[Congressional Record Volume 144, Number 24 (Tuesday, March 10, 1998)]
[House]
[Pages H935-H941]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




  REPUBLICAN LEADERSHIP NEEDS TO ACT NOW ON BASIC PATIENT PROTECTIONS

  The SPEAKER pro tempore (Mr. Jenkins). Under the Speaker's announced 
policy of January 7, 1997, the gentleman from New Jersey (Mr. Pallone) 
is recognized for 60 minutes as the designee of the minority leader.
  Mr. PALLONE. Mr. Speaker, this evening I would like to discuss an 
issue which I have addressed on the floor of the House many times 
before and probably will deal with a lot more as we move through the 
session in this year, 1998; and that is the need for managed care 
reform.
  I believe that the American people have the best health care in the 
world. Unfortunately, the quality of care is being limited by HMOs or 
managed care plans. I think that Congress must act now to enact basic 
patient protections, but to put the ``care'' back in managed care.
  Many of us have talked for the last year or so about the types of 
things that should be included in an effort to reform managed care. The 
President had an advisory committee that issued a report that went 
through various patient protections that could be included. At the same 
time, in his State of the Union address the President talked about the 
need for patient protections and basically called upon the Congress on 
a bipartisan basis to pass managed care reform. I have actually 
introduced a bill, a number of our colleagues have introduced 
legislation that would put patient protections in effect in the context 
of managed care organizations.
  But what has not happened and what needs to happen is that this House 
and this Congress must pass legislation and should get to doing so as 
quickly as possible. The time for talk is over. The time for action is 
now. We do not have a lot of time left because of a shortened 
legislative calendar in 1998, and I think we need to move in committee, 
we need to move on the floor and we need to move in both Houses towards 
managed care reform.
  I have to say that I believe very strongly from every indication that 
I have received that the Republican leadership is not interested in 
moving forward on managed care reform. There has been a tremendous 
amount of money coming from special interest groups, from the insurance 
companies, in particular, that have been lobbying Members of Congress 
not to pass a managed care reform or patient protection act legislation 
in this session of Congress.
  The Republican leadership has been out there saying that they do not 
want to do it, and I think what we have to do as Democrats and those 
Republicans that are willing to join us, is to push the Republican 
leadership. Because they are in the majority, we have to push them to 
bring this legislation through committee to the floor so that the 
President can sign it.
  I have to say that this is a very important issue for our 
constituents. Every time I go back home and hold a town meeting, 
constituents ask me when Congress is going to provide common-sense 
managed care reform.
  In New Jersey, the voters spoke loud and clear and the State 
legislature, along with Governor Whitman, a Republican, enacted model 
patient protections. It was not radical legislation in New Jersey. It 
has not substantially increased costs as the special interest lobbyists 
would have us believe. Instead, it was principled on choice, access and 
quality health care.
  Let me just give my colleagues an idea, if I could, about the types 
of things that we are talking about when we talk about a Democratic 
managed care reform initiative.
  Basically what we are saying is that individuals enrolled in managed 
care plans would be guaranteed that their health plan will have enough 
doctors and health providers in its network to ensure that they get the 
care they need on a timely basis, that they would have the right to 
choose to see providers outside their health plan, that they would have 
the right to see specialists when necessary outside their health plan, 
that they would be guaranteed that their doctor would be allowed to 
tell them about all their treatment options, that is, no plan would be 
able to use gag rules to restrict doctors' communications with 
patients, that they would have access to emergency care without prior 
authorization in any situation that a prudent lay person would regard 
as an emergency.
  For women with breast cancer, they would be allowed to stay in the 
hospital following surgery for a minimum of 48 hours for a mastectomy, 
or 24 hours for a lymph node dissection. For a women to be guaranteed 
the right to direct access to their obstetrician-gynecologist and be 
able to choose their obstetrician-gynecologist as their primary care 
physician.
  When a service and procedure is covered by their plan, that they be 
guaranteed that they and their doctor, not the insurance bureaucrats, 
would decide what care is medically necessary for their treatment, that 
they be able to get authorization for care from their plan in a timely 
manner based on clear, objective written guidelines, that they be 
guaranteed that if they were denied care by their plan, there would be 
a timely, reasonable and meaningful system of recourse for those with 
life-threatening illnesses allowing them to participate in a clinical 
trial for experimental therapies at no extra cost to them, that they 
have protections against discrimination on the basis of health status, 
genetic information and other factors, that for women who have had a 
mastectomy, guaranteed coverage for reconstructive breast surgery, that 
they have access to medically necessary drugs, that they be guaranteed 
that their health plan does not use discriminatory practices when 
choosing doctors or other health providers who participate in its 
network, that they be guaranteed that their health plan would be 
subject to these new protections regardless of whether it is licensed 
at the State or Federal level and that they be provided full, relevant 
information about their plan, including which benefits are covered and 
which are excluded, what the individual costs are, what the plan 
policies are regarding authorization and denial of care and what their 
plan's policies are regarding selection and payment of providers.

  Mr. Speaker, these are a few of the common-sense provisions that the 
American people want enacted. New Jerseyans in my State are fortunate 
to have a responsive State legislature that addressed these issues but 
unfortunately not all in New Jerseyans will be able to enjoy the same 
level of patient protections. That is because the

[[Page H936]]

