, and one of the reasons that it would tend to go down rather than go up, is if they had a truly high deductible policy that would incentivize people to not overutilize the system, I think, No. 1. The second real problem with cost-drivers in health care is perverse incentives. There is no incentive not to overutilize the system and there is every incentive, especially with low deductible and managed care plans, to overutilize the system. There are no strong incentives throughout the country for preventative care. One of the things that we can do that will make a tremendous difference in the long run: preventative care in terms of diabetes, preventative care in terms of hypertension, preventative care in terms of giving the deductible to anybody who decides to choose to have a preventative health care exam so that they can get the benefits of knowing what they can do to change their life, so that they won't succumb to an illness in the future that will cost all of us, including them. Great examples of that are pneumo-vacs for seniors. We have less than 50 percent of our seniors immunized against the No. 1 cause of hospitalization, which is pneumococcal pneumonia. Yet the drug companies that make that and several other people can show us that would be a cost benefit. Why wouldn't we want to incentivize the physicians to immunize their seniors, like we do with flu vaccine? Vaccine programs for children, we are now shifting all that to the health departments around the country because the absolute cost of paperwork alone to administer vaccines to children is a losing proposition for every pediatrician, family practice, and internal medicine doctor in this country. We lose money every time we vaccinate a child. That has to stop. So what happens is we shift the cost. We send them to the health department. Consequently, many of them don't get immunized. We have a program to immunize children, but because it is not reimbursed to a point where it can be justified, we lose. I will wrap up here real quick just by saying I think another significant thing is pharmaceutical costs. We are the only Nation I believe in the world that allows direct consumer advertising. There was recently a study put out by Lancit that questioned the motivations and the advertising techniques and the truthfulness of that. There are significant consequences to that in terms of doctor/patient relationship, in terms of overutilization. We now have to re-educate patients when they come to our office about why they don't need a medicine that the pharmaceutical company convinced them they did through a TV ad. That takes time. That increases cost. That increases complexity. $2 billion is going to be spent this year on TV advertising by the pharmaceutical industry for prescription drugs, without adequate advertising limitations, which the FDA recognizes and as does the general medical field. Finally, one of the most perverse incentives in a study out of Indiana in 1993 discusses the cost of ordering tests that aren't necessary. That is all based on a tort system that says medicine is to be perfect, and it is not. It is an art. We tend to want to think of it only as a science. It is an art that utilizes science to affect the medical or scientific result. Because of that, one-third of all the tests that are ordered in this country are unnecessary. That has been documented. So if we decrease that, we could save another $10 billion just by reforming the tort system in this country so that we order tests--or put the system to a point where it is arbitration, something that says we won't continue to order the tests. Now if you look at that study, it said even the doctors who said they don't order tests to protect their back side, when looked at in retrospect, it said they did. So we all do, because none of us wants to get sued. So we order tests to justify and defend our positions for the future that has nothing to do with the care of the individual. Finally, Medicare has designed a system that is designed to be defrauded. It is easy to defraud Medicare. If you look at what HCFA, which has now changed its name, said about echocardiograms by cardiologists in this country, and that about 500,000 are done each year that don't need to be done, and yet we have not seen any decrease in that number since that statement was made, there have to be some questions as to whether or not the system is designed to be overutilized and defrauded. The last thing the government needs to do is to make more regulations in the health care industry that will require more bureaucrats chasing more paperwork. What I believe that the government needs to do, and for Federal employees as well, is create a program that incentivizes preventative care and incentivizes against overutilization. With that, I will end my testimony. [The prepared statement of Dr. Coburn follows:] [GRAPHIC] [TIFF OMITTED] 79433.035 [GRAPHIC] [TIFF OMITTED] 79433.036 [GRAPHIC] [TIFF OMITTED] 79433.037 [GRAPHIC] [TIFF OMITTED] 79433.038 [GRAPHIC] [TIFF OMITTED] 79433.039 Mr. Weldon. I thank the gentleman for his testimony, and I recognize myself for 5 minutes for questioning. Were you recommending, as you got to the conclusion of your statement there, that FEHBP offer a high deductible option for employers kind of like a medical savings account? Do you have any experience--you said you have been an employer for many years--either as a provider with medical savings accounts or as an employer with medical savings accounts? Dr. Coburn. I have two separate plans, Congressman, that have over 40 employees in them and we now utilize medical savings accounts. We have saved the first year $87,000; the second year, about $60,000, in terms of cost to my businesses for their health care. With that, we put $100 a month into a medical savings account. We cover the entire family, which none of our competitors do. Our employees don't contribute anything. For their first hospitalization, until their medical savings account meets the deductible, we pay the deductible. So they have a no-cost program that has, in essence, saved us a tremendous amount of money. It would have saved us money if we would have had a 20 percent utilization rate at the hospital. So the idea of a high deductible policy that incentivizes people not to overutilize and incentivizes people to have preventative care is something that lowers cost, improves health care, and decreases internal costs in terms of health care providers. There is no paperwork to shuffle. Mr. Weldon. Could you elaborate a little more on the plan that you are using in your business in terms of the premium structure, how it works? Then you have commented a little bit on preventative health care. Have you monitored that at all within your medical savings account plan? Dr. Coburn. We have I think it's a $3,800 deductible this year. Last year the maximum we could have was set by Congress, and it was something lower than that. We are raising the deductible every year as we go, but we are also increasing the amount of money that we are putting monthly into their medical savings accounts, which they have an option to go use on dental or drugs or anything related to health care that they can or they can leave it there and earn tax-free earnings on it. But our monthly premiums were cut by two-thirds as we converted to that system over where we were in an indemnity fee-for-service plan or a PPO plan that we were in. So we have effected great savings for us, and we have increased the care for our employees and their families and actually cut their costs. It is because of the incentives to not overutilize it. Every day in my practice, Congressman, I have 10 people who are in my office who don't need to be there. They have no need to be there. Just one point on that: The No. 1 reason---- Mr. Weldon. By the way, I practiced medicine. Dr. Coburn. I understand. Mr. Weldon. I saw the same thing. Dr. Coburn. The No. 1 reason that I have seniors in my office--and my practice is about 65 percent Medicaid, about 15 percent Medicare, and the rest private practice. So I have a large Medicaid/Medicare practice. The No. 1 reason that seniors are in my office, and this is my summation of why I believe they are there, is they are lonely. The last time they heard from their son or their daughter or their brother or their sister--they are isolated and lonely. They need someone. So, consequently, what is a better deal? Get $30--you pay 20 percent; if you have met your co-pay, you can go and talk to your doctors. It is a great way. So there are all sorts of social motivations that we have that impact our utilization rates. It is not just as simple as economics. There are other issues as well. Mr. Weldon. In the remaining time I have, let me ask you explicitly: We are dealing with FEHBP right now. That is the committee's jurisdiction. Is there one thing that you could recommend for us to do as we look at FEHBP in the future, making changes in the program? Is it offering this high deductible medical savings account option? Are there other structural changes that you think we can or should be making? Dr. Coburn. I think it would be interesting to offer a high deductible. I think you would be surprised at the number of people who would take the difference in what they pay and put it into a checking account and save it for whatever emergency they might have or borrow against some other method for a hospitalization. The real thing that I believe we have to get to for not only Federal employees is we have to have catastrophic health insurance in this country for everybody. We have enough waste in the present system to cover everybody out there that is not presently covered with health insurance. There is $250 billion worth of waste in the present system, in my estimation. If we had a system that was properly incentivized, that cared for those who couldn't care for themselves, made sure we kept our commitments to the seniors, did not underfund the cost of that, then we could, in fact, improve everybody's care and control some of the cost. The American public knows how to purchase everything except what we think they can't purchase, which is health insurance. They don't have enough knowledge, savvy to do that. That has been our estimation through the years, and we have never decided we were going to let them do that. I believe they would do just as well at that as they do every other aspect of purchasing, whether it is autos, homes, or clothes. Mr. Weldon. Thank you. The Chair recognizes the gentlelady from the District of Columbia for a question. Ms. Norton. Thank you, Mr. Chairman, and I appreciate very much your testimony, Dr. Coburn, given your experience both in the Congress and in the practice of medicine. By the way, I will be interested, in light of what you said about the way in which high deductibles are disincentivized, overuse, I will be interested to hear from our OPM witnesses about whether or not people are in fact being driven more and more to higher deductible plans, because I would imagine that would be one way of saving the cost of the premium. I note that two of the things that you mentioned, shifting of costs of Medicare and Medicaid, as a factor in the increasing cost to all the rest of us is important to note. You also testified that we need incentives for preventative care. It seems to me that both of those would add cost to somebody. I take it the cost would be added to the Federal Government. For example, if Medicare and Medicaid costs are not shifted to younger people and insurance plans, then somebody would have to pay the cost. Who do you imagine should pay those costs then? Dr. Coburn. They are paying them already, Congresswoman. Ms. Norton. Well, we are paying them, you said. Dr. Coburn. No, no. We are paying them. The private sector is paying those costs today through inflated premiums because the Federal Government does not cover the cost of care for those people who they have committed---- Ms. Norton. See, that is your point. I take your point, and I am saying, suppose that this cost-shifting was not going on. Would that not mean that the Federal Government would be paying billions more? Is that what you are saying should occur, that we should just step up to the plate and pay for the cost of Medicare and Medicaid instead of shifting the cost to private parties such as those in the FEHBP plan? Dr. Coburn. I believe it would help you better manage the programs. Today you are making decisions on false assumptions of what the costs are. If the Federal Government assumes the cost, that means we all assume the cost. So we are going to pay for it either way, but the goal ought to be to effectively manage it. I think we have a culture that has developed while I have been a doctor. It is, how do you stay ahead of the game? I think this is a real important point. We are out there figuring out--I am budgeting for next year in my practice of five doctors. How do we stay ahead of the game? How do we stay even as our revenues are declining from the private sector, what they are willing to pay us for delivering a baby or caring for a family, and we are getting a small increase from Medicare and no increase from Medicaid. Our costs of doing business are going up. How do we manage to stay even? Ms. Norton. You don't. You don't because people---- Dr. Coburn. Oh, yes, we are figuring it out. Here is what you are seeing: You are seeing increased