[Congressional Record Volume 143, Number 21 (Tuesday, February 25, 1997)]
[Senate]
[Pages S1570-S1571]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. GRAHAM (for himself, Mr. Hutchinson, Ms. Mikulski, and Mr. 
        Chafee):
  S. 356. A bill to amend the Internal Revenue Code of 1986, the Public 
Health Service Act, the Employee Retirement Income Security Act of 
1974, the title XVIII and XIX of the Social Security Act to assure 
access to emergency medical services under group health plans, health 
insurance coverage, and the Medicare and Medicaid Programs; to the 
Committee on Finance.


              THE ACCESS TO EMERGENCY MEDICAL SERVICES ACT

  Ms. MIKULSKI. Mr. President, I am proud to join Senator Graham in 
introducing the Access to Emergency Medical Services Act of 1997. This 
bill prohibits health plans from denying coverage and payment for 
emergency room visits. I support this bill for three reasons. It 
protects patients and patients' pocketbooks. It respects medical 
decisions made by doctors and nurses. It gives HMO's the opportunity to 
do the right thing.
  Personal health is not something to take chances with. That's why 
many people seek emergency assistance when they think something may be 
seriously wrong with their health. They go to the emergency room 
thinking their insurance company covers emergency room treatment. But 
when the problem turns out to be a nonemergency, the insurance company 
denies payment. This is called retrospective denial. I want to end 
retrospective denials. No family should have to second guess getting 
the care they need because they are worried about being stuck with an 
enormous bill.
  Last week my office received a phone call from a woman in Frederick, 
MD. She was distraught. She had begged her husband not to take her to 
the emergency room when she complained of serious chest pains. She knew 
their insurance company wouldn't pay. It had happened before. But her 
husband insisted she go. He was worried about her and wanted her to see 
a doctor. She cried all the way to the hospital. A few weeks later she 
got the notice--her claim was denied. She was stuck with the bill.
  She was right to go to the emergency room. There are approximately 
200 medical problems that could cause the type of chest pain she 
experienced ranging from a heart attack to pulmonary emboli to simple 
indigestion. The point is, no one knows for sure what problem they are 
having until they get treatment from an emergency room physician.
  Maryland already has laws in place to guarantee that HMO's will cover 
to emergency services. But we can't practice good emergency medicine 
one patient, one ER room, or one State at a time. That's why we need a 
national law that ensures that medical decisions are made in the ER 
room, not the corporate boardbroom.

[[Page S1571]]

  This bill will set a new national definition for the term 
``emergency'' without preempting stronger State laws. The ``Prudent 
Layperson Standard'' means that a person with average knowledge of 
health and medicine can seek emergency treatment when they think they 
have a serious medical condition. Quite often, patients do not know 
when they go to an emergency room whether their illness is life-
threatening or not. With this standard, they are not required to know--
they can use their own best judgment. After all, we can't expect the 
average person to be able to diagnose like a doctor.
  I am proud that the State of Maryland was the first State to enact 
legislation to counter these unfair practices. They passed their first 
law in 1993. But it took two follow-up laws to clarify the intent of 
the first one. Work still needs to be done to make sure the law is 
enforced. I salute the Maryland emergency physicians who took this 
issue on, and continue to fight for fair play on behalf of their 
patients.
  I want to see managed care, but I don't want to see doctors managed. 
There is a fundamental distinction. We have to start getting our 
priorities straight and decide where we are going to be making our 
decisions. And in the case of emergencies--I believe the decisions need 
to be made in the emergency room and not the boardroom.
                                 ______