[Congressional Record Volume 144, Number 83 (Tuesday, June 23, 1998)]
[House]
[Pages H5053-H5061]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
MANAGED CARE
The SPEAKER pro tempore. 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, tonight I would like to talk again about
the issue of managed care reform, and I have said before on the floor
that this issue, without question, has become one of the most important
on the minds of Americans, not only in my district but I think
throughout the country.
The reason that it has become so important is because patients are
being abused within managed care organizations. Patients often lack
basic elementary protections from abuse, and these abuses are occurring
because insurance companies and not doctors are dictating which
patients can get what services under what circumstances.
Within managed care organizations or HMOs, the judgment of doctors is
increasingly taking a back seat to the judgment of insurance companies.
Medical necessity is being shunted aside by the desire of bureaucrats
to make an extra buck, and people are literally dying because they are
not getting the medical attention they need and, ironically enough, are
in theory paying for through their premiums.
This is not an exaggeration. Myself and the gentleman from Iowa (Dr.
Ganske), who will be joining me tonight, and other colleagues on both
sides of the aisle have told numerous stories about people throughout
the country who have been negatively impacted by managed care.
As I mentioned before, because of the importance of this issue, there
are a number of legislative proposals that have been introduced to give
patients the protections they deserve from managed care organizations.
And working with the Democratic Caucus' Health Care Task Force, which I
co-chair, the gentleman from Michigan (Mr. Dingell) introduced
legislation which would provide patients with a comprehensive set of
protections from managed care abuses.
His bill, the Patients Bill of Rights, is not an attempt to destroy
managed care. It is an attempt to make it better. To emphasize that
point, supporters of managed care reform want just that, reform, not a
dismantling of managed care.
The Patients Bill of Rights would help bring about that reform by
putting medical decisions back where they belong, with doctors and
their patients. I have to mention that this is also a bipartisan bill,
with 7 Republican cosponsors, including my colleague the gentleman from
Iowa (Dr. Ganske).
Unfortunately, though, the Patients Bill of Rights does not enjoy the
support of the Republican leadership. It is not clear exactly where
they stand on the issue of managed care reform. There is still a task
force that the Republicans have put together and has been meeting, but
so far the Republican leadership has not allowed any managed care
reform bill to be heard in committee or to be marked up in committee or
to come to the floor, and I believe that that is because of the power
of the insurance industry that that has not happened so far.
Mr. Speaker, tonight I just wanted to say that there have been some
recent important developments on this issue. I am going to let my
colleague, the gentleman from Iowa (Dr. Ganske) go into some of this,
but I just wanted to say that legislation was introduced today by the
gentleman from Iowa (Dr. Ganske) and the gentleman from Michigan (Mr.
Dingell), again on a bipartisan basis, to try to bring the Patients
Bill of Rights and possibly other managed care reform to the floor
through what we call a discharge petition. Basically a discharge
petition is necessary when the House leadership will not allow a bill
to come to the floor through the normal committee process.
I just wanted to say how much I appreciate the efforts of my
colleague from Iowa, not only in introducing this discharge petition
today with the gentleman from Michigan (Mr. Dingell) but also because
the gentleman from Iowa (Dr. Ganske) has been an outspoken champion and
leader of the movement here in the House to bring the Patients Bill of
Rights to the floor, and I think he deserves a tremendous amount of
credit for that reason.
The only thing I also wanted to mention today about this discharge
petition is that I believe that there is a tremendous amount of support
for this. As my colleague knows well, we have been working closely with
over 150 groups that support the Patients Bill of Rights. I think the
Patients Bill of Rights now has 192 cosponsors.
Another bill on managed care reform which the gentleman from Iowa
(Dr. Ganske) has supported, the PARCA bill, has even more cosponsors,
from what I understand, so I do not think it is going to be difficult
to get support for this discharge petition.
The last thing that I did want to mention though, before yielding to
the
[[Page H5054]]
gentleman, is that we are going to push for this discharge petition
over this week and during the congressional recess so that when we come
back, we hopefully will get enough signatures so that we can bring the
Patients Bill of Rights to the floor.
I am still very concerned that the Republican leadership is going to
try to produce a watered-down managed care reform bill. As we know, the
Speaker has already rejected one proposal by the GOP task force because
it had too many patient protections in it. There are reports now that
some patient protections have crept back into the GOP plan and that the
task force will come forward with a bill this week or sometime in the
future. But I think we need to watch out that it is not legislation
that is substantially weaker than the Patients Bill of Rights or the
PARCA bill or some of the other strong legislation that we have been
pushing. Obviously, we are going to keep a careful eye on that as we
proceed over the next few weeks.
With that. Mr. Speaker, I yield to the gentleman from Iowa (Dr.
Ganske).
Mr. GANSKE. Mr. Speaker, I appreciate the remarks of my colleague
from New Jersey. Once again, here we are on the floor addressing our
colleagues about abuses in managed care as they relate to a Federal law
that was passed some 25 years ago called ERISA, Employee Retirement
Income Security Act, which basically gave legal immunity to health
plans that are health plans for self-insured employer plans.
I think without that prior Federal legislation, we would not need to
be here tonight. But because the majority of people who get their
insurance from their employer are now in HMOs versus the traditional
type of indemnity insurance, and because so few of them have a true
choice in terms of the health plan that they choose, many employers now
will only offer an employee one plan, take it or leave it, so that if
you are talking about choice in the health care marketplace, you are
really talking about having to change your job before you have a
choice.
I do want to address the issue of the resolution that I introduced
today along with Mr. Dingell. Nothing would please me more than to hear
my Republican leadership say before August recess we are going to have
a full and fair debate on the floor on managed care. After all, we have
two bills, the Patients Bill of Rights, Patient Access to Responsible
Care Act, with broad bipartisan support. I think it is well recognized
that if there is debate on the floor, one of these bills could easily
pass with much more than a majority.
