[Congressional Record Volume 143, Number 21 (Tuesday, February 25, 1997)]
[Extensions of Remarks]
[Pages E313-E314]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                THE HEALTH INSURANCE BILL OF RIGHTS ACT

                                 ______
                                 

                          HON. JOHN D. DINGELL

                              of michigan

                    in the house of representatives

                       Tuesday, February 25, 1997

  Mr. DINGELL. Mr. Speaker, the legislation we are unveiling today is 
not based on theoretical or theological constructs. It is rooted in the 
real-life experience of people dealing with their health care system.
  Ten years ago, fewer than one in seven Americans with private 
insurance were enrolled in some form of managed care. Today, three of 
every four Americans with private insurance are in managed care. 
Including Medicaid and Medicare beneficiaries, more than 140 million 
Americans were covered by managed care plans as of 1995.
  There is a growing body of anecdotal and statistical evidence to 
suggest that many of the changes in our health care system over these 
last few years are not without flaws or imperfections.
  Let me be clear. Managed care plans, and health maintenance 
organizations, perform good and great works every day. With managed 
care, we get a better overview of the care provided, so that we can 
identify and end improper or unnecessary practices. We can better 
coordinate the care received by a single patient. And we can get the 
benefits of bargaining collectively with providers to cut costs.
  The traditional fee-for-service system built in a series of 
incentives to generate more revenue by providing more services. My 
concern is that the pendulum may have swung back too far in the other 
direction. We've gone from cost being no consideration to cost being 
the only consideration in providing health care. And neither extreme is 
healthy for the public.
  You may have heard the stories: Heart attack victims forced to drive 
miles to an approved emergency treatment hospital. Patients denied 
payment for emergency care. Medicaid HMO's refusing to pay for 
antibiotics to stop a childhood dysentery epidemic. Cardiac surgery 
centers selected on the basis of price rather than survival rate. 
Marketers charged with mail fraud, forgery, or bribery. According to 
surveys, 80 percent of the American people agree that quality care is 
often compromised to save money.
  I don't believe these problems are necessarily typical of HMO's or 
the managed care business. The vast majority of plans are operated by 
honorable men and women. The same can be said of any other endeavor or 
profession. Most stockbrokers are honest, as are most doctors, or 
police, or even--believe it or not--most Members of Congress. But that 
doesn't obviate the need for laws or regulations to corral and control 
the bad actors.
  Concern about the practices of some managed care plans prompted us to 
pass legislation in the last Congress to guarantee that a woman and her 
doctor would decide how long she should remain in the hospital after 
giving birth. This Congress, Congresswomen DeLauro and Roukema and I 
introduced similar legislation on the length of stay after a 
mastectomy.
  I'm well aware that some have criticized legislation on births or 
mastectomies because they are specific to one condition. I find that 
criticism amusing. When we tried to enact comprehensive health care 
reform, many of the same people told us we were doing too many things 
all at once.
  I'm also aware of another criticism, and that is that Congress should 
not be making medical decisions.
  I couldn't agree more. Congress shouldn't have to concern itself with 
the length of a hospital stay after a mastectomy or birth. Those 
decisions should be made by qualified medical professionals and their 
patients. But the harsh fact of the matter is that when cost, and not 
care, is the primary consideration, the wisdom of doctors and patients 
is too often supplanted by insurance companies. The Congress is simply 
acting to restore some balance to the equation.
  That's the guiding principle behind the legislation that Senator 
Kennedy and I are introducing today, the Health Insurance Bill of 
Rights Act.
  This legislation deals with the four cornerstones of a system that 
tips the balance in favor of the client--a system that puts patients 
first--access, quality, information, and dispute resolution.
  First, the bill would ensure that patients can get their health care 
in the best place and from the best people--whether it is a primary 
care provider, a specialist, a specialty hospital, or even a high-
quality clinical trial. The key here is the health of the patient, not 
whether a provider is a member of the health plan's network.
  The legislation will make sure that a sick patient can complete a 
course of treatment with the doctor and hospital the patient knows and 
trusts, and that a healthy patient will have real choice of providers 
in receiving routine health care. For example, a woman who regularly 
sees an obstetrician-gynecologist can consider that doctor as her 
primary care provider. Or a cancer patient's oncologist can refer the 
patient to other specialists for related treatments, without going 
through a ``gatekeeper.''