utilization of testing and resources and overutilization because that is a human response in this market. You will never control the costs in health care until you reconnect the purchaser with some of the money coming out of their pocket. That is my whole point with high deductibles. That is why you see a decreased utilization, and it is not an underutilization. You are bringing it back down to the level it should be. The number of young mothers who now don't come into my office because their deductible is high, they make a phone call: ``Should I watch my child with this fever?'' We have children overutilizing primary care facilities like crazy simply because we have raised a generation that has been taught to do so because there has been no financial cost to utilize that resource. All I am saying is we have to reconnect the cost with the utilization of the resource. If we do, we can still have great medicine, and we can still take care of all those--actually, we can do a better job of taking care of those who have no insurance today, if we would do that. Ms. Norton. By paying providers, by the government paying providers what it cost the government, one point I take from your testimony is that, instead of spreading the cost to albeit a large number, but, nevertheless, other insured people, we spread it to an even wider base because you spread it to the entire country through the tax system. I agree, I think that makes better sense. We had just as well face it, somebody's paying for it. Dr. Coburn. Right. Ms. Norton. And the real question is, does somebody who is a Federal worker who can hardly afford insurance payments as it is, is that who the cost should be shifted to? Let me ask you about your really interesting point, one that has struck me as I look at these ads on TV that, as you indicate, invite us all to try to get whatever is advertised. Would you make the cost of those ads less deductible than ordinary costs? I mean, how would you go at that, understanding that censorship and the like is not, of course, allowed in our country? Dr. Coburn. Oh, it is. Ms. Norton. Would you just say you don't get the same rate off for that? Dr. Coburn. No, it is. The FDA has the power today to withdraw those ads. Ms. Norton. And you think they should? Dr. Coburn. Absolutely. They are a wasted resource in terms of improving the quality of health care in this country. Mr. Weldon. The gentlelady's time has expired. Ms. Norton. Thank you, Mr. Chairman. Mr. Weldon. The Chair recognizes the gentleman from Indiana, Mr. Souder, for 5 minutes. Mr. Souder. Thank you. I first want to say I am glad to see you still have your passion and your idealism and haven't gone all soft and flabby now that you are gone from the Congress. Dr. Coburn. Thank you, Congressman. Mr. Souder. I have a couple of questions I want to ask you for the record. You have testified about the danger of rationing associated with government-imposed price controls on health insurance premiums. Are you aware of any evidence that some government workers would rather have health insurance plans that they think are less likely to deny them needed care even if they have to pay for it? Dr. Coburn. I think the opposite is true. I think you have probably seen through the experience of the Federal employees, and I think it is the standard family policy where you have seen, even though premiums have gone up, you have seen a marked increase in utilization of that plan. I believe the American consumer is a smart consumer, and they will make the best choices. Unfortunately, in this country we have manipulated the system to not give them every choice that they should be able to have, which one thing that is missing is a high deductible policy for everybody, so that they can once again be responsible for their health care. Mr. Souder. In other words, you are saying some will at least pay more to get more? Dr. Coburn. Absolutely. Mr. Souder. Because some of us are concerned that, in fact, those choices may deprive individuals. One of the arguments is, some people argue that it is unfair to let some Federal workers who would pay more for a program that, for example, is less likely to ration health care because it would be unfair to those Federal workers who can't afford to pay for it. What is your argument? Dr. Coburn. Well, you are just going to shift costs away, so they are going to end up having to pay more. They are going to end up getting less care. So all that is going to do is accentuate the cost-shifting that we have going on right now. So they are less likely to get care if you limit that because you will shift more cost. Mr. Souder. Well, it is a model plan and I hope we can continue to have that model. I want to ask you one other basic type of question. As a former Member, your idealism was there on the catastrophic, but I think it is important for the record to show that you said, and I would like to ask you to kind of rethink that in this context: You said you believe catastrophic should be covered if we could eliminate the waste, could control the Medicare and Medicaid, presumably have tort reform, and a number of other things. For example, having been a Member of this body and banged our heads against a body that is two-thirds attorneys, do you really think we can get tort reform? Do you really think we are going to pay for Medicare and Medicaid? Do you really think Chairman Burton and I are going to vote against Eli Lilly being able to advertise? Do you really think that we are ever going to get a hold of the waste? In other words, that is an idealistic goal, but is it a realistic goal? Dr. Coburn. I don't know how to answer that, Congressman, without offending you. Mr. Souder. You do all the time. [Laughter.] Dr. Coburn. I believe if the Members of Congress will search their hearts to do what is in the best interest of the country, not what is in the best interest of their region, that in fact all of us would be better off. To do less than that penalizes us every day. Eli Lilly was making lots of money before they started advertising on television. What we have now is the money that they are making is causing an inflated cost elsewhere in the health care industry because we are spending time and charging Medicare more money now because we have a much more complex visit that is covering several other things that you are paying for. So it is wonderful to support our constituency, but the No. 1 oath that we take when we come up here is to defend the Constitution, not our constituents. Mr. Souder. I could make a pretty good argument on behalf of advertising, as somebody in marketing, that in fact that is one way the market sorts through. But rather than do that, let me rephrase my question, and it is my last question. Would you favor instituting catastrophic health insurance coverage if these other things don't occur? Dr. Coburn. We would not have to have catastrophic health insurance if some of the other things would occur. If you have $1.4 trillion, and if I am right, which I honestly believe, and all my staff, we researched this all the time I was in Congress, almost 30 percent of that goes nowhere to help somebody get well--just silly rules that Medicare imposes on a hospital that ends up creating bureaucracies that have nothing to do with quality of care and have everything to do with pushing paperwork, so somebody in a position of power at a Medicare payer can have higher control. Then, yes, we could save a ton of money in health care. My whole point is: Incentivize the proper utilization of this scarce resource. If you allow people a choice to do that, and allow the market to work within a framework that gives preventative care the No. 1 priority that it should be, which will save us dollars down the road, then I think you can save a ton of money. You can lower the cost of Medicare. You can lower the cost of Medicaid. You can get a whole lot more for the dollars that you spend. Tort reform in the states, it has happened; we are seeing the tests go down. So we know it works. The question is--in my State it is one of the worst. Mr. Weldon. The gentleman's time has expired. The Chair now recognizes the ranking member, Mr. Davis, who will make his opening statement and then proceed to questions. Mr. Davis of Illinois. Thank you very much, Mr. Chairman. Let me, first of all, apologize for being late at your first hearing, but let me also congratulate you on being named chairman of this subcommittee and indicate that I look forward to working with you. I was intrigued by the dialog that has taken place. I would like to just make a brief opening statement, and then I do have a question, too, that I would like to ask. Mr. Chairman, over the last several years the subcommittee has held hearings on the dramatic increase in premiums in the Federal Employees Health Benefits Program. Next year these premiums are expected to rise an average of 13.9 percent. This follows a 10.5 percent increase in 2001 and a 9.3 percent increase in 2000. The Office of Personnel Management has cited increased use in prescription drugs and medical services, advances in medical technology, and an aging Federal work force as reasons for the dramatic hike in 2002 premiums. Health care inflation, Federal mandates, and increased prescription drug costs have also been cited as reasons for increased premiums. Regardless of the causes, Federal employees are bearing the brunt of these increases. The question we must ask is, how do we address increased premiums in the Federal Employees Health Benefits Program? Last year OPM established, and was forced to cancel, a pharmaceutical pilot project for the Special Agents Mutual Benefit Association [SAMBA]. SAMBA is a small health plan in the FEHBP that provides coverage for 16,000 active and retired Federal law enforcement employees. Under the pilot, SAMBA would have purchased mail order pharmaceuticals off the Federal Supply Schedule, generating savings to the government, SAMBA, and enrollees in the health plan. However, the three companies that dominate the pharmaceuticals market, Pfizer, Merck, and Parke-Davis, refused to supply their products to SAMBA from FSS. This I think was unfortunate because the pilot program would have provided useful information about alternative methods for controlling the escalating costs of prescription drugs. Alternatively, Representative Steny Hoyer introduced H.R. 1307, a bill that would increase the government contribution for Federal employee health insurance. Currently, the Federal Government and enrollees jointly pay FEHBP premium costs according to a statutory formula. The government contributes 72 percent of the FEHBP premiums. H.R. 1307 would increase the government's contribution to 80 percent of these premiums. Federal employees are feeling the effects of these increased costs every day. Therefore, the subcommittee should hold bipartisan hearings on these and other proposals that specifically address how we can stabilize, if not decrease, premium rates for the approximately 9 million enrollees in the FEHBP program. I thank you, Mr. Chairman, and certainly would like to engage in questions with Dr. Coburn. Mr. Weldon. The gentleman is recognized. Mr. Davis of Illinois. Thank you very much. Doctor, I certainly want to welcome you and indicate that I have always been intrigued listening to your positions relative to health care delivery, coverage, and how we might be able to shape our system in such a way that we get the most benefit for the money that is being paid or the greatest bang for the buck. Let me ask you, do you think that there is a way to actualize cost in such a manner that whoever is receiving the service actually pays that cost? I am saying, whatever payment mechanism that is used is actually paying that cost, saying it is not being shifted any place other than right there. Dr. Coburn. I think it is reasonable to assume that such a market would do that, but you have to have a true market, I believe, to allocate that cost to the individual consumer. What you see in a free market is that costs end up reflecting supply and demand. What we have not done, and the worst thing we can do, is put more price controls on the health care industry. You did not see health care inflation prior to the imposition of Medicare. You did not see significant health care inflation prior to the imposition of Medicare price controls. When Medicare became a price-controlled system and out of the fee-for-service, totally controlled, that is when you saw health care inflation take off everywhere else in this country. It simply reflects a disruption in the market and shifting of the cost. So the only way I believe that you could actually see that is go back to actually a free market system. I am not sure we could do that. I am not sure we could go back to a free market system. We have tremendous moral problems in health care in terms of billings, overutilization. And I am talking about my own profession. I am not talking about just patients, and I am not talking about just doctors. I am talking about every aspect of the system sees a pot of gold out there and grabs in and puts its hand in. That is why the first part of my statement I said this has become a business; it is no longer an altruistic profession to care for somebody's health. It is driven by business concerns, not health concerns. We need to get back to health concerns. Mr. Davis of Illinois. Since that