{time} 1945
There is significant sentiment in the Republican Conference for a
patient protection legislation. So it would please me greatly if my own
Republican leadership would come out and say, do you know what, we
agree with 9 out of 10 Americans that we should pass Federal
legislation with federally enforceable standards for quality
protection.
We are going to bring this to the floor in a fair manner, not with
the type of rule that we have seen with campaign finance reform, which
is death by 1,000 amendments, but a fair rule giving both sides of the
issue a chance to debate this issue on the floor, to talk about the
abuses in the industry, how to fix them, how to provide protections for
the average American similar to the type of protections that we have
already passed for Medicare patients and the balanced budget act. We
will go into that in a little bit more detail.
So nothing would please me more than to have the leadership not make
a discharge petition a necessity. Unfortunately, we have seen over the
last 3 months, one delay after another from the Republican Health Care
Task Force.
We are told that tomorrow we will hear about some principles of
legislation coming out of the task force, but we are also told that a
bill is not available to look at. In fact, there may not be a bill
available until after the Fourth of July recess.
As everybody knows, we are looking at a shortened legislative
session. And I think it is fair to say from conferences I have had with
my colleagues that there are some Members of the House and of the
Senate that want to delay this legislation and delay it and delay it;
delay it until we get into October, and then all of a sudden, gee whiz,
we have to adjourn so we can go home and campaign for the fall
elections. It is just too bad that we did not get to this issue.
I do not think that that is the right way to go, and so I am looking
forward to the Republican leadership responding to the majority of the
House bringing this forward for a full debate in a fair way with a fair
rule, time-limited fashion, prior to August recess. If that is the
case, there will not be any need for a discharge petition.
But I would just like to talk a little bit, before yielding back to
my colleague, about why we need this legislation. We could come here to
the floor every night, and we could give case after case of an abuse in
the managed care in the industry. But I want to just read one story
written by the patient about how he was treated by his HMO.
This is related by a fellow by the name of Edward Mycek, and these
are his words:
In November of 1997, I found out that I had prostate
cancer. After discussing treatment and recovery options, my
doctor advocated surgery to remove the prostate. I decided to
get another opinion.
After consulting with the new doctor at Loma Linda
University Medical Center, I decided on proton and 3-D
conformational radiation treatment. The new physician and his
staff concluded that I was an excellent candidate for the
treatment for a number of reasons.
The doctors at Loma Linda Medical Center then contacted my
insurer, which said that it would pay for the full
treatments. In fact, my insurer called back to inform me that
the insurance policy covered these treatments, and they would
notify the medical center that the procedure had been
authorized. The authorization never arrived at the medical
center.
So, Mr. Mycek continues:
Worried about the delay of my care, I called my insurer,
who told me that they had reversed the decision. The company
claimed that this treatment, this radiation treatment was
`experimental and investigational.' Loma Linda, then faxed
factual information to my insurer which explained that the
procedure was not experimental or investigational.
In fact, I as a physician have known about this treatment for a long
time. It is a commonly accepted type of treatment for prostate cancer.
The medical center doctor also wrote a letter that discussed the
differential recovery rates. The radiation had a recovery rate of 98
percent versus 83 percent for surgery.
Mr. Mycek continues:
After several stressful weeks, I was still denied hope. I
asked my insurer what other treatments were covered. They
responded by saying they could not say. After being passed
back and forth like a ping-pong ball, I could not wait any
longer.
On February 17, 1998, after paying up front himself, I
began my first of 44 radiation treatments. This is a
financial burden on our family. Today I have completed all 44
radiation treatments, and I am due for a checkup.
After all is said and done, Mr. Mycek continues, I still
feel that I have been denied needed care by an agent 3,000
miles away, seated at a desk and appointed by the company to
decide the quality of care I receive. I have worked for this
well-known company for almost 32 years, and this was the
first major claim I ever made.
Because my insurer is protected by ERISA, I can recover no
damages from them. I do not have the resources to pressure my
insurer to provide better care. Is this ERISA law a fair and
just medical insurance law to employees,
Mr. Mycek continues. Not by any means.
Well, this is just one example of thousands that we could bring to
the floor to discuss why we need to have legislation like this.
I keep hearing from my colleagues, my conservative Republican
colleagues, and I should point out that I have one of the more
conservative voting records in the House, that, gee whiz, you know,
this organization could interfere with free markets.
I would just like to point out an article that appeared in the June
26 issue of Human Events. Human Events is one of the more conservative
newspapers in publication. It is published by Eagle Forum. One of the
more conservative columnists is a fellow by the name of M. Stanton
Evans.
Mr. Evans wrote this article: HMO Rationing Threatens Patients: Why
and How Conservatives Should Support PARCA Reform.
Mr. Evans says,
Once seen as a magic cure for rising health costs, managed
care has become a serious problem in its own right.
Remember, this is a very conserv-
[[Page H5055]]
ative columnist for one of the most conservative weeklies in the
country.
He continues:
Reports of care denial, quicker and sicker release of
patients, charges of wrongful death, and suffering are now
familiar items. But lobbyists for business, free market think
tanks, editorialists with leverage on the GOP, have charged
forth defending HMOs from this type of legislation, arguing
that a crackdown on managed care would be an intolerable
interference with `the market.'
Mr. Stanton continues:
However, as previously noted in this column, such arguments
are totally off base. HMOs and managed care are not free
market in any serious meaning of the term. It is worth
repeating the neglected point that HMOs resemble in their
basic structure the so-called global budgets of
collectivist systems overseas in which a certain fixed
amount of money is allocated to pay for everyone's free
care. And doctors get the dirty job of denying treatment.
