consideration; OIRA shall forward to the appropriate agency within 10 days all written communications it receives from non-Government employees with respect to a regulation, and place those documents in a public docket; only the OIRÁ Administrator, or her designee, shall receive oral communications about a regulation from non-Government employees; OIRA shall invite a representative from the issuing agency to all meetings between OIRA and non-Government employees and shall notify the appropriate agency of the date and names when non-Government employees have a substantive oral communication with OIRA staff on the regulation (such information shall be placed in a public docket); and OIRA shall publicly disclose the status of all regulatory proposals under review.

The committee had scheduled prior to the end of the first session a hearing to review initial steps at implementing Executive Order 12866. The hearing will be rescheduled for the second session. 3. Economy and Efficiency of the U.S. Health Care System.

The U.S. health care system needs significant reform. In 1993 we will spend $898 billion on health care or 14.3 percent of GDP. If no steps are taken to control costs the Congressional Budget Office expects total spending to approach $1.6 trillion in the year 2000, or 18.2 percent of GDP.

The Federal Government pays for 31 percent of the Nation's health care bill. All told, in 1993 the Federal Government spent $280 billion, with Medicare accounting for $151 billion and Medicaid $79 billion. According to CBO, Federal spending on health care is the main contributor to high deficits in the 1990's. Huge deficits projected in the year 2000 of around $500 billion will be primarily the fault of rising Medicare and Medicaid expenditures.

Despite this spending 38.5 million Americans are uninsured at any given moment and if nothing is done to reform the system, every year, 1 to 2 million more Americans will lose their health insurance. It is clear that major reforms are needed.

One factor contributing to high U.S. health care costs is that the United States trains and employs a high number of specialists in relation to primary care practitioners. About one-third of U.S. physicians are primary care doctors, and among recent medical school graduates the rate has plummeted to 20 percent. By comparison, in industrial countries with universal coverage, one-half to twothirds of doctors are primary care physicians.

Specialists provide highly intensive care at much higher costs than primary care practitioners. Primary care practitioners are mos cost-effective because they act as gatekeepers, closely monitoring a patient's health, thereby diagnosing and treating an illness much sooner. Limiting referrals to specialists only when necessary results in reduced hospitalization and less reliance on the expensive style of medicine specialists perform.

To provide recommendations to Congress about how to best increase the supply of primary care providers, the committee requested two studies of the GAO. The first, which is cosponsored with the Senate Special Committee on Aging, will be the first comprehensive study to analyze the Federal Government's role in fi

nancing medical education. The Federal Government contributes over $5 billion per year to medical education directly through health professions education programs, as well as through research funding and patient care reimbursements. However, we place no requirements on medical schools for achieving a more balanced ratio between primary care and specialties. The GAO is expected to make significant recommendations with regard to the best means to increase primary care physicians that should assist in the debate over national health care reform in the second session of the 103d Congress.

A second study underway by GAO for the committee will review the methods that other governments with national health programs employ to increase the ratio of primary care physicians to specialists, and the role these governments play in encouraging primary care physicians to practice medicine in medically underserved areas. Issues to be covered include regulation of post-graduate training slots, the formal use of gatekeepers, medical school debt, income disparities among physician specialties, and the role of medical education.

The committee has not only been examining methods of controlling costs in the U.S. health system, but also methods of ensuring that the special needs of certain underserved populations are addressed in a cost-effective manner. One such population includes residents in rural America. Lack of doctors, too few hospitals, and long and hazardous traveling conditions are some of the factors that contribute to the limited access to medical services residents in rural areas experience.

In June the committee held a hearing in Alpena, MI to review the access problems of residents in rural areas. Committee members in attendance included Chairman Conyers, Representative Bart Stupak, and Representative Karen Thurman. Testimony was received from a variety of persons representing a diverse set of constituencies including physicians, hospitals, small business, insurance companies, and consumer organizations.

Another underserved population is young, school-age children from low-income families. One method of delivering the necessary care to these children is by providing health services through clinics in the schools the children attend. School-based clinics, which number over 300 today, have been shown to successfully provide low-cost medical, counseling, and family planning services to elementary and high school students.

Currently the Federal Government spends about $50 million per year through a variety of programs assisting school-based clinics. The President's health care reform plan has proposed increasing spending to about $300 million per year.

The committee asked the GÃO to examine the effectiveness of school-based clinics in providing a variety of health services, including preventive care, treatment of minor conditions, screening and other tests, health promotion, counseling, and referrals. The committee also requested GAO to make recommendations about the most appropriate Federal role in facilitating the development and maintenance of school-based clinics, including whether the activities of more than 10 Federal entities funding some aspect of school-based clinics should be consolidated.

The three GAO reports discussed above will be released in the second session of the 103d Congress.

4. Oversight of the General Accounting Office.

During the 102d Congress, the committee initiated an oversight review of the General Accounting Office [GAO]. This review continued during the 103d Congress and was recently marked by full committee hearings on October 26 and 28, 1993.

The committee's review focused on several broad areas including (1) the level of service GAO is providing to Congress, (2) the efficiency of the agency's operations, and (3) management and other issues which might impair GAO's future effectiveness. In the process the committee closely examined many discrete subissues such as GAO's timeliness in completing various audit phases, the roles of individuals on GAO audit teams, employee concerns, and office improvement initiatives. The committee also examined GAO's resource allocations and the impact of recent cuts in the agency's budget. Whenever possible, prior-year comparisons were made so that GAO's current operations could be viewed in the proper historical context.

During the course of this review literally thousands of pages of internal GAO documents were examined and many GAO executives and staff were interviewed. The committee carefully considered the views that Members of Congress and senior committee staff provided on the agency's performance. In addition, the committee closely monitored House and Senate deliberations on GAO's funding to ensure that any new issues raised in these forums were incorporated into the committee's review.