is the case, since you cannot orchestrate market conditions--I mean, the market is the market, and this isn't to suggest by any stretch of anybody's imagination that you would be in favor of what I am going to ask you. Could a national health plan, where everybody is in, the costs have been determined, and everybody gets service based upon whatever their needs are--obviously, some of the incentive will be gone in terms of certain kinds of practice and certain kinds of practice conditions and all, but would that even in any kind of way the playing field? Dr. Coburn. No, I don't think it would. Even though it might change some of the cost pressures, what it does is ration care. What you are going to see is end-of-life issues. You are going to see that the elderly have no value under that system. That is ultimately where we will go. The value of life, once somebody becomes dependent on the health care system, will no longer have value because the cost associated with that value will be so high. You cannot put a system together like that. Just look at Canada. They ration care now. We have three orthopedists in my home town now who moved to my home town from Canada simply because they couldn't do the things that people needed to have done for them. Now that is not to say that people in Canada don't get adequate care, but there is rationing going on. I would tell you that my own organization, the American Academy of Family Physicians, has endorsed a national payor system because the physicians are fed up trying to chase this monkey. But it is not in the best interest--I would go back and here would be my statement: I believe that in every area in our country, of all resources, that if we allow a true market to work, the most people will get the best benefit if we allow that to happen. We have nothing close to that now in health care, and that is why you have the cost inflation that you have. Mr. Davis of Illinois. Of course, as long as we have advertising as a part of our society the way that we do, of course, that would never exist either. I mean, because people will be influenced and certainly influenced to the extent---- Dr. Coburn. But they are not the payors today, Congressman. We have advertising right now, but they are not the payors. So you get it utilized without it costing you anything. It costs your employer or it costs the Federal Government, but there is no cost to you personally for utilizing it. So you don't have a market. So, yes, you could have that, if there was a reconnection to your billfold when you overutilized the system. We don't have any of that. So there are these perverse incentives: Since it cost me nothing, I am going to utilize the system. That is the problem where we are today in health care, and that is one of the reasons, one of the main reasons besides greed among all in this system, of driving the cost up. Mr. Davis of Illinois. Tom, let me thank you very much. You do remind me, when we start talking about payment of something, what Frederick Douglass was supposed to have said one time, and that is: He knew one thing if he didn't know anything else, and that is in this world we may not get everything that we pay for, but we most certainly will pay for everything that we get. [Laughter.] If we don't pay one way, we will pay the other. Dr. Coburn. Well said. Mr. Davis of Illinois. Thank you. Dr. Coburn. Thank you. Mr. Weldon. The gentleman's time has expired. I want to thank Dr. Coburn for coming here from Oklahoma. Your testimony was very informative, and we certainly look forward to hearing from you again in the future on these issues. Thank you very much. I would like to now call up the second panel. This will include our first witness, Mr. Ed Flynn. He is the Associate Director of Retirement and Insurance Services at the Office of Personnel Management. He has appeared frequently before this subcommittee to discuss FEHBP. The second witness is Steve Gammarino, senior vice president of the Blue Cross/Blue Shield Association. Mr. Gammarino has also testified a number of times before this subcommittee on FEHBP. Colleen Kelley, our third witness, is president of the National Treasury Employees Union and represents many Federal employees who rely on FEHBP. Our fourth witness is Lawrence Mirel, the commissioner of the District of Columbia's Department of Insurance and Securities Regulation. Commissioner Mirel is an expert on insurance, including health insurance. He has thought carefully about some of the problems affecting health insurance today. Bob Moffitt is our final witness on this panel. Mr. Moffitt is the director of domestic policy studies at the Heritage Foundation. He has studied the FEHBP for years and has developed a real expertise in this area. I thank all of our witnesses for participating and I am looking forward to hearing your testimony. I see you know the drill. You remain standing. [Witnesses sworn.] Mr. Weldon. Note for the record that the witnesses responded in the affirmative. I would like to go ahead and recognize Mr. Flynn for 5 minutes. STATEMENTS OF WILLIAM E. FLYNN III, ASSOCIATE DIRECTOR, RETIREMENT AND INSURANCE SERVICES, OFFICE OF PERSONNEL MANAGEMENT; STEPHEN W. GAMMARINO, SENIOR VICE PRESIDENT, BLUE CROSS BLUE SHIELD ASSOCIATION; COLLEEN M. KELLEY, PRESIDENT, NATIONAL TREASURY EMPLOYEES UNION; LAWRENCE MIREL, COMMISSIONER, DISTRICT OF COLUMBIA, DEPARTMENT OF INSURANCE AND SECURITIES REGULATION; AND ROBERT E. MOFFITT, DIRECTOR, DOMESTIC POLICY STUDIES, THE HERITAGE FOUNDATION Mr. Flynn. Good afternoon, Mr. Chairman and members of the subcommittee. Thank you very much for your invitation. You have already entered my prepared remarks, and I will just summarize from those, with your approval, Mr. Chairman. I would like to focus my remarks on this year's average premium increase in the Federal Employees Health Benefits Program, the changes that will occur in the Blue Cross and Blue Shield Plan, and the need to do something about the continuing withdrawal of health maintenance organizations. At OPM we run the Nation's largest employer-sponsored health insurance program. Since its inception, it has provided high-quality, affordable health care to almost 9 million Federal employees, retirees, and family members. The program is part of the government's overall compensation package and it helps government attract and retain its share of the talent needed to carry out critical public work. Almost 85 percent of employees sign up for the program, and our surveys indicate a high degree of satisfaction with participating health plans, satisfaction levels that have remained stable even with the premium increases of the last several years. The average increase next year will be just over 13 percent. No one is happy about that, least of all the Director of OPM and all of us who work on this program. There are, however, three key points I want to make about next year's increase. First, market competition, consumer choice, and intensive negotiations with health plans do work to provide comprehensive benefits at an affordable cost. At the same time we are operating in a market where, according to USA Today, and I might just mention according to the New York Times of today, health insurance prices nationally are soaring and will range from 13 to 50 percent next year. Other surveys and some announcements by major public and private employers bear this out. Second, we bargained hard for what we were able to get this year. Shortly after being sworn in, we briefed Director James on the key aspects of the program. Her charge to us was clear. She wanted us to get the best deal possible for participants without cutting benefits across the board or making major changes, and we did just that. Initial proposals from health plans would have led to a premium increase of almost 16 percent. Through intensive bargaining, we shaved 2 points off that number and project an overall average of just over 13 percent at the end of open season. Finally, there are trends we can identify that do affect the cost of this program. As has been the case in past years, the rising utilization and cost of prescription drugs tops the list, accounting for over one-third of the total. Other factors include overall utilization, technology advances, medical inflation, and a covered population that gets older on average each year. Responding to our guidance and the same trends we were seeing in health care generally, the Blue Cross and Blue Shield Plan will introduce several major changes next year. They will merge their High Option Plan into the Standard Option and create new, lower-cost Basic Option which provides benefits essentially for in-network providers only. Had Blue Cross and Blue Shield not made this proposal, about 125,000 elderly participants in the High Option Plan would have faced a premium increase in the 30 to 35 percent range. I might also add at this point that it is not unusual for health plans to merge, add, or drop options. That has always been a part of this program, reflecting its market orientation. We carefully consider proposals like these and we paid special attention to the Blue Cross/Blue Shield proposal because of its scope and the importance of the program overall. In addition, throughout the spring and summer several participating health plans learned of the outline of the Blue Cross proposal and expressed concerns about its impact. We met with the Coalition to Preserve Choice and others to ensure we understood and addressed their concerns as we negotiated with Blue Cross and Blue Shield. While we are confident we made the right decision in accepting the Blue Cross proposal, we will carefully monitor both its implementation and its effects to ensure the continued strength of the program. Next year approximately 30 health maintenance organizations will leave the program. Because of that, almost 150,000 participants will have to select new plans. This continues a trend we have seen over the past several years. While we know that plans are leaving for business reasons unrelated to our administration of the program, it is, nonetheless, an area of concern to us. We have taken a number of concrete steps in the last several years to increase the number of health plans, albeit with limited success. The President's budget reflects, among other things, a commitment to consider options to ensure that the program offers quality and cost-effective health plans not only now, but for the future. We are exploring ways to increase the health care options available to Federal employees, thereby increasing competition within the program. We look forward to working with you and the members of the subcommittee and others on this issue. Mr. Chairman, that concludes my statement. I will be happy to answer any questions you may have. [The prepared statement of Mr. Flynn follows:] [GRAPHIC] [TIFF OMITTED] 79433.040 [GRAPHIC] [TIFF OMITTED] 79433.041 [GRAPHIC] [TIFF OMITTED] 79433.042 [GRAPHIC] [TIFF OMITTED] 79433.043 [GRAPHIC] [TIFF OMITTED] 79433.044 Mr. Weldon. Thank you, Mr. Flynn. Now, Mr. Gammarino, you are recognized for 5 minutes. Mr. Gammarino. Good afternoon. I am Steve Gammarino, senior vice president at the Blue Cross/Blue Shield Association. On behalf of the Blue Cross/Blue Shield plans, I thank you for the opportunity to appear before you today. With your permission, Mr. Chairman, I would like to submit my written statement for the record. Mr. Weldon. Without objection. Mr. Gammarino. In your letter of invitation you requested that I address several questions on health care trends and efforts by Blue Cross/Blue Shield to manage the rising cost of health insurance premiums. In addition, you requested that we discuss the new Basic Option Plan and any other issues that are important to the continued viability and stability of the Service Benefit Plan. For 2002, overall health insurance premiums for the Blue Cross/Blue Shield Standard Option Plan will rise 15 percent. The premium increases we are experiencing are similar to industrywide trends. To gain insight into the trends in health care, it is useful to explain what we are experiencing in the marketplace. I call them the three ``C's'': cost, consumerism, and coverage. First, premiums are being driven today by increased costs in all areas of health care. Prescription health costs continue to be driven by the rapid development of new, more expensive therapies which often substitute for less costly, existing therapies; rising prices for existing drugs and heightened demand and use of prescription drugs, fueled by the ever- increasing direct-to-consumer advertising. Under Blue Cross/Blue Shield's Standard Option Plan, drug costs today represent almost 30 percent of our benefit cost. In addition, over the past couple of years we have begun to see an increase in cost for provider services which is due to rising prices in the use of hospital and physician services. It is also important to realize that the FEHBP is dealing with an aging population. For example, the average Blue Cross/ Blue Shield Service Benefit Plan enrollee today is 60 years old, and the average FEHBP member is 54. This is a much older population and a higher-risk group than most health plans in the private sector. The second ``C'' is consumerism. In today's marketplace, especially in a competitive and individual choice market such as FEHBP, the consumer drives decisions. With the combined forces of the backlash