They do things this way abroad because there is no market.
Then Mr. Stanton Evans continues:
The bottom line of this repressive sequence is that HMOs
are rationing machines in a government-spawned nonmarket
setting, which means the market plea of protecting them from
PARCA or a patient bill of rights fizzles.
Finally, Mr. Stanton Evans continues, and he summarizes:
A more sensible position on the topic might look
approximately as follows: First, so long as HMOs are called
on to ration care in a nonmarket framework, PARCA or
something like it should be adopted and amended so as to
distinguish between legitimate indemnity insurance on the one
hand and top-down health care denial on the other.
I would just like to point out this is a very conservative
publication. There is broad bipartisan support across the ideologic
spectrum for a patient bill of rights type of legislation. This is
something that we ought to move forward on and pass and at least have a
debate on the floor of Congress on this issue.
Mr. PALLONE. Mr. Speaker, I appreciate the gentleman's remarks, and I
think that there is no question that these patient protections are
needed. We will get into more of them.
Mr. Speaker, I would just like to continue along the line of what the
gentleman from Iowa (Mr. Ganske) mentioned. We said over and over again
the type of patient protections that we are seeking either with the
patient's bill of rights legislation or the PARCA bill is really
nothing more than a commonsense approach, the type of protections that
I think most Americans would think that they already have with their
health plan or with their health insurance but, unfortunately, they do
not.
I just wanted to get into two provisions of the patient's bill of
rights and give two examples again similar to what the gentleman from
Iowa (Mr. Ganske) did. One is the important access, if you will, to
specialty care. The bill, the patient's bill of rights, establishes
certain standards to ensure hassle-free access to appropriate specialty
care.
What it says basically is that plans must have a process for
individuals to access specialty care if they need it. If the plan does
not have an appropriate specialist in the network, it must provide an
outside referral to such a specialist, at no additional cost to the
patient.
I had an example. There is a group called Consumers for Quality Care
that actually put out what they call ``Casualty of the Day.'' Every
week, they put out some examples of patients who suffered casualties
from abuse by HMOs.
This one I think applies very well to this issue of specialty care or
lack of access provided by the HMO or the managed care organization to
specialty care. If I could just use it as an example. This is Judith
Packevicz from Saratoga Springs, New York. Actually, that is a
different example I want to give for another one. I apologize.
The example I want to give with regard to the specialty care is
Francesca Tenconi, who is an 11-year-old girl from Oakland, California.
Again, this is from Consumers for Quality Care. She suffers from, and
the gentleman from Iowa (Mr. Ganske) probably will be able to help me
with this better, pemphigus foliaceous.
Mr. GANSKE. Mr. Speaker, will the gentleman yield?
Mr. PALLONE. I yield to the gentleman from Iowa.
Mr. GANSKE. I believe it is pemphigus foliaceous.
Mr. PALLONE. I am not pronouncing it, but I thank the gentleman for
the help. This is an autoimmune disease in which the body's immune
system becomes overactive and attacks the protein which adheres to the
top layer of skin to the body.
Her parents had to battle with their HMO to insist upon appropriate
diagnosis and medical care. According to Donald Tenconi, Francesca's
father, her medical insurance ordeal began in December 1995 when, at
the age of 11, she developed what was diagnosed as a skin rash.
By March, the condition had spread and become worse. By late April,
the condition was so bad she could not attend school. During this
period, several requests were made for referrals to specialists outside
the HMO, and these were all denied.
Finally, on May 8, 1996, almost 6 months after the first appearance
of symptoms, the HMO sent biopsies to out-of-network doctors and
finally obtained an accurate diagnosis. The diagnosis was the disease
that I mentioned and that the gentleman from Iowa (Mr. Ganske)
translated for me.
Even after receiving the diagnosis, the Tenconis' HMO still insisted
on treating the disease primarily with its own doctors, in-network
doctors. It was not until February of 1997, over 1 year after the
symptoms first appeared, that the HMO finally agreed to allow Francesca
to receive care at Stanford Medical Center, which possessed the doctors
capable of providing the best care available in the San Francisco Bay
area.
Explaining the prolonged and unnecessary pain of lying down without
skin on your back for over 1 year, Donald said, this is her father
again, ``If you feel this pain, you will shed tears of pain, the same
pain that Francesca shed night after night, week after week for many
months.''
Again, I mention it because I think that it is necessary to have the
patient protection that provides access to specialty care outside the
network when the in-network doctors do not have the ability to take
care of the individual.
{time} 2000
Under the Patients' Bill of Rights, not only is that the case that
they have to allow you to go outside of the network if there is not
someone inside who has that specialty ability, but also patients with
serious ongoing medical conditions are able to choose a specialist to
coordinate their primary and specialty care. So if you have a chronic
illness that requires this kind of specialty care over a long period of
time, essentially your specialist becomes something like your primary
care provider so you do not have to constantly go back and get these
referrals.
The other example I wanted to mention, again one of the other major
protections that we talk about is that decisions about provision of
medical care should be based on what is medically appropriate for the
patient. They should not be based on the cost considerations of an
accountant or bureaucrat. The Patients' Bill of Rights prohibits health
plans from arbitrarily overriding medical decisions by your physicians
when these decisions are made according to generally accepted
principles of medical practice. Again that refers to length of stay in
the hospital, equipment, a particular type of surgery that may be
required, that this is supposed to be done based on what is medically
appropriate based on the decision of your doctor rather than the
bureaucrats.