  Our bill deals carefully with the thorny issue of drug substitution. 
We don't mandate prescription drug coverage, and we don't forbid drug 
formularies. We simply say that health plans ought to consult with 
their own doctors in developing their formularies, and ought to provide 
a way for those doctors to substitute drugs when they believe it's 
medically necessary.
  Second, quality.
  This bill lays out a number of components of a good quality assurance 
program--components that mirror what the best of your health plans 
already do for their patients. We would require health plans to collect 
data and make information available in plain language, so patients can 
compare different plans and make wise choices.
  Third is patient information. The minimum quality and information 
components in this bill are things we have been told patients want and 
need to know: The plans' criteria for determining medical necessity, 
appropriateness, efficiency, and access; their policies to ensure 
confidentiality of medical records; the scope of their utilization 
management activities; and the way the plans evaluate consumer 
satisfaction. In other words, the bare-bones components of a top-notch 
health plan.
  Our bill would require health plans to provide simple information 
like addresses, telephone numbers, what benefits are included, the cost 
of premiums, and any cost-sharing requirements. Patients also need to 
know about the credentials of providers, how to obtain authorization 
for services, and how to get referrals to providers who are not plan 
participants. In other words, patients ought to have enough information 
at their fingertips to navigate the system without frustration and 
failure. I am sure that any good health plan would be not only willing 
but anxious for consumers to have all of this information.
  And while on the subject of information and communication, I should 
also mention that this bill incorporates the patient-friendly concepts 
first introduced by Representatives Markey and Ganske in the last 
Congress--the concepts that underlie the ability of doctors and 
patients to communicate freely and understand each other effectively.
  Finally, the legislation provides an absolutely essential component 
of a consumer-friendly health plan--an appeals process that works: 
Timely notice of a plan's decision not to provide a certain benefit, or 
not to pay for it, and a workable process for the patient to appeal. 
This process must be fast when it needs to be fast--such as when the 
patient is seriously ill or near death. And, as the icing on this cake, 
the plan must have a real, fair, dispute resolution process which takes 
account of the views of the patient and provider as well as a third 
party, such as an ombudsman, who can look at the situation from a new 
perspective.
  This legislation was developed through consultations with literally 
dozens of interested and affected parties: Consumer groups, hospitals, 
medical professionals, health plans, and others. It is modeled on State 
statutes that were fully bipartisan. For instance, the State of New 
York, with a Republican Governor and Democratic legislature, has 
enacted similar legislation.
  I'm well aware that I'll be criticized for proposing Government 
intervention and regulation. But the fact is that through our 
democratic institutions, we routinely establish fair

[[Page E314]]

terms for competition. We prohibit practices we deem unfair, 
discriminatory, outlandish, or improper. The American people expect 
Government to set minimum standards of behavior, and keep the playing 
field level.
  In the area of health insurance, we need to see that competition is 
based on more than just price. Price often tells us very little about 
value or quality. One of the arguments for changing the Consumer Price 
Index is the argument that it fails to take into account improvements 
in quality. And let me observe that if price were the only 
consideration in buying a care, we'd all be driving around in Yugos.
  When it comes to health care, I don't want a Yugo, and I don't need a 
Rolls-Royce. A Dodge or Chevy or Ford will do quite nicely.
  In this instance, that means a system in which patients receive 
appropriate, quality health care, in which they can understand 
decisions about their care, and in which they can act effectively on 
their own behalf. My legislation will accomplish that.

                          ____________________