against managed care restrictions on access and direct consumer advertising on prescription drugs, the consumer has become a key force in health care decisionmaking today. The third category of health care trends is the changing perception of health coverage. Over the years expectations of what health insurance should cover have shifted. The original intent of insurance was to protect against catastrophic or acute situations while consumers paid for day-to-day expenses, similar to how car insurance works today. However, today health care covers both catastrophic needs and routine care. Consumers have come to expect and demand from their State and Federal legislatures that health insurance plans cover a wide range of treatment that includes preventative care, care that is experimental, and even care that is yet to be proven scientifically. As the Service Benefit Plan continues to face increasing cost trends and an aging population, we are constantly exploring ways to manage those costs. While we are concerned about the trends and keeping overall costs contained, we are equally, if not more, concerned about the overall health outcomes and ensuring that our members receive quality care. To that end, we have also focused resources on strategies and programs that will improve patient safety and quality outcomes. In your letter of invitation, you asked me to address our 2002 benefit changes; in particular, the rationale for merging High Option and introducing a new Basic Option. As you are aware, Blue Cross and Blue Shield currently offers two options: High and Standard. Each year we take a close look at our products to ensure that they provide value to our customers. Our research consistently shows that the Federal employees and retirees are very concerned about the cost of health care and that they want the best value when selecting a health plan. Blue Cross/Blue Shield decided to merge High Option into Standard Option because High Option is no longer a viable product. Due to exceedingly high benefit costs, it has become a tremendous challenge to keep the product affordable. In response to the demand for cost-effective health care coverage, we are introducing a new option for Federal employees and retirees. This new option, called Basic Option, is a preferred provider-only benefit package that includes co- payments for many services, no deductibles, and preventative dental coverage. It is designed to provide Federal employees and their families with a premium that is lower in cost than the majority of health plans in the FEHBP. We believe it is a ground-breaking product and offers what most individuals look for in a health care plan; that is, choice, access, and simplicity. With regard to your inquiry on ways in which FEHBP can be improved, in our experience there has to be an appropriate balance between incentives and risk. With the reduction in the number of health plans participating today, we would suggest that the subcommittee might want to further examine the financial incentives and the significant underwriting and compliance risk required by a carrier participating in the program. Finally, your letter of invitation expressed an interest in any matters beyond the specific focus of this hearing. One that is critical to Blue Cross/Blue Shield's continuing participation in the FEHBP is the exemption from the inappropriate application of the cost accounting standards. For the past 3 years, Congress has passed an appropriations act, a full statutory waiver requirement related to these requirements, and we urge the subcommittee to seek final resolution of this matter. The Blue Cross and Blue Shield Association is proud of its role it has played in the Federal employee marketplace. I hope my remarks will help you in your deliberations and discussions. We look forward to working with you to find ways to preserve and improve the strength and stability of this program. Again, thank you for the opportunity to appear before you today. I will be pleased to answer any questions you may have. [The prepared statement of Mr. Gammarino follows:] [GRAPHIC] [TIFF OMITTED] 79433.045 [GRAPHIC] [TIFF OMITTED] 79433.046 [GRAPHIC] [TIFF OMITTED] 79433.047 [GRAPHIC] [TIFF OMITTED] 79433.048 [GRAPHIC] [TIFF OMITTED] 79433.049 [GRAPHIC] [TIFF OMITTED] 79433.050 Mr. Weldon. Thank you. Ms. Kelley, you are recognized for 5 minutes. Ms. Kelley. Thank you, Chairman Weldon. As the national president of the National Treasury Employees Union and the 150,000 Federal employees who we represent, I would like to congratulate you on your chairmanship of this subcommittee and look forward to working with you in the future on these important issues. Mr. Weldon. Thank you very much. Ms. Kelley. The Federal Government faces a human capital crisis today with inadequate pay and benefits being the primary obstacles to both attracting and retaining highly qualified employees by the Federal Government. The FEHBP used to be considered a crown jewel in the Federal employee benefit package, but today it has become prohibitively too expensive for lower-paid employees and unattractive to prospective employees. More than 9 million Federal employees, retirees, and their families depend on the FEHBP for coverage, and they are alarmed over the recent dramatic premium increases. OPM's announcement of over 13 percent on the average rate increases for 2002 follow premium hikes the past 3 years of 10.5 percent, 9.3 percent, and 9.5 percent in 1999. Since 1997, FEHBP premiums on the average have increased a total of more than 46 percent. To put this in perspective, during the same timeframe from 1997 through 2001, Federal employees' salaries increased an average of 17 percent. Mr. Chairman, Florida's 15th Congressional District is the home to more than 23,000 Federal employees and retirees. An employee in the district saw their FEHBP premiums consume 8.6 percent of their take-home pay in 1998. By 2001, that amount has increased to over 11 percent. For these reasons, it is critical that the FEHBP receive careful scrutiny. NTEU does not believe that occurred this year. Earlier this year NTEU raised concerns about Blue Cross's proposal to merge its High and Standard Option programs. To date, we do not know the impact of that merger on future rates or on the stability of the FEHBP or even whether there is a need for the new Blue Cross plan. We do know that this will result in increased premiums for those in the Blue Cross Standard Option and the need for a major education campaign of both employees and retirees, so that they know and understand the changes in the Blue Cross plans. We all agree that the government needs to better use the size of the FEHBP pool to obtain better rates from insurance carriers and from health care providers. According to the Kaiser Family Foundation's Employer Health Benefits Annual Survey for 2001, FEHBP premiums increased at a rate higher than many other large employers: over 13 percent for FEHBP and an average of only 10.8 percent in 2001 for firms and companies with 5,000 or more employees. The numbers were similar in the year 2000, when the Kaiser Survey reported an average premium increase of 7.1 percent and the FEHBP premiums increased 10.5 percent. But the differences the Annual Kaiser Survey reveals do not stop here. As an employer and as Ranking Member Davis has noted, the government pays an average of 72 percent of the premium. Employees pay the other 28 percent. As the chart attached to my testimony shows, the average employee in employer-sponsored health insurance pays 15 percent of the premium for single coverage and 27 percent for family coverage. Not surprisingly, when asked by Kaiser, employers cited recruitment and retention of employees as one of the main reasons that they absorbed most of the health insurance premiums for their employees. Most State and local government employers today pay at least 80 percent of the premium. To help address the effect that health insurance premiums have had on the human capital crisis for the Federal Government, NTEU worked with Congressman Steny Hoyer on bipartisan legislation, H.R. 1307, that would increase the employer's share of the FEHBP premiums to the most common industry standard of 80 percent. Without competitive pay and benefits, the Federal Government will be unable to compete for the talent that it needs. NTEU asks that you hold hearings on this important legislation. Nothing is driving premiums increases as rapidly as prescription drug costs. We have heard that already from a number of speakers. In the year 2000 OPM stated that prescription drugs represented $1 of every $4 in FEHBP costs, and when announcing the 2001 premium increases OPM stated that 40 percent of the premium increase was the result of the drug costs. NTEU thinks that OPM should negotiate discount prescription drug rates for the FEHBP similar to those that are available under the Federal Supply Schedule. Ranking Member Davis described in great detail the SAMBA pilot that was canceled in 1999. This was a lost opportunity for a potential solution to the prescription cost at least of the FEHBP. But lost, too, were the taxpayer savings that were inherent in negotiating the discount prescription drug rates. The SAMBA pilot was estimated to save $2.4 million a year, savings that would have flowed to both Federal employees and to taxpayers. Reducing drug costs programwide in the FEHBP holds the potential to save much more. This idea continues to merit exploration, and NTEU asks that this subcommittee pursue this issue. This concludes my remarks. Thank you very much, and I would be glad to answer any questions you have. Mr. Weldon. Thank you very much for your testimony. We will now hear from Mr. Mirel. Did I pronounce your name correctly? Mr. Mirel. Yes, you did, thank you. Most people don't. Mr. Weldon. OK. Mr. Mirel. I appreciate that. Mr. Weldon. You are recognized for 5 minutes. Mr. Mirel. Chairman Weldon, members of the subcommittee, Delegate Norton in particular, my Representative in the Congress, I am Larry Mirel, commissioner of insurance for the District of Columbia. The agency that I head was created originally in 1901 by Congress to regulate the business of insurance in the District of Columbia. It is now part of the home rule government that was created in 1974. Although I am a member of that government, I am testifying here today on my own behalf and not on behalf of the Williams administration. Our Department regulates all lines of insurance, including health insurance. But I have to tell you that I have not seen the kind of anger with any other line of insurance that we see regularly with health insurance. I can't tell you how many people call my office or come in and complain that items that they thought were covered in their insurance it turns out were not covered. I hear from doctors all the time furious with the kinds of hoops they have to go through to get themselves paid for services that they have provided; hospitals who come in and complain that they are facing bankruptcy because they cannot get reimbursed for services that they have actually provided. And the insurance companies are not happy either. They don't like the mandates that are enacted that throw off their calculations, and the system in general, it seems to me, could not be designed to be worse, to create that kind of anger. I don't think I am alone in that view. I think many Americans share that view of our health payment system. I have thought a lot about the reasons why this should be the case. I think really there are two fundamental flaws with the current system of health insurance in this country, paying for health care. The first is that a large portion of what is paid for is just not insurable and should not be covered by insurance. I take the point that Mr. Flynn, I guess it was, made before, which is that originally you bought insurance to protect yourself against catastrophic loss; that is, the loss from serious illness or injury. But over the years the concept has been expanded and now covers what used to be considered routine health care costs that you paid out of your pocket. The problem with that is that we have left the entire system in the hands of insurers. Insurers are just the wrong people to run a system like that. It is the wrong mindset for routine health care. Insurers are very cognizant of utilization. A good insurance company is one that limits the number of claims that are filed. The essence of insurance is underwriting. The idea of limiting claims is a good one if you are talking about major illness or injury. To give just one example, Workers Compensation insurers spend a lot of time and money and energy trying to make the workplace safer, so that there will be fewer claims. They do it for the noblest of reasons, which is they earn more money when there are fewer claims. That is how insurance companies think. The problem is you can't apply that same kind of thinking to routine health care. You want people to go to the doctor. You want them to get inoculated. You want them to do the kinds of preventative things that they should to take care of their health. When you put it in the hands of insurance companies, what they do is they start managing it the way they would any other kind of claims to reduce the number of claims. So you get the kind of paperwork that you have, and you have the kinds of managed care issues that you have--all of which