Employee Retirement Income Security Act of 1974, ERISA, says that State 
laws do not apply to companies that self-insure. This means that many 
of the constituents of my State are left without adequate health care 
quality standards.
  In a sense there is a two-tiered standard in my State and in many 
others. Only Congress can act to address this shortfall. ERISA comes 
under Federal law.
  The Democrats are gearing up to fight for the rest of the American 
public's right to common-sense, quality health care. We understand that 
it is good that State legislatures passed these individual laws in 
their State, but it does not apply to a lot of people who are self-
insured. It also obviously does not apply from one State to the other. 
That is why we need Federal action.
  I am pleading with the Republican leadership not to sit on the 
sidelines. They have to basically realize that regardless of what the 
special interests say, this is the type of legislation that the 
American public wants, that the American public needs, and that we 
should be addressing here during our debate this year in 1998.
  One of the things that I noticed, Mr. Speaker, is that when we have 
forums back in my district in New Jersey, and we have had some and we 
are going to have a lot more on the issue of managed care reform, that 
many people will show up and basically tell the story, if you will, 
about their individual problems that they have had, or their children 
have had or their mothers, their fathers have had, or friends with 
managed care plans that have denied them coverage or denied them 
certain services, and how difficult it has been for them to appeal with 
the denial of certain coverage and to get through the bureaucratic 
process that many managed care plans necessitate when you try to get 
some service or some procedure that they deny or that they will not 
allow.
  I could give my colleagues many examples of that, but I wanted to 
give one example tonight because this was a woman who came to our 
hearing that we held in January. Her name is Cheryl Bolinger. She in 
particular, I thought, explained very well the morass or the maze, if 
you will, that one has to go through when trying to get the managed 
care plan to approve a service or procedure that they do not want to 
approve.
  I do not know if I am going to read the entire thing, because I know 
I am going to be joined by another Member here, but I wanted to at 
least start with some of the testimony that Ms. Bolinger gave at a 
hearing that I held, along with Senator Torricelli, back in January on 
the issue of managed care reform.
  She said that she is the mother, Mrs. Cheryl Bolinger from New 
Jersey, of a 15-year-old child who has multiple developmental 
disabilities and complex chronic mental problems. Her daughter 
Kristin's medical problems began shortly after her birth. At 6 weeks of 
age, she developed unexplained intractable seizures. Because of the 
severity and the debilitating effects of her condition, she must be 
followed by many specialists and undergo many specialized and expensive 
diagnostic tests.
  ``Today, that was in January, Kristin remains nonverbal and 
nonambulatory and requires customized durable medical equipment for 
every aspect of daily living. Customized equipment is also needed to 
prevent and minimize the effects of orthopedic problems. She also 
requires physical and occupational therapy to enhance and maximize her 
potential in terms of her orthopedic status and general medical 
condition.
  ``During Kristin's infancy and early childhood we were fortunate 
enough to have a fee-for-service insurance plan. As long as our medical 
documentation was current and in place, in other words, prescriptions, 
follow-up care and letters of medical necessity, we did not encounter 
problems obtaining adequate and proper medical care regarding all areas 
of our daughter's acute and long-term care. In 1993, however, our 
insurance plan was changed to an HMO.''
  This is something, Mr. Speaker, that of course has happened to many 
people who had a fee-for-service plan where they could choose their 
doctor and switched and were forced basically because their employer 
switched to an HMO.
  Ms. Bolinger goes on to say that at that point, when she changed to 
the HMO, ``We encountered many difficulties regarding Kristin's medical 
care. According to the plan, we had to choose a pediatrician who had 
contracted with the HMO to serve as her primary care physician. The 
pediatrician who had been seeing Kristin for many years was not a 
participant in the plan. Likewise the specialists who had been treating 
her for so long also were not plan participants.
  ``My husband and I were very upset over this change and need to give 
up the excellent care Kristin had been receiving from these physicians. 
We were very concerned about the future of our child's health care. 
Nevertheless, we tried to be optimistic, and we visited a plan-approved 
pediatrician who would serve as Kristin's primary care physician. To 
our dismay and disappointment, we were not satisfied with the level and 
quality of care provided.
  ``Our freedom to choose a suitable physician for our child, while 
receiving adequate insurance coverage have been taken away by the 
HMO.''
  If I could just stop here, Mr. Speaker, from Ms. Bolinger's statement 
before our hearing, this is, of course, the problem. Now that people 
who for many years had been taken care of by primary care physicians 
whom they knew and whom they respected and who they felt were doing a 
good job, now all of a sudden had to be replaced by someone within the 
HMO.
  I think what I am going to do at this point is to stop here in 
talking about Ms. Bolinger's case, because I can go back to it later 
on, because I want to, if I can, give time to one of my colleagues from 
the Committee on Commerce, the gentleman from Texas (Mr. Green). He, I 
know, has been involved with this managed care issue for some time now 
and has had many experiences in his own district where people have come 
up to him and talked about some of the problems that they have had.

                              {time}  1900

  Mr. GREEN. Mr. Speaker, I want to thank my colleague from New Jersey 
(Mr. Pallone) for requesting this hour special order talking about 
managed care and patient protection. A lot of folks, though, and I 
found out in my own district in Houston, I represent a very urban 
district, we had a managed care town hall meeting not yesterday, but 
the week before, and just asked senior citizens, average working folks, 
we had physicians, providers, even some hospital representatives come 
talk about managed care.
  What I found out is that first of all, for the discussion tonight, we 
need to make sure that people know that some States like New Jersey and 
Texas have passed legislation but that only covers insurance policies 
or HMOs that are licensed to practice in that State.
  A great many employers come under what we call the ERISA Act. It is a 
Federal act that was passed in the early 1970s. Because so many of our 
employers are multi-State and sometimes multinational, an employer in 
Texas and New Jersey, obviously, they would not want to have to jump 
through both restrictions in each State, so Congress passed something 
that said, okay, you can come under Federal law for your health care, 
and so many of our constituents now come under Federal law.
  So what is happening, though, is that we are lagging behind some of 
the innovative efforts that States are doing to provide for more 
patient protections. Both the bill of the gentleman from New Jersey 
(Mr. Pallone), and of course the gentleman from Georgia (Mr. Norwood) 
has his bill that has over 200 cosponsors, and the gentleman from New 
Jersey (Mr. Pallone) and I are members of the Democratic Health Care 
Task Force where we are working on legislation that will be similar on 
managed care reform, patient protection reform. The gentleman from 
Michigan (Mr. Dingell), our ranking member on the Committee on 
Commerce, is putting that together and will be the lead sponsor on 
that.
  We need to ensure that every American enrolled in an HMO or a PPO or 
a PSO, also known as managed care, gets first-rate health care with 
benefits and the quality and the protections that both they come to 
expect and that they also deserve. Americans should not be required to 
give up access to their quality health care just because we in