Again, I think the gentleman from Iowa mentioned the other day an
example of somebody who needed a liver transplant. I do not know if
this is exactly the same example, but I would just like to mention it
again if I could. This is the case I mentioned before, Judith Packevicz
from Saratoga Springs, who suffered from a rare form of cancer of the
liver. The HMO refused to pay for a liver transplant which was
recommended by her oncologist with the support of all her treating
physicians. Again, a decision that was made based on what the doctors
felt was appropriate under the circumstances to have this liver
transplant, but because it cost an estimated $345,000, the HMO, of
course, refused to have it done and did not really give an explanation
about why. I will say here it was undoubtedly the cost of it. Again
they made a decision to deny her this liver transplant
[[Page H5056]]
even though her son, Thomas Dwyer, was a willing and able donor. There
were 13 other friends of Judith who volunteered to donate a part of
their liver. So she had somebody willing, able, would not do it because
of the cost undoubtedly, and she actually had to bring suit, again
under ERISA. She cannot recover damages, only the cost of the procedure
that was denied in the first place, and although it is possible that
she ultimately would get the liver transplant, there was no way for her
really to sue for any damages that would result because of the issue
that you brought again which is that the HMO basically cannot be sued
for damages.
Mr. GANSKE. If my colleague would yield, for the reasons that we have
outlined tonight and in previous special orders, there is broad support
by a number of organizations for this. I have eight pages here in fine
type of endorsing organizations for both the Patients' Bill of Rights
and the Patient Access for Responsible Care Act. With your indulgence,
I will just read through a few of these. These are all organizations
that have endorsed this type of legislation:
The Alzheimer's Association, the American Academy of Child
Psychiatry, the American Academy of Emergency Medicine, the American
Academy of Pediatrics, the American Association of Respiratory Care,
the American Association of Nurse Anesthetists, the American
Association of Pastoral Counselors. I am obviously not hitting all of
these organizations on this list, just selecting a few, so for those
that I do not mention, forgive me.
The American Association of Retired Persons, AARP, the American
Association of Mental Retardation, the American Cancer Society, the
American Dental Association, the AFL-CIO, the American Federation of
Teachers, the American Heart Association, the American Lung
Association, the American Medical Association, the American Nurses
Associations, the American Public Health Association, Catholic
Charities, Children's Defense Fund, Consumer Federation of America,
Consumers Union, Families USA, even companies like Genzyme, League of
Women Voters, Meals on Wheels of Lexington, National Association of
Rural Mental Health, National Association of Children's Hospitals,
National Association of Public Hospitals, National Consumers League,
National Council of Senior Citizens, National Multiple Sclerosis
Society. These are all organizations. Let me continue.
NETWORK: A National Catholic Social Justice Lobby; Service Employees
International Union, United Cerebral Palsy. Mr. Speaker, I submit these
lists for the Congressional Record, as follows:
Organizations Supporting the Patient's Bill of Rights Act of 1998
ABC for Health, Inc.
Access Living
AIDS Action
AIDS Law Project of Pennsylvania
Alamo Breast Cancer Foundation and Coalition
Alcohol/Drug Council of North Carolina
Alliance for Rehabilitation Counseling
Alzheimer's Association Greater Richmond Chapter
Alzheimer's Association NYC Chapter
American Academy of Child and Adolescent Psychiatry
American Academy of Emergency Medicine
American Academy of Neurology
American Academy of Pediatrics
American Academy of Physical Medicine and Rehabilitation
American Association for Marriage and Family Therapy
American Association for Psychosocial Rehabilitation
American Association for Respiratory Care
American Association of Children's Residential Centers
American Association of Nurse Anesthetists
American Association of Pastoral Counselors
American Association of Private Practice Psychiatrists
American Association of Retired Persons
American Association of University Women
American Association on Mental Retardation
American Autoimmune Related Diseases Association
American Board of Examiners in Clinical Social Work
American Cancer Society
American College of Emergency Physicians
American College of Obstetricians-Gynecologists (ACOG)
American College of Physicians
American Counseling Association
American Dental Association
American Federation for Medical Research
AFL-CIO
American Federation of State, County, and Municipal Employees
American Federation of Teachers
American Gastroenterological Association
American Group Psychotherapy Association
American Heart Association
American Lung Association
American Medical Association
American Medical Rehabilitation Providers Association
American Music Therapy Association
American Network of Community Options and Resources
American Nurses Association
American Orthopsychiatric Association
American Psychiatric Association
American Psychiatric Nurses Association
American Psychoanalytic Association
American Psychological Association
American Public Health Association
American Speech-Language-Hearing Association
American Therapeutic Recreation Association
Anxiety Disorders Association of America
Arc of Washington State
Asian and Pacific Islander American Health Forum
Association for the Advancement of Psychology
Association for Ambulatory Behavioral Health Care
Association of Behavioral Health Care Management
Bazelon Center for Mental Health Law
Brain Injury Association
California Advocates for Nursing Home Reform
California Breast Cancer Organizations
Catholic Charities of the Southern Tier
Center for Patient Advocacy
Center for Women Policy Studies
Center on Disability and Health
Children and Adults with Attention Deficit Disorders
Child Welfare League of America
Children's Defense Fund
Clinical Social Work Federation
Coalition of Wisconsin Aging Groups
Colorado Ombudsman Program--The Legal Center
Communication Workers of America--Local 1039
Consortium for Citizens with Disabilities Health Task Force
Consumer Federation of America
Consumers Union
Corporation for the Advancement of Psychiatry
Crater District Area Agency on Aging
Dekald Development Disabilities Council
Delta Center for Independent Living
Disabled Rights Action Committee
Eastern Shore Area Agency on Aging/Community Action Agency,
Case Management Department
Epilepsy Foundation of America
Families USA Foundation
Family Service America
Family Voices
Federation for Children With Special Needs
Florida Breast Cancer Coalition
Gay Men's Health Crisis
Gazette International Networking Institute (GINI)
General Clinical Research Center Program Directors
Association
Genzyme
Glaucoma Research Foundation
Health and Medicine Policy Research Group
Human Rights Campaign
Independent Chiropractic Physicians
International Association of Psychosocial Rehabilitation
Services
League of Women Voters
Mary Mahoney Memorial Health Center
Massachusetts Association of Older Americans
Massachusetts Breast Cancer Coalition
Meals on Wheels of Lexington, Inc.