adds enormous costs as well as frustration to the system. That is the first problem. The second problem, in my view, is that health insurance is a contract; that is, it doesn't cover anything that goes wrong with you in a health context. It covers only the things that are specified in the contract and are not excluded. The contract, however, is negotiated between the employer, who pays for it, and the insurance company that provides the coverage, the health plan that provides the coverage. The people who are mostly affected by that contract, however, are the employees, the ones who are covered, and the providers, those who provide that coverage. Neither of them are part of the negotiating process. This, in my view, is a very bad way to do business. It is bad in another way, too, and that is that insurance is a very competitive business. Employers are always looking for ways to save money. They, therefore, look to cheaper insurance plans. The insurers know this. So they vie with each other to provide cheaper plans, so that they will be able to pick up a larger share of the market. There are really only two ways to reduce the cost of insurance, in my view. One is to reduce the benefits that are provided, and the other is to pay the providers less. Insurance companies are doing both. They are dropping coverages that they used to routinely cover, and they are continually squeezing the providers to do more for less money--to the point where the providers are finding themselves strapped and unable to provide what they think of as good medical costs. Are there solutions to this kind of a situation? I believe that there are, and I believe that the solution lies in something that Dr. Coburn talked about before, which is a high deductible policy that covers catastrophic loss of illness and injury, and then covering the rest by a medical savings account; that is, taking the money that is saved by buying a high deductible policy which is cheaper and putting it in individual medical accounts for the employees. The employees would then be able to control their own medical care, pay for the things they want to pay for, and have more direct connection with the doctors and the providers that they deal with. I will stop at this point. My entire statement I believe is in the record. I would be glad to answer questions. [The prepared statement of Mr. Mirel follows:] [GRAPHIC] [TIFF OMITTED] 79433.051 [GRAPHIC] [TIFF OMITTED] 79433.052 [GRAPHIC] [TIFF OMITTED] 79433.053 [GRAPHIC] [TIFF OMITTED] 79433.054 [GRAPHIC] [TIFF OMITTED] 79433.055 Mr. Weldon. Thank you very much, and we will conclude with our witness from the Heritage Foundation, Mr. Moffitt. Mr. Moffitt. Thank you very much, Mr. Chairman and members of the subcommittee. My name is Robert Moffitt. I am the director of domestic policy studies at the Heritage Foundation. In that capacity, I oversee the Foundation's analytical work in the area of health care policy, including the financing and delivery of health care services and government programs. It is an honor and a privilege to appear before the subcommittee today to discuss the current status and the future of the Federal Employees Health Benefits Program. It should be understood that the views I express here today are my own and do not necessarily represent those of the Heritage Foundation. I ask that my written statement be submitted for the record, Mr. Chairman. Mr. Weldon. Without objection. Mr. Moffitt. The Federal Employees Health Benefits Program is, as Mr. Flynn pointed out, the largest group health insurance program in the world. It provides health care coverage to all members of the Federal Government, including Congress, the White House, the Federal judiciary, as well as approximately 9 million Federal and Postal workers and retirees and their families. This is an unusual program. It is run largely on the free market principles of consumer choice and market competition. No other insurance-based system of financing and delivery in the United States provides patients with such a broad range of choice of plans and benefits. It is virtually the only system in the country in which individuals and families can choose from a broad range of health care plans, picking the kinds of benefits and treatments they want at prices they wish to pay, while pocketing the savings of wise choices. In that key respect, Mr. Chairman, it is virtually the only health care delivery system that even vaguely resembles anything that looks like a normal market in the area of health insurance. The Office of Personnel Management, the Federal agency that administers the FEHBP, has broad authority, repeatedly upheld in Federal courts, to negotiate premium rates and benefits on behalf of Federal employees. As the Congressional Research Service observed in 1989 in the most comprehensive analysis ever published on this program, the basic structure of the FEHBP is ``sound'' despite changes in administration and the health care sector of the economy. While the FEHBP retains a sound structure and a superior performance as a health care delivery system for its enrollees, it is, nevertheless, in 2001 a troubled program. Its problems are rooted in shortsighted government policies that are incompatible with its structure. The structure is the structure of consumer choice and competition, and the solutions to those problems are likewise rooted in government policies that are not only compatible with its structural advantages, but also would enhance consumer choice and competition. For the next year, OPM projects an average premium increase of 13.3 percent among FEHBP plans. This does continue a painful pattern of significant premium increases over the past several years. While these premium increases have been less than those commonly found in the private sector, they are, nonetheless, worrisome to Federal employees and retirees and their families. As Mr. Flynn pointed out and Mr. Gammarino, these cost increases surely reflect the broader changes that are taking place in the health care system, particularly the growing patient demand for high-quality prescription drugs delivered through the mechanism of health insurance. But there are also other factors which are peculiar to the program that are driving the cost increases in the FEHBP and these factors are not inherent in the structure of the program. The first, of course--Mr. Flynn had mentioned it, so did Mr. Gammarino--is the artificially skewed demographics of the Federal work force, which is significantly older than the private sector work force and is rapidly aging. Health care costs of older workers are, of course, significantly higher than those of younger workers. Related to the aging of the work force is the disproportionately large number of Federal employee health policyholders, roughly 40 percent, who are retirees. In contrast, many private sector companies have ceased or limited coverage for retirees. A second reason for recent cost increases is the recent tendency of OPM to break with what the Congressional Research Service once described as its passive management of the program and adopt a much more aggressive regulatory approach to program management. Between 1990 and 2001, the executive branch, either independently or sometimes at the urging of Congress, made 44 specific benefit decisions relating to different aspects of health care benefits. If understood as ancillary to the basic statutory benefit requirements established clearly in Chapter 89 of Title V, these additions would have the equivalent economic impact of health care benefit mandates that are a prominent feature of State health insurance laws. While it is true that any one of these benefit additions taken alone could be justified as fulfilling some particular need or desire, and while the degree of the impact of these benefit decisions on cost is a matter of some dispute, there is no debate that they add to premium cost. Whatever the merits of any particular intervention, mandates impose higher costs. The more mandates, the higher the costs. My colleagues have pointed out that Members of Congress should maintain some perspective on the FEHBP increase, and they are right. Even with the 13.3 percent projected increase, when all is said and done, when the numbers are over and submitted in the year 2002, FEHBP is still likely to outperform private sector health insurance, particularly the corporate health insurance. Note that FEHBP benefits have, in fact, been increasing in value over the past 15 years; that is to say, the number and the quality of the benefits. Second, the annual projected increases in the FEHBP do not automatically translate into actual premium increases. I have a number of suggestions, Mr. Chairman, to improve the program, which I have submitted in my testimony, but let me just make two fundamental points. One, FEHBP needs fresh blood. You have to get a change in the actuarial pool of this system or you are going to see greater and greater demographically driven price increases that are not reflective of what is going on in the general economy. The second point is that you must start to examine the impact, the economic impact, of the mandate system or the regulatory initiatives that have been taken over the past 10 or 15 years to get a clearer idea of how that is affecting the cost. You should also change the underwriting system in the FEHBP and do what Mr. Mirel suggests: Allow people to pay for health care services directly without imposing any kind of a tax penalty for doing so. Flexible spending accounts that are very common in the private sector for millions of Americans are one way to do it. Another option, of course, is medical savings accounts. But, in either case, make the health insurance system in the FEHBP operate more rationally, in accordance with and make it compatible with the basic structure of the program which, as the Congressional Research Service said, is structurally sound. Thank you, Mr. Chairman. [The prepared statement of Mr. Moffitt follows:] [GRAPHIC] [TIFF OMITTED] 79433.056 [GRAPHIC] [TIFF OMITTED] 79433.057 [GRAPHIC] [TIFF OMITTED] 79433.058 [GRAPHIC] [TIFF OMITTED] 79433.059 [GRAPHIC] [TIFF OMITTED] 79433.060 [GRAPHIC] [TIFF OMITTED] 79433.061 [GRAPHIC] [TIFF OMITTED] 79433.062 [GRAPHIC] [TIFF OMITTED] 79433.063 [GRAPHIC] [TIFF OMITTED] 79433.064 [GRAPHIC] [TIFF OMITTED] 79433.065 Mr. Weldon. Thank you, Mr. Moffitt. I want to thank all of our witnesses. This has been very informative and certainly stimulates a lot of areas for questioning. I recognize myself for 5 minutes. The one I want to touch on first is the issue of the mandates. I am a little bit uncertain as to the full impact of the cost of the mandates. I have seen some data out of OPM that these mandates have had a negligible impact. I am curious if you, Mr. Moffitt, agree with that analysis, if you feel that we should get an independent analysis of that through an entity like GAO. There are a lot of mandates coming down from States on health plans, and how much the collective impact of these mandates is having on premiums I think needs to be explored in more detail. Mr. Moffitt. Exactly. Mr. Chairman, let me respond. I said in my testimony, borrowing a line from my old boss, Ronald Reagan, trust but verify. I trust OPM. I think they do a great job. I used to work at the Office of Personnel Management. I have profound respect for the staff. The point that I made in my testimony is simply this: If you look at their analysis of the overall impact of 44 changes in benefits over the past 10 years and you look at the professional literature, the peer-reviewed journals of econometric analysis of benefit mandates at the State level, what you are finding is a significant difference. The General Accounting Office did, indeed, do an analysis of the impact of mandates at the State level in 1996. In fact, I mentioned this to Congresswoman Morella's staff. I cited this in my testimony. The GAO estimated that State-mandated benefit laws accounted for 12 percent of the claims cost in Virginia, which had then 29 benefit and managed care mandates, and 22 percent in Maryland, which in 1996 had 36 mandates. This covers everything from mandatory chiropractor coverage to substance abuse, in vitro fertilization, you name it, psychological counseling. In Maryland today I think it is well over 50, maybe 54 or 55 mandates. My point is that I think that you need, in the interest of Federal employees and the families who are paying these premiums, you have got to be clear in your own minds that the Office of Personnel Management is absolutely right. Because my point is that study after study shows that mandated benefits do, in fact, increase cost significantly. But two widely respected economists have indicated that one out of four of the people in the United States who are uninsured are uninsured because they have been priced out of the market by State- mandated benefits. So my point is that you have a discrepancy here. I am not saying that OPM is wrong. I am saying it is our responsibility and the responsibility of the Bush administration to make sure that our understanding of the economic impact of these mandates is correct. Mr. Weldon. Mr. Flynn, did you want to counter to that or add to that at all? Mr. Flynn. Mr. Chairman, I would simply say that we would welcome verification. I think the list of 44 mandates that Mr. Moffitt talks about is the same list that we prepared