[[Page H937]]

Congress are not doing our job in bringing the Federal law into the 
same realm that the private industry is doing.
  The gentleman and I were both here in 1993 and 1994 when we heard the 
fear of government-run insurance. Well, we did not pass any of those 
bills and now we do not have government-restricted care, we have 
industry-run insurance. So we have seen the fear of 1994 and 1994 come 
to light, and in 1996, 1997 and 1998, because we are seeing restriction 
in choice, and it is not because the government is telling someone that 
they have to do it, it is because the market is doing that. Employers 
are trying to cut the cost for their bottom line, and I understand that 
and I am for that, but I also know that is what one can do, when we are 
seeing a cutting of the cost and also a cutting of the benefits and 
what people are assuming hopefully will be quality health care.
  There are some great managed care networks in our country, and some 
of them are really good. What I would like is just to have, whether it 
be the Norwood bill or the Pallone bill or the Dingell bill, that would 
just give some guidance to managed care networks in our country so 
people will know what they can expect, that they have some flexibility; 
that, importantly, they should not lose control of the decisions 
regarding their personal health care.
  Although I have to admit trends are bleak unless we pass legislation, 
the picture is limits on access, limits on information, and even limits 
on accountability. The trend is not acceptable and must be corrected by 
those of us who the people elect in Congress to deal with that.
  An individual in my district, they do not have the ability to 
negotiate. Their employer often does, and I have even had employers who 
come up to me and say, ``I would like to have some guidance.'' Our 
concern is to provide the best care for our employees at the cheapest 
rate and the cheapest price. But there is bound to be a convergence of 
that, and I do not think we are seeing that, whether it be in my 
district or around the country.
  It is time for the managed care companies, the insurance companies 
and the plans to be more accountable in delivering quality care and 
respecting basic human rights, consumer rights. By setting this 
standard and the guidelines, what we could have will be an effective 
tool for delivery of first-rate health care. But it also will give 
people, the consumer, the ability to know that when they go out on the 
market, whether it is as an employer or employee, they will also know 
some of the guidelines that each company that is bidding on their 
business would have to comply with.
  Our health care task force and our full committee and our 
subcommittee, we have not had as many hearings as I would like to have, 
but our Democratic Health Care Task Force has adopted an agenda that 
will assure patients high-quality health care by requiring these HMOs 
or insurance companies or managed care plans to provide patients with 
access to specialists, coverage for emergency services which cannot be 
denied by the plan. I have heard it, and I have heard it from other 
Members of Congress, and I have had constituents who have gone to an 
emergency room because they had chest pains, and because they did not 
have time to pre-clear going to a different hospital than was on their 
plan, their plan will not pay for it because their chest pains turned 
out to not be a heart attack.
  Well, the gentleman and I are not physicians and we are not the 
people, and neither are our constituents, that should diagnose their 
illnesses. They go immediately because we know with heart conditions, 
the quicker you get to health care, the better. So that is why it is 
important to have easy access to emergency services.
  Also, internal and external appeals process, so if someone is 
watching who is making those decisions, that is what is important; and 
then confidentiality of medical records.
  Mr. PALLONE. Mr. Speaker, if I could just interrupt my colleague for 
a second on that last point, when I was using this example of Ms. 
Bollinger as one of the people that has written to me and talked to me 
about the problem that she had with her child, one of the things that 
was most important to her was the last thing you mentioned about the 
grievance and appeal procedure. Because my colleague understands and I 
understand, but I think a lot of people do not, that if you are an 
individual like her that has a daughter that needs this kind of care 
that has been denied, it is very difficult, first of all, in that 
strenuous situation which she was in, to be calling up the bureaucrats 
and telling them this is what you want them to do, and getting the 
papers together and trying to find a means, if you will, to overturn a 
decision that they have made to deny the care. So if there is not some 
sort of expedited procedure that is easily accessed by someone to make 
an appeal or to express a grievance, they are not going to be able to 
succeed in changing the decision the insurance companies made.

  So I just wanted to mention that, because even though it does not 
seem like it is very important, it is crucial to these people that are 
trying to get justice and make sure that the coverage is there.
  Mr. GREEN. Again, it is just some guidance so people will know that 
if they make that call for pre-clearance, that if that decision is made 
that they have some appeal process, and that is just fair. I do not 
want to particularly go hire a lawyer to do it, I just want to have 
some process that that layperson can do.
  The confidentiality of medical records, I know it is part of the 
President's plan; and also, with what we are concerned about with 
genetic privacy, we need to make sure that our medical records are as 
confidential as possible and yet still allow for research. But with 
what is happening in the National Institutes of Health and the 
discovery of genetic makeup of ourselves, we need to make sure that we 
protect individuals so that they are not excluded from health care 
because of their genetic makeup that they do not have anything to do 
with, because we are forcing them then onto the public system where all 
taxpayers have to pay.
  In the patient participation in medical decisions, during our town 
hall meeting on health care about 8 days ago I had a hospital come in, 
it is Texas Children's Hospital in Houston, that is a secondary HMO, 
because they only deal with children, and they talked about the 
scenario that they are a recent HMO, they have only gotten in the 
business as a PSO or provider service organization.
  But one of the things they want to do is sit down, and they are doing 
it with the parents and the children, so that the parents will know, 
and it is even more important with children, because as a parent we are 
concerned about what happens to our children, so we want to make sure 
that those decisions are made cooperatively and that we understand what 
is happening with our children. Like I said earlier, similar 
protections have been made in health insurance reform, like I said, in 
the State of Texas and also in New Jersey, but the State of Texas 
reform is being challenged by one of the insurance carriers. But the 
problem exists here on the Federal level. The States can only do so 
much, and we have to respond to our constituents.
  I know I have a colleague from Texas (Ms. Eddie Bernice Johnson) who 
has a health care background, is a nurse, and I have had the honor of 
serving with the gentlewoman for 25 years, and I have always looked for 
her guidance with her health care background because I do not have any 
health care background. I was a printer and a lawyer and a business 
manager. So the gentlewoman has been able for many years as a State 
legislator and here in Congress to help bring us that perspective to us 
in Congress.
  But that is why it is so important for us in Congress to respond, 
whether it is the Norwood bill, or Pallone bill, or Dingell bill. No 
matter what we do, we have to address the need for reform and the way 
health care and managed care and HMOs are delivered, and follow the 
lead of a lot of States that have tried to do this as best they can 
with the State insurance policies. We have to do it on a national 
basis.
  Mr. PALLONE. Mr. Speaker, I appreciate the gentleman's remarks, and I 
just want to point out what the gentleman pointed out over and over 
again, that this is really pretty common sense. The things that the 
gentleman listed are things that we really should have in place on the 
Federal level. Even though it is true that the