Mental Health Association in Illinois
Mental Health Net
Minnesota Breast Cancer Coalition
National Abortion and Reproductive Rights Action League
National Alliance for the Mentally Ill
National Association for Rural Mental Health
National Association for the Advancement of Orthotics and
Prosthetics
National Association of Children's Hospitals
National Association of Development Disabilities Councils
National Association of Homes and Services for Children
National Association of Nurse Practitioners in Reproductive
Health
National Association of People with AIDS
National Association of Protection and Advocacy Systems
National Association of Psychiatric Treatment Centers for
Children
National Association of Public Hospitals and Health Systems
National Association of Public Hospitals
National Association of School Psychologists
National Association of Social Workers
National Black Woman's Health Project
National Breast Cancer Coalition
National Caucus and Center on Black Aged, Inc.
National Consumers League
National Council for Community Behavioral Healthcare
National Council of Senior Citizens
National Hispanic Council on Aging
National Marfan Foundation
National Mental Health Association
National Multiple Sclerosis Society
National Parent Network on Disabilities
National Partnership for Women & Families
National Patient Advocate Foundation
[[Page H5057]]
National Therapeutic Recreation Society
NETWORK: A National Catholic Social Justice Lobby
Nevada Council on Developmental Disabilities
Nevada Council on Independent Living
Nevada Forum on Disability
Nevada Health Care Reform Project
New York City Coalition Against Hunger
New York Immigration Coalition
New York State Nurses Association
North Carolina State AFL-CIO
North Dakota Public Employees Association--AFT 4660
Oklahoman for Improvement of Nursing Care Homes
Older Women's League
Ombudservice
Oregon Advocacy Center
Paralyzed Veterans of America
Permanency Planning Services, Inc.
Physicians for Reproductive Choice and Health
President Clinton
Reform Organization of Welfare (ROWEL)
RESOLVE
Rhode Island Breast Cancer Coalition
Rockland County Senior Health Care Coalition
San Diego Federation of Retired Union Members (FORUM)
San Francisco Peakers Senior Citizens
Service Employees International Union
Service Employees International Union--Local 205
Service Employees International Union--Local 585, AFL-CIO CLC
South Central Connecticut Agency on Aging
Southern Neighborhoods Network
The ARC
Tourette Syndrome Association, Inc.
United Automobile, Aerospace & Agricultural Implement Workers
of America (UAW)
United Cerebral Palsy Association
United Church of Christ, Office for Church in Society
Vermont Public Interest Research Group
Voluntary Action Center
Volunteer Trustees of Not-For-Profit Hospitals
West Side Chapter NCSC
Western Kansas Association on Concerns of the Disabled
Women in Touch
____
Groups Endorsing H.R. 1415, the Patient Access to Responsible Care Act
Academy of General Dentistry
American Academy of Child and Adolescent Psychiatry
American Academy of Emergency Medicine
American Academy of Nurse Practitioners
American Association of Children's Residential Centers
American Association of Marriage and Family Therapy
American Association of Nurse Anesthetists
American Association of Oral and Maxillofacial Surgeons
American Association of Pastoral Counselors
American Association of Private Practice Psychiatrists
American Association of Psychiatric Services for Children
American Association of Psychosocial Rehabilitation
American Chiropractic Association
American College of Emergency Physicians
American College of Nurse-Midwives
American College of Radiology
American Counseling Association
American Dental Association
American Federation of Home Health Agencies
American Group Psychotherapy Association
American Mental Health Counselors Association
American Occupational Therapy Association
American Optometric Association
American Orthopsychiatric Association
American Physical Therapy Association
American Podiatric Medical Association
American Psychiatric Association
American Psychiatric Nurses Association
American Psychoanalytic Association
American Psychological Association
American Society of Radiologic Technologists
American Speech-Language-Hearing Association
American Student Dental Association
Anxiety Disorders Association of America
Association for Ambulatory Behavioral Healthcare
Association for the Advancement of Psychology
Association of Behavioral Healthcare Management
Center for Patient Advocacy
Children and Adults with Attention Deficit Disorder
Clinical Social Work Federation
Cooperation for the Advancement of Psychiatry
Family Service America
Home Health Services and Staffing Association
International Association of Psychosocial Rehabilitation
Services
Medical Association of Georgia
National Alliance for the Mentally Ill
National Association for Home Care
National Association for Rural Mental Health
National Association of Protection and Advocacy Systems
National Association of Psychiatric Treatment Centers for
Children
National Association of Social Workers
National Community Pharmacists Association
National Council for Community Behavioral Healthcare
National Federation of Societies for Clinical Social Work
National Kidney Foundation
National Mental Health Association
National Mental Health Association
Opticians Association of America
Partnership for Recovery
Betty Ford Center
Hazelden Foundation
Valley Hope Association
Research Institute for Independent Living
Mr. Speaker, people say, what is in this legislation? We have already
addressed some of this. The funny thing about it when we are looking at
all of the opponents to this legislation is that the majority of the
Members of Congress have already voted for the majority of items that
is in this legislation.