that I believe you and members of the subcommittee have seen. It covers a period over the course of the past 10 years. The net effect of those changes at the Federal level was about 1.5 percent. Even if you put aside for the moment the effect of mandates that decrease costs in the program, over that same 10-year period we have seen premiums rise in the program approximately 72 percent, and the mandates that increase cost amount to a little bit less than 4 percent. So I think in the context, while it is true that every time you add a benefit, you tend to add cost, I think it is important to look at it in the context of what has been going on in the program overall. The other one quick thing that I would just simply say is that there is a lot of discussion in health care today about mandates, particularly those that are imposed at the State level. In the Federal Employees Health Benefits Program we have what is known as a preemption provision, where with the single exception of health maintenance organizations that are domiciled and operate solely within a State, we preempt State- mandated benefits. For example, we don't have the Blue Cross and Blue Shield plan providing State-mandated benefits in California, Pennsylvania, West Virginia, New York, and what have you. It is a standard benefit package across the United States because of the preemption authority that we have in the FEHBP law. So the effect of mandates at the State and local level is very, very minor, we estimate about one-quarter of 1 percent of the total cost of the program. But those that have occurred at the Federal level, whether imposed by Congress or as part of the administration, we think, setting aside those that have actually reduced costs, amount to about 4 percent of that 72 percent increase in premiums over the same period. But we would welcome GAO, anybody, to come in and look at our numbers. We think we have pretty good data. Mr. Weldon. My time has expired. I would like to now recognize the ranking member, Mr. Davis, for 5 minutes. Mr. Davis of Illinois. Thank you very much, Mr. Chairman. I listened rather intently to the discussion, and I must confess that I really appreciate the testimony that each one of you has provided. It seemed to me that, as I was listening, that there are, in fact, ways, based upon experiences that I have seen, to reduce cost, but of course oftentimes those are unacceptable to the users or it decreases users' satisfaction. My question is a rather generic one. The more options and choices that consumers have, the more likely they are to use those. I am saying, if there are more choices, there are more options, the greater the use of those, which has a tendency to drive up costs. So my question is: Is there a way to provide the consumers what they need and at the same time get the cost down for what they would find satisfactory? Mr. Mirel. Mr. Davis, let me take a crack at that. The alternative that I was talking about, which I think is the same thing that Dr. Coburn talked about in his testimony, is, first of all, a voluntary choice. We are talking about offering a choice that is not now offered through the Federal Employees Health Benefits Plan. That is a high deductible choice. With that would come additional nontaxable compensation, payment, in the form of additional untaxed salary that would be put into the individual employee's medical savings account. The individual employee then could spend that money any way he saw fit, knowing that once the deductible had been met, $3,800 or whatever it is at the moment, the backup plan would kick in. That means that you don't have to go through the difficult task of deciding what should be in the plan and what shouldn't be in the plan. It is up to the employee. If the employee wants to spend it on eyeglasses, he can spend it on eyeglasses. If he wants to spend it on dentistry, he can spend it on dentistry. It is his choice. What it does is it cuts out an enormous amount of the transactional cost that now exists in the plans. What I would like to see happen is to have this offered as an option and see what happens, if people will take it and if they will like it, and if it will, in fact, reduce costs. I think it will have all of those effects. Mr. Davis of Illinois. Why don't I just ask Ms. Kelley, would the unions be up in arms about such a plan, the high deductible choice? Ms. Kelley. We have a lot of concerns about the high deductibles and the medical savings accounts, most of which we are on record for. Would we be up in arms? I don't know. But we have concerns, and they are based around a number of things. First of all, the choices that you described that Federal employees have today, in fact, have been one of the hallmarks of the FEHBP, that employees have had those choices. Yet, what we have seen every year is choices have decreased and yet premiums have increased. So decreasing the choices has not had the impact on the premiums that some would have hoped. I think there are a number of issues around the high deductibles and the fear that employees would enroll in a program that wouldn't meet their needs, and they would find themselves later in a situation where they needed to move back into a traditional plan in the FEHBP. There is that movement every year now where employees have that choice, and they make a lot of use it. We know that. So there are a lot of concerns that we would have and that employees would have. The fear is that they would be losing benefits, and that once those deductibles kicked in, where would the coverage come from? Maybe if there was a formal plan out there, we would be more than willing to look at it and to provide specific comments, but as a general rule, yes, we have a lot of concerns about the high deductibles and the medical savings accounts. We would much rather see something that we had started to work on and have seen the beginning of, the pre-tax flexible spending accounts that were mentioned by Mr. Moffitt, which now are available to Federal employees for their premiums only, not for their out-of-pocket expenses. Expanding that to Federal employees for their out-of-pocket expenses would be something that would be very much supported, and Federal employees have asked for this for years because the rest of the country has access to that, and yet Federal employees don't. Mr. Davis of Illinois. Thank you. Mr. Weldon. The gentleman's time has expired. The Chair now recognizes the gentlelady from the State of Maryland, the great State of Maryland. Mrs. Morella. Thank you. The great State of Maryland. Thank you, Chairman Weldon. I want to congratulate us and to congratulate you on your chairmanship of this important committee. It is one that I have been on during my 15 years because I think that, if you have a thriving democracy and a good democracy, you have a good civil service. I am pleased that you take over the chairmanship at a time when confidence in public service has been elevated. So this is a good time for us to move forward with recognition and encouragement of our public service. OK, I am going to start off. This is a good panel. I am going to start off with Mr. Flynn. Nice to see you, and I think the panel was excellent. The Center for Studying Health System Change has released a new study that shows employees nationwide pay lower premiums on average than those in the FEHBP program. I know that the FEHBP program has an older age population, as has been mentioned, but that increases premiums by less than 1 percent, according to your own data. I wondered if you might comment on that disparity? Mr. Flynn. Thank you, Mrs. Morella. It is good to see you again as well. We actually have looked at that report. I think the first thing that I would do is comment on the year-to-year changes going back over the past 4 years that report comments on. If I recall it correctly, if you go back over the past 4 years, not counting the rate increase for 2002, it indicates that Federal premiums are 8.7 percent higher than private sector premiums. I might just point to testimony from several of the witnesses, but actually go back 10 years and say to you that Federal premiums have increased 72 percent while private sector premiums have increased 87 percent. So a lot of times it depends on the time period you are looking at, the particular methodological assumptions that you make, whether they are pre- or post-negotiation increases, and so on and so forth. I think, Mrs. Morella, the point that I would make is actually whether you looked at 4 years or whether you looked at 10 years, and I've seen actually studies that go even further which show that the differences are actually narrower, I am amazed that the figures are as close as they are when you consider all of the numbers and, as I say, some of the methodological differences that go into this. I think what either set of numbers would reflect is a health care system at large, not just the FEHBP, which has seen increases over the past 4 years, over the past 10 years, that are well above the rate of inflation and that, for one reason or another, we have been largely unable to contain. In that respect, the FEHBP is no different. Mrs. Morella. You present the broad-brush looking back. I guess there is some validity to that. But let me ask you about an offshoot of that. For the last several months I have been looking into different ways to try to alleviate the high cost of the FEHBP plan premiums and to lower costs. One approach was to lower prescription drug costs by taking advantage of the number of FEHBP participants. The idea was to create a programwide drug benefit incorporated into each FEHBP that employs pharmaceutical benefit managers--I noticed that Mr. Gammarino had mentioned that--to leverage the Federal community's large economy of scale. I know that OPM has looked into this because we have discussed this before. I am interested if there is any new information that you might offer about this concept. Actually, maybe I could just also throw in the idea that Mr. Gammarino would note that the Blue Cross switched to a pharmacy benefit manager in its prescription drug benefit and received significant cost savings. Maybe you could, if I have time, Mr. Gammarino, comment on whether or not FEHBP should look at that. Mr. Flynn. I will try to do this very quickly to give Mr. Gammarino some time to respond to that as well. You are absolutely correct, Mrs. Morella, we have had discussions with you, your staff, and others about the possibility of doing something like this. The first thing I would say is that, whether it is the mail order benefit or prescription drug benefits in general, they are already largely managed by the 180 health plans that participate in the Federal Employees Health Benefits Program. Mr. Gammarino can talk about that design in the Blue Cross/Blue Shield program. So the first thing that I want to make sure we are all clear on is that it is not a situation where we have completely undiscounted drugs being made available to Federal participants today versus moving to prescription drugs being purchased in the aggregate and getting those discounts. It is a question of the marginal difference between the discounts that are currently being achieved under pharmacy benefit management programs versus those that might be achieved through the aggregation and use of the entire Federal Employees Health Benefits Program population as one purchasing pool. It has been discussed already, the experience that we had with the SAMBA program last year. I think, had that program moved forward, we would have demonstrated modest savings, but savings, nonetheless, for those program participants. I think this is an area that continues to be worth analyzing, discussing with all the stakeholders. But it does come up against some of the arguments that you have heard from Mr. Moffitt having to do with large numbers of health plans competing with one another through informed consumer choice and the impact that has on the market as well. It is an area that we need to continue to explore, but I can't provide you with a definitive outcome. Mrs. Morella. OK. Mr. Gammarino. Yes, I could give you a couple of observations. Mrs. Morella. I know my time has expired though. Mr. Weldon. Go ahead and answer the question. Mr. Gammarino. Congresswoman Morella, we would not support a government carveout of the prescription drug program and do direct contracting. One, philosophically, it is not consistent with the FEHBP, which is built on a private individual choice market with individual underwriting. Two, as a manager of a health plan, I guess my question would be: Who's managing the shop? Am I doing it or the government? Clearly, the intent of the FEHBP is that the private sector manage this. Third, you are getting at probably a marginal issue. If price of the products were the only thing driving the trends that you are seeing, maybe we would all jump on board, but it would make a marginal difference in the rates you are seeing. Drug costs today are driven not as much by price as it is by use and the introduction of new drugs which provide a new pricing platform in which to start. Mrs. Morella. Thank you. Thank you, Mr. Chairman. Mr. Weldon. The gentlelady from the District of Columbia is recognized for 5 minutes. Ms. Norton. Thank you, Mr. Chairman. Mr. Flynn, I note that you say in your testimony--well, first, let me say that, as you may remember