[[Page H938]]

gentleman's State and my State have adopted some patient protections, 
it does not help a lot of people, even in our own States, and certainly 
does not help anybody who is not in our States, and that is why we need 
Federal action.
  Maybe tonight we can go through some of these patient protections in 
a little more detail and give some examples of how it might impact 
people, because I think as the public understands what we are talking 
about, they understand how simple and common sense these principles are 
and why they should be enacted into Federal law.
  Ms. EDDIE BERNICE JOHNSON of Texas. Mr. Speaker, will the gentleman 
yield?
  Mr. PALLONE. I yield to the gentlewoman from Texas.
  Ms. EDDIE BERNICE JOHNSON of Texas. Mr. Speaker, I thank the 
gentleman.
  There is real concern going on, because as we began to talk about the 
patient concerns, we began to see ads coming onto television to attempt 
to actually frighten people. I think that what we are attempting to do 
now makes a lot of sense.
  As long as we have health care that is focusing on how much dollars 
the insurance companies can save and how much they make, and they make 
a lot of money, then we get away from patient basic needs. Clearly, we 
want every business, legitimate business to make money, but in health 
care when it is only focused on how much the insurance companies make, 
we tend to get away from basic human desires and needs. I believe we 
have gone too far, and I think that is one of the reasons why 
bipartisanly concerns now are being expressed here in the Congress.
  We are seeing situations where patients are being taken away from the 
doctors they have had for 25 or 30 years, and they do not get an 
opportunity to get to know who the doctor is on that staff because they 
do not spend any time with them. The anxiety levels go up, and often 
the interventions, the contact the patients might have might increase 
instead of decrease.
  We see a number of people in my district that are complaining about 
getting sick after 5 o'clock, or getting to the office of an HMO about 
a quarter to 5 and they close at 5 and they will not let them in, and 
if they are really sick they have to go to the emergency room, which 
costs twice as much as having a simple intervention. When patients have 
to give up physicians that know them individually and know their 
records, because no matter what the illness is, individual bodies react 
differently, and when they have had the same physician for a number of 
years and all of a sudden they have to give that physician up, it 
affects that patient negatively.
  The complaints are so great that I do not know how we can address 
them without this legislation. When we talk about Patient's Bill of 
Rights, often nobody knows what we are talking about, but it is really 
a very simple thing to address the concerns that patients have now.
  I suppose that one of the major concerns is the fact that they cannot 
choose their own physician, which often makes it so that they have to 
travel miles across town to get to where they need to go, and this is 
especially a problem in a large metropolitan area that I represent a 
major part of. When we have people that live 25 and 30 miles away from 
the nearest office of an HMO, and they are elderly and they are 
depending on public transportation, it makes it very difficult to get 
there. And if they work, it makes it almost impossible to get 
preventive care, which is primary care, which is the least expensive 
care, which is the most important to invest in, because once someone 
gets the information, learns how to take care of themselves, it reduces 
the health care bill because they do not have to go as often when they 
have that information.

                              {time}  1915

  Mr. PALLONE. Mr. Speaker, if I could interrupt 1 minute, I think this 
issue of choice of doctors is so crucial to the whole emphasis that we 
as Democrats are putting on managed care reform. The President has 
talked about this, and, of course, as the gentleman from Texas (Mr. 
Green) mentioned, our health care task force, which is about to put out 
a bill that the gentleman from Michigan (Mr. Dingell) is going to be 
the lead sponsor of, talks about patient choice.
  I am not saying, and I do not think we can maybe say that, in a 
network, in an HMO network, that we have to guarantee in every case 
that we can choose any doctor we want.
  Ms. EDDIE BERNICE JOHNSON of Texas. No. I do not think that makes 
sense.
  Mr. PALLONE. But that maybe would break up the whole idea of managed 
care.
  Ms. EDDIE BERNICE JOHNSON of Texas. That is right.
  Mr. PALLONE. But at least people, when they initially choose a plan, 
should have a choice that, if they want a point of service option so 
they can go outside the network, they can.
  That means they might have to pay a little more of a nominal fee; I 
do not have a problem with that. But there has to be some way so that 
people have the option of choosing a doctor if they are not satisfied 
with the doctor they have.
  That is the problem I think that so many people bring to my attention 
now that they do not have that choice anymore. It has been denied them.
  Ms. EDDIE BERNICE JOHNSON of Texas. Yes. It is clear that, if every 
person chose every doctor that they wanted or not wanted to move from 
any physician, it probably would interfere, clearly it would interfere 
with the concept of a health maintenance organization. However, there 
ought to be choices within that network. Personnel does not always 
click with personalities.
  Often, physicians as skilled as they are, might have particular areas 
with which they show concern, and they are very interested in a 
particular area and might not be as interested in another area.
  I think that patients ought to have a right to choose within that 
network what physician they see, because that patient/physician 
relationship has a lot to do with the progress of that patient. This is 
a new experience anyway for these patients, and just having that 
opportunity could make it a much more acceptable experience for them.
  We recognize that the cost of health care soared. We understand that 
these interventions are for the purpose of controlling some of that 
cost. But when we have to give up all of the quality, it is not worth 
it. We have to maintain a level of quality that our patients can do 
well with. In order for them to do well, they absolutely have to have 
some choices. Not everyone can go to the hospital with the same 
diagnosis and get out in 3 days. It might take some 5.
  Mr. PALLONE. If I could ask the gentlewoman from Texas to yield back 
to me, I think it is particularly important when the gentlewoman talks 
about access to specialists, because, oftentimes, the HMO, the network 
will not have the specialty care that is needed. And I think that there 
should be a guarantee.
  One of the things we have talked about as part of this managed care 
reform, that if the plan, if a network does not have a specialist that 
is qualified or can handle that particular situation, that we should be 
able to go outside of the network to get the specialist. That is 
another complaint that I hear quite a bit about.
  Ms. EDDIE BERNICE JOHNSON of Texas. That is correct. Clearly, that is 
why we have specialists, because certain physicians specialize in areas 
that are needed. We need the specialists. If patients do not have 
access to those specialists, then we are not offering them the greatest 
opportunity for recovery or for getting the best information that they 
can have, the best approaches for taking care of themselves.
  Clearly, a majority of the long-term care can be self-administered. 
But they must have the information, they must have access to the right 
and the best information in order to do well and to prosper healthwise 
after making the intervention with the health care provider.
  We cannot get away from having some type of individualized care. We 
cannot wholesale all health care. Human beings are different. They 
react to medications differently. They do better under various 
different circumstances. That has to be taken into consideration.
  When we get to the point where absolutely no individualized 
opportunities