I have here, Mr. Speaker, a side-by-side comparison of the items in
Medicare Plus Choice that this House passed last year as it relates to
internal appeals, external appeals, access to care, information
disclosure, gag rules, advance directives, provider incentives,
nondiscrimination, confidentiality of medical records, provider
protections, quality measurement, utilization review, health quality
boards, and ERISA. I have a side-by-side comparison on this. It is an
interesting thing when we talk about the liability issue. A Medicare
person who chooses a Medicare Plus Choice plan has the ability to
legally redress malpractice, but somebody who is not a Medicare patient
cannot under ERISA. This is a side-by-side comparison. Mr. Speaker, I
include this comparison for the Congressional Record, as follows:
COMPARISON OF PROTECTIONS IN MEDICARE+CHOICE V. PATIENTS' BILL OF RIGHTS
------------------------------------------------------------------------
Patients' Bill of
Issue Medicare+Choice Rights
------------------------------------------------------------------------
Internal Appeals............ Requires plans to Plans must establish
have procedures for procedures to allow
reconsideration of ``appealable
adverse decisions. decisions'' to be
appealed.
Time for Review............. Appeal must be Normal appeals must
decided within 60 be completed within
days of receipt. 15 days (with
extension for up to
an additional 10
days).
Expedited Appeals........... Generally must be Same.
decided within 72
hours.
Qualifications of reviewer.. Must be a physician Review by a
or appropriate ``clinical peer,''
specialty not who can be selected
involved in by the plan but who
original decision. must not have
participated in the
original decision.
Notice of Decision.......... Patients must be Patients and
sent a notice of provider must be
decision and notified of
reasons for it. decision and
Also must be told reasons for it and
of rights to a told of any further
hearing if amount appeal rights.
in controversy is
greater than $100.
External Appeals............ External Appeals Plans must have a
process must be process for
available after all external appeals if
internal processes decisions
are exhausted. jeopardize a
patient's health or
exceed a
``significant
threshold.''
Who conducts................ The Secretary must Plans must be done
contract with by independent and
outside groups to qualified third
handle these parties. There can
appeals. be no financial
incentives for
these groups to
affirm the plan's
original denial.
Procedure and timeframe..... Appeals are first The external appeal
sent to HCFA, which must hear the issue
hears the appeal. de novo. Decisions
If the appeal is must be made in 60
again denied, the days, except
patient may have exigent appeals (72
rights to a further hours). Patients
hearing before an may have rights to
administrative law further appeals in
judge or a U.S. state court if the
district court. plan prevails on
appeal.
Review body qualifications.. No provision........ Standards for
external reviewers
include: no
conflict of
interest, review by
clinical peers,
entity must have
legal and medical
expertise. Entity
must be certified
by the State or by
HHS.
Costs....................... No provision........ Plan must bear the
costs of the
appeal.
ACCESS TO CARE
General provisions.......... Requires plans to Plan must have
ensure benefits are sufficient mix and
accessible with distribution to
reasonable deliver all
promptness. benefits.
Point of service............ Plans may offer Enrollees must have
enrollees a point the option to
of service option. purchase a point of
service plan unless
the insurance is
provided through
more than one
issuer or two or
more coverage
options are
offered.
Choice of specialist........ Plans must have Plans must allow
appropriate access enrollees to select
to specialty care. the specialist of
their choosing from
the list of
participating
doctors, unless the
plan clearly
notifies enrollee
of limitations on
choice.
Ob-gyn care................. No provision........ Enrollee may
designate ob-gyn as
primary care
provider. Plans may
not require pre-
authorization for
routine ob-gyn
care.
Standing referrals.......... No provision, but Enrolless with
plans must make all conditions that
care available with require on-going
reasonable specialty care may
promptness. get standing
referrals.
Clinical trials............. No provision........ Plans may not
discriminate
against patients in
approved clinical
trials and must
cover their routine
costs.
[[Page H5058]]
Prescription drugs.......... No provision........ Plans that use
formularies must
involve M.D.s and
pharmacists in its
selection; must
disclose formulary
to patients; and
have a process for
patients to get non-
formulary drugs
when medically
necessary.
Emergency care.............. Prudent lay-person Similar provision.
standard, etc.
INFORMATION DISCLOSURE
General..................... Secretary must mail Plans must provide
to beneficiaries information in a
information helpful timely manner to
in selecting plans. enrollees. Should
be done in a
uniform way to
allow people to
compare different
plans.
Specific information that Covered benefits, Same.
must be disclosed. liability for non-
covered services,
and coverage of
emergency services.
Other disclosures........... Beneficiary cost- Same, plus
sharing, caps on availability of
out of pocket ombudsman
spending, balance assistance.
billing
protections,
description of
appeal and
grievance rights.
Information available upon Number of grievances Same, plus drug
request. and their aggregate formulary
disposition. information.
Comparative information..... Plans must--to the Summary quality data
extent possible-- on patient
give enrollees satisfaction,
comparative data on disenrollment, and
patient the plan's loss
satisfaction and ratio. On request,
outcomes. Also give plans must provide
disenrollment rates. information on how
they keep
information
confidential.
Network characteristics..... Plans must give Plans must provide
enrollees; the information on: the
number and mix of service area of the
providers, out of plan, out of area
network coverage, coverage, the
any point of extent to which
service option, any benefits from out-
other availability of-network
of care through out- providers is
of-network available, how
providers. Plans enrollees select
must also give HHS providers, any
enough data to point of service
ensure they are in option, and the
compliance with types of financial
physician incentive payments made to
(capitation) rules. providers.
On request, the plan Same.
also must provide a
general description
of physician
payment
arrangements.
Utilization review.......... Plans must inform Plans must provide
enrollees about how information on any
utilization review prior authorization
procedures work. or review
Upon request, the requirements that
plan must notify could result in non-
enrollees of their coverage or non-
procedures to payment.
control utilization
of services and
expenditures.
Provider credentials........ No provision (focus Upon request, plans
is on plans, not must make available
providers). information on
provider
credentials and a
list of
participating
providers.