from the time that President Clinton tried to get us into a national health care program, there were many of us who thought that the FEHBP might lead the whole Nation. I don't think a lot of us think that way anymore, frankly. We are not sure how to lead the whole Nation. You say in your testimony that the fact that 85 percent of the eligible work force participate in the Federal Employees Health Benefits Program attests to its popularity. I wouldn't take that to the bank. I think people participate because they are intelligent people, they need health care, and they don't have any alternative. I would rather go to the part of your testimony which is more explorative of ways to make that popularity more than something that people would almost have to do for their own sake, rather than risk being here without any health insurance. That is on page 10, where you say you are exploring ways to increase health care options available to Federal employees, thereby increasing competition within the program. This is, of course, the great savior that we all are looking for. Of course, we see the opposite trend, for reasons, frankly, far beyond your control. When it is 245, there were 245, now 180, I know full well that has almost nothing to do with FEHBP, but with structural problems in health care in our country. But what some of us were leery of, the notion of opening of FEHBP to kind of the great unwashed herd out there because we weren't sure that it wouldn't do anything but drive up rather than keep what was then fairly stable costs. It is as if the insurers were afraid that there was going to be some real government mandate to deal with health care for all the American people, and it was almost, ``Let us keep these costs down,'' because the moment that went away, health care began to rise again. We had a few years of extraordinary stability. I think it was absolutely artificial. If we look now at FEHBP, even though, according to your own records, the demographics don't account for very much of this hyperinflation, one can't help but look at this average age of 48, for God's sake, for the FEHBP, and 71, the average age for the retirees, and wonder how much longer you can keep a viable plan going that way. I lay that predicate to ask this question, noting what Blue Cross/Blue Shield has done: Here Blue Cross/Blue Shield has collapsed its High Option, and if it hadn't, according to the testimony, then it would have become untenable. It collapsed probably because the High Option people were people who used health care most often. So they mixed up their pool. Is there any way to--and here I am not advising spreading FEHBP the way we in our wild imaginations thought might be possible just a few years ago--but is there any way to think about selective opening of FEHBP to sectors that might have some incentive to come into such a plan, which in many other ways may be very efficient, so that we could mix the pool up a bit and begin to reduce costs the old-fashioned way, by having a broader pool of those who are insured? Mr. Flynn. Ms. Norton, that is an extremely interesting question. Let me preface my comments about it by just simply mentioning, you mentioned the stable premiums in the FEHBP and how that was seen as a model or something to sort of move toward during the debate on health care reform. It has not always been the case that premiums in this program have been stable. We were seeing a period of increases that are of great concern to us now in the late 1980's; 1987, 1988, 1989, premiums were going up close to 20 percent a year; then in the late 1970's/early 1980's a similar period of premium increases. Ms. Norton. So why did it stabilize for those few years? Mr. Flynn. Well, you know, I guess I should say I am not an expert in health care policy. I think I am reasonably expert in acting as a purchaser of health insurance for an employer that wants to sponsor that as part of its compensation program. That is actually the avenue of my answer to your question, which is I would be very concerned about opening this program up to groups of people who have something other than an employment relationship with the Federal Government. This is part of the compensation program. It is in that respect the same thing that General Electric and General Motors and other employers offer their employees, and in some cases retirees, although, as Mr. Moffitt says, retiree health benefits in this program actually stand unique from what other employers tend to do. So I would be very concerned about that. I do think, however, that while I would be very concerned about opening this up to new groups of participants, I am less concerned about looking for ways in which we could perhaps open this up to new groups of health care delivery mechanisms. We have talked about the exodus of HMOs. We have done specific things to try to get health plans into the program over the past several years, but we are limited by the Federal Employees Health Benefits statute in terms of admitting plans other than health maintenance organizations. I think that is an area where, working with the committee, working with other stakeholders and others who have an interest in this program, we may very well be able to come to some consensus about bringing in, for lack of a better term, other health insurers or health care delivery mechanisms to increase the level of competition in the program and have the kind of salutary effect that has been talked about by many of the people who have given testimony today. Ms. Norton. Thank you, Mr. Chairman. Mr. Weldon. The gentlelady's time has expired. I would like to thank all of our witnesses. It has been very informative. None of you really commented on the exodus of HMOs directly. Am I to interpret that to mean good riddance? Is that what you are all saying? [Laughter.] Mr. Flynn. Mr. Chairman? Mr. Weldon. Yes? Mr. Flynn. I would be happy to offer just a quick comment on that. Going back to Mr. Moffitt's earlier testimony, this is an area where actually GAO came in and did verify that health maintenance organizations were leaving the program largely because of business reasons unrelated to the administration of the Federal Employees Health Benefits Program itself. Congresswoman Norton mentioned the fact she was not surprised by the reduction in HMOs because it is largely what is going on in the national economy. So from that standpoint, it is something that we can live with, but at the same time it is something we need to think seriously about in terms of looking at ways we can enhance competition and give people more choices as we go forward, because I think that is one of the strengths of the program. Mr. Weldon. Again, I want to thank all the witnesses. It has been a very informative hearing. This hearing is now adjourned. Mrs. Morella. Could I ask another question or would you prefer that I submit the question? Mr. Weldon. Is the lady asking for a second round of questioning? Mrs. Morella. Only if it is amenable to you, because if not, I will submit it in writing. Mr. Weldon. OK, well, why don't we just have a second round of questioning. I think I already took about a minute asking one question. So let me give myself another 4 minutes. Under the plan, as I understand it, you have to offer two plans, correct? If you are in the FEHBP, is that true? Mr. Flynn. In the Blue Cross/Blue Shield Service Benefit Plan there are two options required by law, but not all plans are required to offer two options. Mr. Weldon. OK. So they can have three options, four options? There is no limitation on the number of options? Mr. Flynn. No, I am sorry, I believe the issue is not more than two options. Mr. Weldon. Not more than two? Mr. Flynn. Though the Service Benefit Plan is required to have two options. This is an area where it might be worthwhile to discuss whether or not additional options on the part of participating plans might be warranted. It is another area to think about, Mr. Chairman. Mr. Weldon. Would that require a change in statute? Mr. Flynn. Yes, sir, it would. Mr. Weldon. OK. If you had that kind of flexibility, would that have changed how you dealt with the situation you were in this year, Mr. Gammarino? Mr. Gammarino. It certainly would have given us more flexibility. However, the High Option was in trouble. Mr. Weldon. Now when you say ``High Option was in trouble,'' the demand was just not there? Mr. Gammarino. Well, yes, but we haven't mentioned this word, and that is ``adverse selection.'' That is, you had a group of enrollees that had significant health care needs. The pooling of insurance where you have users and non-users really didn't work too well with High Option. You primarily had high users and they needed medical care. So the issue of cost for that group was really not an issue at all. They needed care and they needed somebody to pay for it. Mr. Weldon. And that is why the premium, if you had kept that in place, would have gone up 30-50 percent? Mr. Gammarino. It was based upon the experience of that group. In order to continue to underwrite that group and have the revenues to pay the expenses, you would have had to increase our rates. Just a reminder that plans like ours are experience-rated. Our premiums reflect the actual experience of the group. So getting back to your question, would we have done something, we probably would have considered a third option. It would have been easier. It would have been easier to do. But the fact remained that the High Option product in terms of long-term viability had significant issues. Mr. Weldon. Mr. Flynn, as I understand it, within FEHBP you can only charge individual or family, and you cannot prorate or adjust the family rate based on the number of dependents? Mr. Flynn. Right. Mr. Weldon. Is that correct? What is going on in the private sector in that arena? Is that the standard in the private sector? It is either individual or family, or do they tend to adjust premiums based on the size of the family and the number of dependents? Mr. Flynn. Mr. Chairman, if you would allow me, I would like to do some confirming back at the office, but there is no sort of standard out there, but I would say that there are more health plans that center on the sort of self-plus-family, which is the family enrollment, without distinguishing in terms of one spouse, one spouse/one dependent, one spouse/two dependents, and things like that. We have actually done some studies of what the effects of that might be on premiums, and they are sort of counterintuitive, but I think the dominant practice is still individual coverage, family coverage. Mr. Weldon. Mr. Gammarino, in the private sector is that basically the way it is handled as well? Mr. Gammarino. Yes, I would agree. I mean, there are exceptions to that, but primarily the major employers pretty much have the same type of health plans in terms of family and single coverage. Mr. Flynn. Where you do see some differences, Mr. Chairman, is that there is a larger proportion of employers, private employers, who will typically pay 100 percent of the self-only coverage and then ask the individual being covered to pick up the difference between that and family coverage. Again, that is not a predominant practice, but you see that more frequently in the private sector than you do in the public sector. Mr. Weldon. My time has expired. Mr. Davis, did you have a question for the second round? Mr. Davis of Illinois. Yes, thank you, Mr. Chairman. Mr. Moffitt, I believe you mentioned the fact that we need to get some new blood or we needed to mix the demographics, that we needed a different composition. Then I noted that Delegate Norton mentioned the fact that 58 is an average age. Mr. Moffitt. Right. Mr. Davis of Illinois. Are you suggesting in any way that we need to place more emphasis on factoring in the age of the population group that we are dealing with or that we need to do something to shift part of that age group out of the program? Mr. Moffitt. No. Congressman, what I am saying is basically expand the program. I think Mrs. Norton actually put her finger on it. We want to be careful how we do this. A suggestion that I made in my formal testimony is to expand it to people who do have a direct relationship with the Federal Government. That group are young military families who are enrolled right now in the military health care system. You are talking about between 5 and 6 million people. Young military families are healthy. Their national representatives have testified before Congress that they would like to be in the Federal Employees Health Benefits Program. But the central value of it would be that it would improve the actuarial profile of the pool. As a result, it would stabilize and possibly even bring down premiums and give young military families access to what is clearly a superior health care delivery system than what they have got today. So that is my view, Congressman. I think that there is an opportunity here and I think we ought to take advantage of it because we have a large number of people who would, in fact, benefit directly by having the opportunity to enroll in the best group health insurance program in the world, despite its minor flaws. Mr. Weldon. Would the gentleman yield? Mr. Davis of Illinois. Yes. Mr. Weldon. Are you saying dependents---- Mr. Moffitt. Yes. Mr. Weldon [continuing]. Only? Mr. Moffitt. I'm not talking about--no, the military health care