[[Page H939]]

are there for patients, then we have gotten away from the real meaning 
of having health care and really even having specialists.
  We have come to a point where we must allow a physician to practice 
medicine. Physicians are trained. They are educated. They must be 
allowed to practice medicine.
  Insurance companies simply cannot practice medicine for that 
physician. They must be given the leeway of practice so that they can 
look at that patient and determine what is best for that patient. We 
have gotten a little bit away from much of that.
  I have had numerous visits from hospital staff, from physicians 
themselves asking for that right to have the opportunity to simply 
practice their art. That is what they are educated for. They have the 
expertise.
  No insurance company can make that determination for individual 
patients. Sure we can have broad categories, but physicians must retain 
their right to practice.
  Mr. PALLONE. If I could interrupt the gentlewoman from Texas again, 
we had a perfect example of this, of course, with the drive-through 
deliveries for pregnant moms, where it had gotten to the point where 
many of the women, when they went to the hospital, actually had to 
leave within 24 hours.
  It did not matter whether or not the physician thought that was 
appropriate or whether the women felt that it was not appropriate, the 
health insurance company said that is it. She is there for 24 hours. I 
think it was 2 days for C-section. Again, I think that was a perfect 
example.
  Ms. EDDIE BERNICE JOHNSON of Texas. And for mastectomies.
  Mr. PALLONE. Exactly. It has got to be that that decision is made by 
the doctor with the patient, not by the insurance company. 
Unfortunately, that is getting to be the case with so many different 
types of care, not only mastectomies and child birth, but so many of 
the situations.
  Ms. EDDIE BERNICE JOHNSON of Texas. That is why it is so important 
that we consider legislation now, because it gets to be rather 
unmanageable to have to bring every particular ailment before this 
Congress to legislate for that particular ailment.
  We need a systemic type of approach. Unless we have an overall 
general approach as we get the outcry from our constituents around the 
country, we will be piecemealing it. Every year, we will put 
something else to be covered by an insurance company or how it is to be 
covered. That also is not a wise way to do the reforms for our health 
care system.