At the conclusion of its review, the committee scheduled 2 days of oversight hearings to publicly air its findings. The committee's first day of oversight hearings was held on Tuesday, October 26, 1993. Members of Congress from both sides of the aisle testified on GAO's performance and the importance of the agency's assistance to Congress. Comptroller General Charles Bowsher presented testimony on key aspects of GAO's operations and responded to questions and concerns raised by Members.

Former Comptroller General Elmer Staats testified on the second day of the committee's hearings. As GAO's "elder statesman," Mr. Staats described GAO's role and mission as envisioned at the time of the agency's creation and as codified in its authorizing statute. Mr. Staats also offered his assessment of GAO's role in evaluating Federal expenditures, programs, and other issues of importance to the Nation. Regional and headquarters representatives of two GAO employee groups also appeared on the second day to present an “insiders" view of GAO. They identified the issues causing the most concern among GAO staff and areas which they believe are ripe for improvement. These individuals represented the views of GAO's band I and band II employees (GS-7 through GS-14)-which comprise over 70 percent of GAO's total work force. Finally, officials from the Departments of Energy and Interior presented the agencies' viewpoint on general auditing procedures and the role that audits play in improving executive branch operations.

The Committee on Government Operations conducts oversight of the General Accounting Office on an ongoing basis. The committee

initiated this most recent oversight review in keeping with its responsibility to hold periodic oversight hearings over agencies that carry out the laws within the committee's jurisdiction. This responsibility is set forth in Rule X of the House of Representatives.

The Government Operations Committee has legislative jurisdiction over the entire body of law governing the organization and operation of the GAO. This legislation includes GAO's authorizing statute, the Budget and Accounting Act of 1921, the Budgeting and Accounting Procedures Act of 1950, the Congressional Budget and Impoundment Act of 1974, the General Accounting Office Act of 1980, and the Chief Financial Officers Act.

In addition, as the House's principal oversight committee, the Government Operations Committee has jurisdiction over the many Federal programs and agencies which GAO is ultimately directed by Congress to audit. For this reason, the committee is especially familiar with GAO's operations and capabilities, and the importance of the services GÃO provides to Congress. The committee will continue to oversee the management and operations of the GAO during the next session of Congress. Particular attention will be given to GAO's efforts to streamline its audit processes and resolve outstanding employee concerns.

5. Review of the Recommendations by the Vice President's National Performance Review.

On September 6, 1993, the Vice President released the recommendations from the National Performance Review [NPR). The review produced a 124 page report titled, "Creating A Government That Works Better & Costs Less," which contained 384 major recommendations, covering 27 Federal agencies and 14 government systems.

The NPR's mission is to "reinvent" government with new management strategies, performance goals, and paradigms. The effort was staffed by some 200 Federal employees, who began their research with reports from the General Accounting Office, the inspectors general, the Committee on Government Operations, and from other resources.

The committee paid particular attention to issues on financial management, performance-based budgeting, debt management, and procurement reform.

The committee also closely monitored and researched recommendations on the budget process. The Vice President's National Performance Review recommended adoption of a 2-year budget cycle for the President and Congress. This 2-year cycle would apply to all steps in the current annual budget cycle, including the submission of the President's budget request to Congress, the congressional budget resolution, and all appropriations bills. The proposed budget cycle would commence in the even-numbered year. Consequently, no budget would be submitted by a President, or considered by Congress, in the first year of a congressional session or a new administration. The NPR also recommends more frequent usage of multiyear authorizations.

The Legislation and National Security Subcommittee held a hearing on October 7, 1993, to evaluate the Vice President's Na

tional Performance Review recommendation that the Federal Government adopt a biennial, or 2-year, budget cycle.

On October 21, 1993, the full committee held a hearing on the National Performance Review.

The Director of the Office of Management and Budget, Leon Panetta, and the OMB Deputy Director for Management, Philip Lader, testified to the committee about the recommendations of the NPR and the administration's plan for implementing the reform proposals.

Legislation to implement some of the National Performance Review's recommendations, H.R. 3400, passed the House of Representatives on November 22, 1993.

6. Program Evaluation Efforts in the Federal Government.

The committee has commenced a review of Federal program evaluation measures in executive branch agencies.

In order to better understand program evaluation efforts across the Federal Government, the committee asked the agencies to answer questions about their program evaluation efforts, which included: the amount of funding for program evaluation for fiscal year 1994, and the projected amount of funding for fiscal year 1995; the current amount of full-time staff assigned to program evaluations and to whom they report; the amount and type of program evaluation units that exist and what types of studies have been conducted; and, an explanation of how program evaluation studies are used and who uses them.

The committee also asked if the 3 percent administrative costs cut ordered by the President would have any effect, negative or otherwise, on current and future program evaluation efforts in the agencies. Staff also asked for the agencies to comment on OMB's general role and attitude about program evaluation efforts.

A hearing is planned to review agency responses in the second session of the 103d Congress.

7. Debt Collection.

The committee continued its oversight on credit management, cash management, and debt collection efforts by executive branch agencies.

The administration began drafting legislation in the summer of 1993. The committee staff worked closely with officials of the Department of the Treasury's Office of Financial Management Services and the Office of Management and Budget on this legislation, known as the Federal Credit and Cash Management Act of 1993. This legislation is still undergoing agency review within the administration.

Some of the initiatives under review are: requiring GSA and all agencies to certify competency of new contractors and to screen for delinquency on Federal debt; establishing an interagency team to review lenders participating in Federal loan guarantee programs; and delegating to a lead agency responsibility for reviewing lenders participating in Federal loan guarantee programs.

The legislation would also create a central data base of government debtors for screening borrowers and/or administrative offset (equivalent of combining ČA/VERS and administrative offset data