Gag Rules................... Bans them, subject Goes further, as it
to conscience contains a broader
clause. definition of
medical
communication and
protects speech to
others within the
plan (and also to
the public in the
whistleblower
provision).
Advance Directives.......... Plans must have No provision.
policies on advance
directives, such as
living wills and
durable powers of
attorney.
Provider Incentives......... Plans must follow Similar provisions.
federal law
requirements on
physician incentive
plans and must
provide HHS with
data to ensure they
are in compliance.
Non-Discrimination.......... Plans may not Similar provision.
discriminate
against individuals
based on age, sex,
health status
(except ESRD
status), genetic
information, etc.
Confidentiality of medical Plans must establish Similar provisions.
records. procedures to
protect the privacy
of individually
identifiable
enrollee
information. Also
requires them to
have procedures to
ensure accuracy of
the records.
Ombudsman................... No specific Federal grant
provision, but program for the
other provisions of creation and
law authorize operation of state
states to establish Ombudsman programs
programs to provide to help consumers
counseling and choose their plans
assistance to and to deal the
Medicare grievances and
beneficiaries with appeals.
their health
insurance coverage.
Funded through a
user fee on
Medicare+Choice
plans.
PROVIDER PROTECTIONS
Contracting procedures...... Plans must have Similar provisions.
reasonable Also requires plans
procedures for to consult with
physician physicians
participation regarding the
including notice of plan's medical
participation policies and
rules, written procedures.
notice of adverse
participation
decisions, and a
process for
appealing those
decisions.
Non-discrimination in Prevents Similar provision,
selection of providers. discrimination plus a general
based on class of prohibition on
licensure. discriminating in
selection based on
race, color, sex,
sexual orientation,
age, etc.
Whistle blower.............. No provision........ Prohibits
retaliation against
providers who
disclose
information to
appropriate
authorities after
exhausting internal
procedures.
QUALITY MEASUREMENT
General provisions.......... HHS must disseminate Plans must collect
information on plan and share
quality, including information in
performance data, uniform manner,
disenrollment including:
rates, and enrollee aggregate
satisfaction. utilization,
demographics of
participants,
mortality and
morbity rates,
enrollee
satisfaction,
grievance and
appeals data, etc.
Allows HHS to waive
these requirements
based on variations
in the types of
delivery systems.
Internal quality improvement Medicare+Choice Plans must have
plans must have a ongoing quality
quality assurance assurance programs,
program that with written
stresses health procedures for
outcomes and systemic review of
provides for the quality of
ongoing measurement health care
of the quality of provided and its
high volume and consistency with
high risk services good medical
and the care of practice. Must have
acute and chronic a process for
illnesses. providers and
patients to report
possible quality
concerns. The
program must review
the plan's drug
utilization
program.
Further provides
that these
requirements can be
met through
accreditation by a
national
accrediting group
that the Secretary
of HHS says has
standards as
stringents as those
in the bill.
The Secretary may
provide for
variations as
needed to reflect
differences in plan
design.
External quality improvement Medicare+Choice No provision.
program. plans must have
external review of
the quality of
inpatient and
outpatient care and
of their response
to consumer
complaints of poor
quality care.
UTILIZATION REVIEW
General provisions.......... No provision, but Plans must do
plans must meet utilization review
rules for initial in accordance to
determination of written procedures
care. developed with the
input of
appropriate
physicians.
Retrospective UR may
not revise or
modify pre-
authorized
determinations.
Qualified health
professionals must
oversee review
decisions and
review a sample of
adverse clinical
decisions.
Prohibits financial
incentives to UR
agents that result
in inappropriate
denials.
Requires toll-free
access of peer
review personnel
during business
hours.
Providers and
patients
dissatisfied with a
UR decision must
have an opportunity
to discuss the
decision with the
plan's medical
director (who has
the authority to
reverse the
decision).
Prior authorization
decisions must be
made within three
days of receipt. UR
of continued and
extended care must
be made within one
business day.
Retrospective review
of services must be
completed within 30
days. Notice of an
adverse action must
be writted and
included the
reasons for the
denial and the
process for
appealing that
decision.
Health Care Quality Board... No provision........ Directs the
President to
establish an
advisory board to
provide information
on issues relating
to quality
monitoring and
improvement. The
board shall
identify, update,
and share measures
of group health
plan quality,
advise on the
proper minimum data
set and
standardized
formats for
information on
group health plans.
Mastectomy Stay............. No provision........ Plans may not limit
in-patient stay to
less than 48 hours
for mastectomy and
less than 24 hours
for lymph node
dissection. The
patient is free to
leave sooner if she
decides to, but the
plan may not
provide any
incentives to
patient and
provider to avoid
these protections.
Breast Reconstruction....... No provision........ Plans that provide
breast surgery as a
covered benefit
must provide
coverage for
reconstruction
resulting from a
mastectomy.
Adequate Reserves........... Plans must be No provision.
licensed under
state law and meet
state solvency
requirements.
Establishes a
temporary waiver
process for PSOs
under certain
circumstances.
ERISA....................... No provision (though Amends ERISA to
ERISA does not pre- allow state causes
empt a Medicare of action to
beneficiary from recover damages
suing a resulting in
Medicare+Choice personal injury or
plan for acts of death. The employer
negligence. cannot be sued
unless they
exercise
discretionary
authority to make
medical decisions.
------------------------------------------------------------------------
Mr. Speaker, to continue, I will not go through every single item on
here, except to point out that, time for review, Medicare Plus Choice,
60 plus days, except that today the President shortened that period.