  We need a more organized, a more intellectualized way of approaching 
these problems. But if we fail to do that, we will have to continue to 
look at mastectomies one year, childbirth the next year, prostate 
surgery the next year, and something else the next year. That is not 
the appropriate way to address problems.
  Mr. PALLONE. One of the areas that concerns me the most in this 
regard is emergency care, because what I find increasingly is that the 
people are denied emergency care in the emergency room, or they are 
allowed into the emergency room, and they are provided care, and, 
later, the health insurance company does not cover it because they say 
it was not necessary; it was not an emergency.
  So one of the things I think is really crucial is this sort of 
prudent layperson standard; in other words, that you have to be 
provided and you have to cover the emergency care if a rational or 
reasonable person would think that that was an emergency, again, a 
decision based on what a doctor would think or what the average patient 
would think, not what the insurance company would think.
  Because I am getting more and more cases where, as I said, either 
people have been denied emergency care or they simply do not cover it, 
and they send them the bill on their own, which they cannot afford, 
which, as we know, emergency room care can be exorbitant if we are 
paying for it privately.
  Ms. EDDIE BERNICE JOHNSON of Texas. That is correct. If someone gets 
ill in traffic on their way home from work, and they happen to stop by 
an HMO, I had a constituent that this happened to just recently, 15 
minutes before it is to close, and be told to come back the next day 
because they are getting ready to leave. The person has to go to the 
emergency room, and he ends up being hospitalized. Then that is a 
situation that can only be governed by a change of attitude where the 
attitude is toward the care of that patient rather than watching the 
clock for an employee making a decision at the door before a physician 
is even seen.
  This is when the system is out of control. When the price tag goes 
up, the cost emotionally and physically to the patient is greater 
because the employees say it is 15 minutes before it is time for us to 
get off, and we simply cannot take care of it today. I do not want to 
be here overtime.
  Mr. PALLONE. One of the things that the gentlewoman has really 
brought out, and I think is so important, is that the emphasis, again, 
has to be on the quality of care and not so much on the cost of it. We 
understand that managed care reform has brought great cost savings, but 
the bottom line is that now it is just out of hand.
  If we implemented these patient protections that we are talking 
about, the cost really is very minimal. I know that that is an argument 
that is used that, oh, this is going to increase costs, but I do not 
believe it when we are looking at the kind of common sense approaches 
that we are talking about here that there is any significant cost 
increase.
  It seems to me, in the long run, we will probably save money, because 
a lot of it is preventative, and we end up helping people so they do 
not get sicker.
  Ms. EDDIE BERNICE JOHNSON of Texas. One of the fallacies of a system 
that has failed us is distrust, one of the outcomes. Once the patients 
distrust a system, the cost of it generally goes up, because there are 
more complaints, more anxieties, more concerns, and not confident that 
the quality of care will be there.
  Mr. PALLONE. If I could give the gentlewoman an example, just an 
example of this, when my wife and I had our son 2 years ago, they had 
just implemented this policy with the pregnant women that they were 
only allowed the 2 days for a C-section, because he was born with a C-
section. She had a C-section.
  As they were about to release him from the hospital for the 2 days, 
they had a pediatrician that was required, I think under the law, had 
to come in and look at him before he was checked out. They found that 
he was jaundiced. So they let him stay an extra day. They let her stay 
an extra day.
  If that had not happened and had not been detected, he could have 
easily gone out of the hospital, gotten worse with the jaundice, end up 
having to come back to the hospital and stayed a week or more, which 
would, of course, cost more money.
  So, to me, a lot of this is just preventative and actually saves the 
system money in the long run.
  Ms. EDDIE BERNICE JOHNSON of Texas. Oh, indeed. Most obstetricians 
will tell us that depression and anxiety after childbirth, especially 
for the first child, is very common. If that mother is forced to leave 
the hospital while they are still in a real state of uncertainty and 
not confident whether they know exactly what to do, they are more 
likely to exaggerate and exacerbate those symptoms than to have their 
anxieties alleviated.
  Clearly, just 24 hours, which we saw the need to correct in the last 
Congress, is not enough to ensure that that anxiety will not cause 
unnecessary bleeding and lots of other symptoms that might occur.
  When we insist upon these very hard decisions, notwithstanding what 
that individual reaction might be, then the system has gotten away from 
the human part of it. That is a major part of healing. That is a major 
part of well-being with anyone who has a physical symptom.
  It seems to me that, under the current system, without correction, we 
have just said it does not matter. It really does not matter. As long 
as we stay within the guidelines of this insurance company, that is all 
that matters.
  I do not believe this country is ready for a system that does not 
care. I think that is why the outcry is now. It is not that people do 
not respect and do not feel the need for some type of reform.

[[Page H940]]

                              {time}  1930

  It is just that when that reform becomes so calculating, so antihuman 
that it becomes then a failed system. That is why we have the outcry 
now.
  It does not take a lot of big government to correct it. It really 
takes a very few simple steps to do it that will not be costly. As a 
matter of fact, I think the costs will be greater to ignore the demands 
of our general public.
  This approach is not partisan. It is really not going to be solved 
based upon any hard-core decisions. It is going to be solved with us 
recognizing that patients across this country from all income levels, 
all walks of life, are rejecting what their experiences are now. I 
believe we restore the confidence and restore some quality that 
patients deserve when we can address this through this simple, what we 
call the patient's Bill of Rights.
  It is really not asking a lot. It certainly does not bring in a big 
government arm to direct everyone around, but it does return some 
reason. It does return some rights to the patient, that they can feel 
confident that they have just a little bit of say about what happens to 
them when they are ill.
  It is not a free system. It as a matter of fact, it costs more for 
the patients to get less. And that will not change with what we are 
talking about doing. That clearly will not change. But what can change 
is to have a little better opportunity for a little bit more quality in 
that care.
  Mr. PALLONE. I appreciate the gentlewoman's comments. I think it is 
absolutely to the point.
  I guess I started out today by saying that I really think that we 
know what has to be done here now. We have talked about this, and the 
President came forward with a Bill of Rights. Some of the Republicans 
have sponsored legislation. As we mentioned before, our Democratic 
health care task force has put forth a set of principles which are 
going to be put forward in a managed care consumer protection bill that 
will be introduced very shortly that we are going to be talking about 
and that we believe we have support for amongst the Senators as well as 
the White House in favor of this legislation.
  But what really needs to be done is, we need to push the Republican 
leadership to bring this managed care reform to the floor of the House, 
to bring it up in the relevant committees, to push that it come to the 
floor of the House, and do the same in the Senate.
  We do not have a lot of time here between now and the end of this 
legislative year. If we do not act quickly, and after all the 
Republicans are in charge of the process, they are in the majority; 
they are the ones that are going to decide what can come to the floor. 
If they do not bring this up and allow for debate and allow for a vote, 
then it is not going to happen.
  Part of the reason why we, as Democrats, constantly talk about this 
and will continue to talk about it is because we know that we need to 
push them to bring it up. Otherwise, it is not going to happen this 
year.
  Ms. EDDIE BERNICE JOHNSON of Texas. Mr. Speaker, I thank the 
gentleman for his leadership. I hope that we can depend on our 
Republican leadership to be responsive to the voices of the American 
people.
  It is not just Democrats that we are hearing from. My district has as 
many Republican voices speaking out and asking for some type of redress 
as do Democrats. It is an issue that all Americans have concern about, 
especially those working Americans who cannot actually pay for the cost 
of health insurance in an independent plan.
  We know we have to have these larger, supposedly affordable plans. 
But these plans do not work with gag orders. These plans are not 
working with all of the restrictions. Patients need a little bit more 
freedom of choice, and they need to feel confident that there is a 
little that they can expect coming to them after paying into these 
plans.
  I do not believe it is asking too much. I think the profits for the 
insurance companies would still be good, because in the long run it 
would reduce cost; it would reduce cost because you reduce anxiety, you 
reduce skepticism and you restore some confidence that when care is 
needed, care will be there.
  Once we restore some of that confidence, remove the gag orders so 
they will know the full truth, then I believe that we will certainly 
continue to control that cost. Otherwise, we have a system that is 
considered to be broken. And just because we ignore those voices does 
not mean they are going away. They will continue to speak out.
  I think we have a duty and a responsibility to be responsive to those 
voices. I thank the gentleman for his leadership.
  Mr. PALLONE. I thank my colleague from Texas also for joining me, and 
for her insight into this as a nurse, as well, because it is often 
those who are involved in the health care system as nurses, physicians, 
they are the ones that have the most knowledge and understand the kind 
of problems that many patients now face with the existing managed care 
or HMO systems.
  I was going to ask my colleague, if I could indulge the Speaker 
tonight, I began this evening by going through the testimony of a New 
Jerseyan, Cheryl Bolinger, who had experienced some severe problems 
dealing with the managed care system with her daughter. I did not 
complete her statement. I know that there is not enough time in the 
time that is allotted to us to complete it. I would like to either 
include it in the record now, if I could; or if not, I will put it in 
as an extension of remarks this evening because she really outlines 
very well the kinds of problems that a mother or somebody goes through 
when they are trying to get through this sort of Byzantine labyrinth of 
managed care.
  I just cannot imagine myself, if it was my daughter or my son, to 
have to go through this experience to get the proper care and to make 
the appeals and to deal with the objections and follow a grievance 
procedure. She was spending, from what I can see, more time doing this 
than she was with her job. She was not a woman who was in a position to 
be able to spend the time from 9:00 to 5:00 taking appeals of decisions 
that were made by HMOs.
  So many people face this on a regular basis. Fortunately, her 
daughter had a mother who had the willingness and aggressiveness and 
understanding about what to do, but many people do not. That is the 
problem. That is why we need our legislation.
  Ms. EDDIE BERNICE JOHNSON of Texas. Let me just quickly say that I am 
from Texas. It is not known to be a liberal State. As a matter of fact, 
we are kind of known to be a rather stubborn State. But one of the 
Republican leaders in the State Senate introduced and passed a bill to 
allow for HMOs to be sued.
  We have had a real fiasco in our State in how they have been able to 
function and the kind of quality that has virtually disappeared in 
health care.
  This was not brought forth by a liberal spending person. It was 
brought to the legislature by a very conservative Republican, because 
we have had probably one of the most unpleasant experiences in our 
State in dealing with our HMOs. We have had a number of, just a 
burgeoning number of complaints with them virtually having no way to do 
anything about it. I know this is not just my State. I believe this is 
happening around the country. I think that we have the responsibility 
to address these issues for the American people.
  During the district work period week of February 20, President 
Clinton issued an executive order directing all federal health plans, 
which serve over 85 million Americans, to come into compliance with his 
quality commission's consumer bill of rights. At the same time, many 
constituents asked me when Congress would follow the President's 
example and pass legislation that assures that the initiatives in his 
executive order for the patients' bill of rights becomes standard for 
all Americans.
  Four weeks later, I still have to inform my constituents that the 
majority has not scheduled a vote on such an important matter.
  As a member of the democratic health care task force, I look forward 
to the challenge of ensuring that more than 160 million Americans in 
managed care plans get the quality care they deserve, with more 
choices, protections and freedoms.
  Some special interests wish to label reform efforts as more big 
government. Giving more choices and quality care to more consumers in 
not big government, it is a ``patients bill of rights'' that has people 
and their well-being in mind.
  One example of the problems Americans experience with managed care is 
illustrated by a Kaiser Family/Harvard University poll which