system is divided. You have a military health care system which is designed for military combat, and that is covering military personnel. I am talking about the program that covers dependents, which is a different program. Very frankly, Mr. Chairman, this debate has been going on for some time internally within the Department of Defense, and certainly I am sure it is going to go on within this administration. But Department of Defense officials have recognized that there is an inherent tension between providing military services for basically civilians who are dependents of military personnel and the demands of a combat-ready medical system. My argument is that we have a 9 million pool right now that is rapidly aging, which has an unusually large number of retirees compared to any other group health insurance system in the country. We can actually improve that pool by allowing young military families to take advantage of it. What I said in my testimony is we can do this in a budget- neutral fashion. That is to say, let them come in on the terms and conditions that apply to Federal employees, but allow them to keep any of the benefits that they would reap by entering the FEHBP with either pay increases or rebates directly to those families. Mr. Davis of Illinois. Well, let me ask Mr. Flynn. Mr. Flynn, how would you respond, OPM respond to that suggestion? Mr. Flynn. Mr. Davis, as Mr. Moffitt has indicated, this is an issue that has been discussed over a number of years and under a number of different administrations. There are views on the matter within the Defense Department and within the administration. I am going to express the view that we have always expressed when it comes to this program and how it might serve as a model. We stand ready at any time and at any place to help people, employers and others, satisfy the health care needs of their employees, populations, what have you. But when it comes to fundamental changes to the nature of the FEHBP, we want to make sure that we understand exactly what it is we are being asked to do and what the pros and cons of any such step might be. I will admit to you that at first blush there are some attractive notions associated with bringing military dependents into this program, but I also know, given the discussions that have gone on for as long as I have been in this job and before, that there are some very serious issues that need to be considered, not the least of which is the adequacy of the military health care system to serve its combat role on an ongoing basis under such a structure. So I would simply say that is something else that clearly should be discussed. I am somewhat fine when we talk about new blood. I was saying to Director James that if we just hired 500,000 new Federal employees, we would bring premiums down in a heartbeat. [Laughter.] But she keeps reminding me that I shouldn't be talking like that. [Laughter.] But fresh blood, however it would be characterized, would have that type of effect on premiums in the long run. Mr. Weldon. The gentleman's time has expired. The gentlelady from Maryland is recognized for 5 minutes. Mrs. Morella. Mr. Chairman, thank you for allowing this second round. Mr. Weldon. Yes. Mrs. Morella. I did want to ask our two gentlemen, Mr. Mirel and Mr. Moffitt, about MSAs. You both have commented on being supporters of them, but I just wondered if you are aware that there was a 1998 CBO report that stated that imposing MSAs in the FEHBP Program would result in nearly $1 billion in new costs to the taxpayers and enrollees, and it would siphon off relatively healthy enrollees. Although it sounds good on the surface, I think that is a really pertinent point to consider with regard to MSAs. I might add another part to the question, too. Is there anything that you think would stop an individual from so-called ``gaming the system'' by switching to a comprehensive plan during the FEHBP annual open season in any year that they know that their health expenses, health care expenses are going to be higher? So I put these two points out because I think that it seemed to us there were problems. Mr. Moffitt. Congresswoman, they are excellent questions. I will go first, and Mr. Mirel is chomping at the bit, but he will have patience, I'm sure. [Laughter.] The CBO did make that analysis, and I am, frankly, only superficially familiar with it. So I don't want to comment on something that I am not thoroughly familiar with. I think that this is one of those areas where either the committee or the Congress or the administration should make an effort to run some kind of a demonstration program in the Federal Employees Health Benefits Program to find out exactly what the effect would be of introducing a medical savings account option, the standard medical savings account option, like a high deductible plan with a catastrophic piece. The CBO has said that this will cost money and that there will be significant adverse selection. The Rand Co. did a study in 1996; the subject of it was, ``Can Medical Savings Accounts for the Non-Elderly Reduce Health Care Costs?'' The Rand researchers predicted that, if all insured non-elderly Americans switched to MSAs, their health care expenditures would decline by as much as 13 percent. You've got a competition here in terms of analysis. I think we have to study that further. But I would say one way to do this would be to run a demonstration project of maybe 100,000 or 200,000 Federal employees. Run it for a couple of years and see how it works. With regard to the other question you are talking about, which is the gaming of the system, that goes on now. That goes on now because neither OPM nor the Congress has yet to address the issue of adverse selection in the Federal Employees Health Benefits Program, even though this has been going on, this debate has been going on as long as I can recall. I have made a suggestion in my testimony to deal with that, and that is to vary the contributions among enrollees based on their age. That is to say, allow underwriting on the basis of risk, and at the same time vary the contributions of the government on the basis of that risk, in order to protect high- cost elderly or high-risk employees against substantial premium increases. That is an old idea actually. It has been kicked around by economists, who are familiar with the FEHBP, for many years, but nobody has ever acted on it. But what you have got now is an irrational system. You have a system where, if you are an 88-year-old smoker, as I said in my testimony, or a 22-year-old jogger, you pay the exact same premium. So that means that every single time you have an elderly person enroll in a health care plan and that drives up utilization or the cost, it is an incentive for younger people to leave the program. If you would vary the contributions and allow a rational adjustment for risk, you would actually improve dramatically the functioning of the program. You would still have cross-subsidization, but you would be doing it through the government contribution system rather than trying to do it through the insurance market. Mrs. Morella. If I could comment on the demonstration project, the National Association of Retired Federal Employees did submit separately a testimony. In looking it over, it indicates the fact that ``adverse selection and subsequent premium increases in comprehensive plans occurred when the plans were offered to public employees in Ada County, ID and Jersey City, NJ. As a result, the county and city stopped offering MSAs to their employees.'' So we have had an example or demonstration program in that regard. I guess I don't have more time. I will submit another question to you later. Mr. Weldon. The gentlelady's time has expired. Mrs. Morella. Thank you. Mr. Weldon. The gentlelady from the District of Columbia is recognized for 5 minutes. Ms. Norton. This question is to Mr. Flynn, and it is based on the assumption that the further we get from the present system in our recommendations, the less likely it is that those changes will be made by Congresses as diverse as this one. So, Mr. Flynn, for example, whether we are talking about MSAs or--I mean, Mr. Souder made this point--whether you are talking about MSAs or whether you are talking about the government paying the full cost of Medicare and Medicaid, if it is not within the pattern, it is not likely to happen. That is why I am a little disappointed, Mr. Flynn, in your response to Mr. Moffitt's suggestion because your response was very much in the box: ``We are a health care plan like GM. We are an employer. We are set to offer a plan the way employers do''--even given the fact that you have a very atypical work force in many ways because it is older and getting older. It is likely to get older before it gets younger because of what is happening. Young people are certainly not coming to the Federal Government. They are going to the dot.coms or wherever else they go. I would like to follow Mr. Moffitt's suggestion with even suggestion on top of Mr. Moffitt's suggestion. Mr. Moffitt's suggestion talks about young families. I mean, I have gone just since September 11th to send off young men and women from our National Guard who are leaving people at home without health benefits. I think that is a disgrace. Yet, it seems to me this Congress in a bipartisan way would be more likely to accept dependents of people going off to fight as a result of our country being attacked than it is to do some of the other things that some of us have suggested. I was going to suggest I like Mr. Moffitt's suggestion, particularly coming as it does, which drives home the inequity of leaving people here to take care of themselves with no often major person who earns the funds. But I would like to go even further. What is increasingly happening to the government is that we contract out much of our business. So I would like to ask, especially since some of those contractors are virtually permanent employees, whether you would count at least those people--at least those people--as Federal employees, since for all intents and purposes those are Federal employees and are likely to be far younger than the average Federal employee or the increasing rise in our work force. Would you accept those as people that we might look to, even though it might make it bureaucratically a little more difficult for you to run? Don't worry, we will study it first. But would you be willing to look at that as a pool that might bring down the age, diversify the actuarial pool, and help cut costs? Mr. Flynn. Ms. Norton, if I conveyed from my earlier response that we don't want to talk about dependents of military members at all---- Ms. Norton. That is what I got, sir. I didn't hear you say, yes, that is something we ought to look at. Mr. Flynn. Let me quickly correct that. All I simply meant to say was that there is a long history of discussions of that we need to take into account. We certainly can continue discussions within the Defense Department and the administration on the desirability of doing that. Similarly, with respect to---- Ms. Norton. See, that is exactly what I am after. I am asking whether or not somebody is willing to fish or cut bait on, one, taking care of finding a way to expand health care benefits and, two, diversifying the actuarial pool of the Federal Government. What you are telling me is something we should continue to discuss. That is what we have been doing every year since I have been on this committee, with inflation taking away whatever there used to be for FEHBP. I am asking, is OPM willing to take some initiative in trying to diversify the work pool by moving this discussion beyond the discussion phase and seeing if we can come back to this committee with a proposal? Mr. Flynn. Ms. Norton, I am willing to take that back and to get the appropriate people around the table to talk about it---- Ms. Norton. Thank you. Mr. Flynn [continuing]. Without question. The one quick point I wanted to make was the point you made about Reservists leaving and leaving their dependents behind without health care coverage. There is a law that affects most employers. I don't know exactly the title of it, but it is called USARA. It affects the Federal Government and it affects private employers. If individuals are called to Reserve duty and ship out with their units, employers generally are maintaining health insurance for dependents. So if they had health insurance when the call-up occurred, I think generally you are finding that is going to be continued at least for some period of time. Ms. Norton. Suppose they didn't. Many of my constituents did not. If, in fact, the person who earned the income is going off, it does seem to me that you are going to cover him now because he is going to be in the Persian Gulf, but his family is left here with nobody to cover them. Mr. Flynn. Yes, I don't know--you know, I am not technically expert in that. If they didn't have it to begin with, I doubt that the protections of that law would come into play. But I think for most people who did have it, there are significant protections for health insurance and other benefits under that law. Mr. Weldon. The gentlelady's time has expired. I want to again thank all of the witnesses for your very informative testimony. The hearing is now adjourned. [Whereupon, at 3:45 p.m., the subcommittee adjourned, to reconvene at the call of the Chair.] -