[[Page H941]]

found that three-fifths of Americans feel managed care has resulted in 
doctors spending less time with patients.
  Americans are clear on the need for managed care reform. Congress 
should be clear on their commitment to enact it. The American people 
leave no doubt about their displeasure with health plans because of 
cost considerations and withholding important information from patients 
because of ``gag orders.''
  As a lawmaker, registered nurse and businesswoman, I know the 
benefits of not only protecting patients, but also giving them choices. 
Protecting patients and giving them choices are good policy, good 
health care and good business.
  This year, I will work to ensure that Congress answers the calls from 
Americans who are dissatisfied with their health care plans. It is 
important that Members of Congress from both parties work to provide 
Americans with a basic ``patients bill of rights.''
  I ask that the leadership in Congress answer the President's call, 
but more importantly, the American people's call to pass a ``patients 
bill of rights this year.''
  If we do not act now, we are faced with the reality that millions of 
Americans in private health plans may never be assured that they will 
also have the protections that their counterparts in federal plans 
enjoy.
  I yield the balance of my time.
  Mr. PALLONE. Mr. Speaker, it is important for us to tell these 
stories because I think that it is only when we tell the stories of our 
constituents and the people that have been through the system and the 
public and the other colleagues down here understand what our 
constituents are going through that we will get a ground-swell of 
support for managed care reform. I think it is very important that we 
relate those stories.
  I want to thank my colleague again.
  Mr. Speaker, I include for the Record the testimony to which I 
referred:

                      Testimony of Cheryl Bolinger

     January 22, 1998.

       Good morning Senator Torricelli and Congressman Pallone. 
     Thank you for your interest in hearing about the struggles my 
     family has had in trying to receive good, quality medical 
     care from an HMO for our daughter.
       My name is Cheryl Bolinger and I am the mother of a 15-year 
     old child who has multiple developmental disabilities and 
     complex, chronic medical problems. My daughter Kristin's 
     medical problems began shortly after her birth. At six weeks 
     of age, she developed unexplained intractable seizures. 
     Because of the severity and the debilitating effects of her 
     condition, she must be followed by many specialists and 
     undergo many specialized and expensive diagnostic tests.
       Today, Kristin remains non-verbal and non-ambulatory, and 
     requires customized durable medical equipment for every 
     aspect of daily living. Customized equipment is also needed 
     to prevent and minimize the effects of orthopedic problems. 
     She also requires physical and occupational therapy to 
     enhance and maximize her potential in terms of her orthopedic 
     status and general medical condition.
       During Kristin's infancy and early childhood, we were 
     fortunate enough to have a free-for-service insurance plan. 
     As long as our medical documentation was current and in 
     place, (i.e., prescriptions, follow-up care, and letters of 
     medical necessity), we did not encounter problems obtaining 
     adequate and proper medical care regarding all areas of our 
     daughter's acute and long-term care.
       In 1993, however, our insurance plan was changed to an HMO. 
     At that point, we encountered many difficulties regarding 
     Kristin's medical care. According to the plan, we had to 
     choose a pediatrician who had contracted with the HMO to 
     serve as her primary care physician. The pediatrician who had 
     been seeing Kristin for many years was not a participant in 
     the plan. Likewise, the specialists who had been treating her 
     for so long also were not plan participants. My husband and I 
     were very upset over this change and need to give up the 
     excellent care Kristin had been receiving from these 
     physicians. We were very concerned about the future of our 
     child's health care.
       Nevertheless, we tried to be optimistic and we visited a 
     plan-approved pediatrician who would serve as Kristin's 
     primary-care physician. To our dismay and disappointment, we 
     were not satisfied with the level and quality of care 
     provided. Our freedom to choose a suitable physician for our 
     child while receiving adequate insurance coverage had been 
     taken away by the HMO.
       After such a disheartening experience, we decided that it 
     would be in Kristin's best interest to remain with her 
     current pediatrician and specialists. They were the doctors 
     who knew her best. As a result of our decision, our benefits 
     were reduced and we were required to pay out of pocket.
       Also in 1993, we were advised by our insurance company's 
     medical review board that it had deemed Kristin's therapies 
     to be not medically necessary. Even though medical 
     documentation recommending these therapies was in place, 
     benefits were ceased. Because of the importance and necessity 
     of therapies for our child, we paid for them out of pocket.
       In 1994, Kristin developed a scoliosis curve which required 
     bracing. We used an orthotist in our HMO plan to manufacture 
     the brace. When I returned to our orthopedist with the brace, 
     he told me it was worthless and would probably increase 
     the curvature rather than inhibit it. My doctor was irate 
     that the HMO had contracted with a company that provided 
     substandard equipment; he referred us to an orthotist of 
     his choice who manufactured the brace free of charge.
       I called and wrote to my HMO regarding the inferior quality 
     of the brace the orthotist in their plan had made for us. 
     They responded by telling me they wouldn't handle the problem 
     and to contact the agency they contract with. I phoned and 
     sent written correspondence to the agency regarding the 
     problem. However, other than someone saying they would make a 
     note of the situation, I never received a satisfactory answer 
     or explanation regarding the inadequate and inferior quality 
     of the brace.
       In August 1997, Kristin underwent scoliosis surgery, which 
     required spinal fusion and instrumentation--a complicated and 
     serious surgical procedure. Fortunately, we were able to use 
     a reputable prominent surgeon in New York City who was on our 
     plan as a participating specialist. At this time, Kristin's 
     post-operative condition was very fragile. Upon discharge 
     from the hospital, Kristin was to receive nursing care and 
     physical therapy at home. The surgeon wrote very specific 
     orders regarding the medical care and rehabilitation needed 
     at home.
       After Kristin had been home for nine days, I received a 
     phone call from the contracted nursing agency informing me 
     that nursing services would no longer be covered and were to 
     cease. Contrary to our surgeon's recommendations, the HMO 
     opted to provide a home health aide instead of a nurse to 
     care for Kristin's nursing needs. The level and quality of 
     care provided by a home health aide was not adequate for my 
     daughter's complex medical needs. I immediately became 
     actively involved in requesting that the HMO cover the 
     necessary nursing care. After several additional letters of 
     medical justification, repeated taxes, phone calls, and 
     communication, the HMO conceded that they should follow the 
     initial recommendations of their surgeon. Nursing care was 
     reinstated after seven days.
       The surgeon also wrote very specific instructions regarding 
     special therapy for rehabilitation. Physical therapy was 
     ordered for 12 weeks. However, after only about six weeks--
     half the period recommended by the surgeon--I received 
     another phone call from the contracted agency stating that 
     physical therapy would no longer be covered and would cease. 
     Once again after my repeated attempts to correct the 
     situation, the insurance company reinstated therapy after a 
     two-week lapse. In both situations, continuity of vital 
     services for my daughter was interrupted due to poor 
     decisions made by the HMO.
       On our most recent follow-up visit to the surgeon (January 
     14, 1998) he was not satisfied with Kristin's post-operative 
     rehabilitation. He requested Kristin receive additional 
     physical therapy so that she could regain her post-operative 
     abilities and level of functioning. To date, I am still 
     awaiting a response to this request from the HMO.
       Because of surgery and the changes in Kristin's body 
     alignment, a new wheelchair is needed to accommodate her 
     post-operative status. We have been waiting for three-and-a-
     half months for secondary approval of this crucial and 
     essential piece of equipment and have still not received a 
     decision from the HMO. In the meantime, we have no choice but 
     to keep our daughter in a wheelchair that no longer meets her 
     needs while we continue to wait for a response.
       In conclusion, I would like to state that HMO's present the 
     following problems to families trying to obtain health care 
     for a family member who has developmental disabilities and 
     requires long-term care.
       Freedom to choose qualified physicians is compromised.
       The quality, continuity, and duration of care is subjected 
     and often does not meet the medical need of the patient.
       Durable medical equipment that must be customized and is 
     not a stock item is often inadequate and inappropriate for 
     specific medical needs.
       Many crucial requests are denied or delayed for too long a 
     time.
       The time and effort our family invests in trying to correct 
     the poor judgement of our HMO and the stress this creates 
     takes away from the valuable time we need to care for our 
     child. Unfortunately, this is the constant battle we must 
     wage to try to obtain proper, quality care for our daughter.
       Thank you very much Senator Torricelli and Congressman 
     Pallone for listening to the problems I have had in obtaining 
     good quality medical care for my daughter, Kristin.

                          ____________________