Patients' Bill of Rights, 15 days for a normal appeal, with an
extension up to 10 days. Notice of decision. Who conducts the external
appeals. Review of qualifications. These are all things that are in
Medicare Plus Choice that we hear some of our colleagues oppose. I
cannot understand how they could have voted for all of these provisions
for Medicare Plus Choice and yet they oppose these items in a Patients'
Bill of Rights as being, quote, too bureaucratic. I think that
[[Page H5059]]
we need patient protections, the Patients' Bill of Rights for all
citizens, not just for the ones that we have already voted on for
Medicare or for Medicaid.
Mr. PALLONE. Again, I may be being cynical, but I think the reality
is that when we put most of those patient protections in the Medicare
legislation, in our own Committee on Commerce which both the gentleman
and I are a Member of, the bottom line is that when those came to the
floor, because of the widespread clamor, if you will, by senior citizen
organizations and groups that these protections should be part of the
Medicare program, and rightly so, I think the leadership, the House
Republican leadership and most of the Members were unwilling to not
support that because they were concerned about the power, if you will,
and the clout of the senior vote, that they did not want to be denying
senior citizens, who vote often and regularly, those kinds of patient
protections. A thank-you is due to the seniors and the power of the
senior vote and the senior organizations to make sure that that
happened, but at the same time it is not fair to deny those protections
to everyone else who is under 65 or who happens to not have the benefit
of a Medicare program. That is really what we are about here. We are
saying that those kinds of patient protections should be available to
anyone who has health insurance, who is in a managed care organization
or an HMO.
I am glad that you brought this out. It again points out that these
are not really anything radical, these are not anything unusual, we
have already adopted them for the largest Federal health insurance
program, Medicare.
I just wanted to go back, if I can, because I know that the gentleman
from Iowa has put a lot of emphasis on the ability to sue and recover
costs that is denied now under ERISA, and I talked a little bit about
the patient protection with regard to specialty care. I know that, at
least from the reports that I have been reading in the various
publications that we get on Capitol Hill that those are two areas that
the House leadership seems to be reluctant to deal with. It may not
actually be part of anything that the Republican leadership ultimately
puts together.
Mr. GANSKE. If the gentleman will yield, as a Republican, I have been
in favor of legal reform. I have voted for securities litigation
reform, I voted for medical malpractice reform. I have voted for
product liability reform. But I think we have a problem with ERISA,
because we have given basically total legal immunity to health plans.
We have not given that legal immunity to any other industry in the
country.
When I as a physician am treating a patient, I would never argue that
I should have immunity from malpractice. I might argue for some
reasonable changes, but I would never argue that I should not have any
legal responsibility for malpractice. That is why physicians, nurses,
other practitioners carry medical malpractice insurance. And so I think
that it is a basic principle of American law that responsibility for
decisions should lie where the decision is made. If an HMO is making
medical decisions and that results in malpractice, then they ought to
be legally liable for that.
In fact, on the front page of last Friday's USA Today, the very front
page center story was exactly on this issue. What most American
citizens do not realize is that quite frankly when their HMOs if they
are through their employer are making decisions, their HMOs do not have
any legal responsibility. In my opinion that is wrong, and, quite
frankly, I think the vast majority of the House if they would vote on
this issue would feel the same way. Would you want to be on the record
as voting for legal immunity for an HMO when the HMO has made a
malpractice decision?
Mr. PALLONE. Absolutely not.
Mr. GANSKE. I do not think I would want to be and I do not know too
many of my Republican colleagues who would want to be on the record for
giving an HMO legal immunity for causing somebody's death or
disfigurement.
Mr. PALLONE. If I could recapture my time, this was done, as the
gentleman pointed out, years ago when HMOs and managed care
organizations were not the vehicle for most Americans to get their
health insurance. Now this loophole which was there has grown into a
tremendous loophole that exists actually for most Americans. I do not
know what was being thought of at the time when this was voted on, but
the bottom line is the circumstances have changed now, because so many
more Americans are impacted by this loophole.
I just wanted to say briefly, if I could, I am not sure that everyone
understands when we talk about this inability to sue or this exemption,
if you will, from liability, exactly what we mean. The problem is that
you can only sue to recover the costs of whatever procedure was needed
but denied. You cannot sue for damages. In other words, I will use an
example. If you lose, say, an arm or a leg or an eye and you end up
victimized for the rest of your life because your HMO denied you the
care that could have saved the limb or the eye, you cannot sue for
anything other than the cost of what the medical procedure to save the
limb or the eye would have been. You cannot sue for losing the body
part or for the deterioration of your health condition. So basically
you are able to recover a very, very limited amount that does not help
you to deal with the problem and the damages that you have suffered.
That is really what we are talking about.
Mr. GANSKE. If the gentleman would yield, the opponents to this
legislation would say, well, if you pass legislation on this, it would
increase the cost of premiums, and, therefore, some employers would
choose not to insure their employees.
A recent survey by Kaiser Family and Harvard interviewed 800 small
business executives exactly on this issue. They found that even if
there were a mild increase in the cost of a premium related to this,
that only 1 to 3 percent of those employers would change their
coverage. But the interesting thing was that something like two-thirds
of those small business owners and executives agreed with the need for
legislation to close that loophole. You might ask, why is that? It is
because they are also covered by HMOs. More than 50 percent of them
have said, we have seen abuses by HMOs either in our employees or in
our own families, and we think there should be a remedy for that.
{time} 2018
But I would just like to continue on something else that we are
likely to hear about tomorrow, and that is that hopefully the
Republican Health Task Force will at least enunciate some principles to
legislation, even if we will not see any specifics written in the form
of a bill. And one of those things that the GOP task force is looking
at is the idea of health marts, and this is basically where you gather,
you would extend ERISA to multiple employer working associations,
otherwise known as MEWAs, or other groups, so it is an extension of the
ERISA exemption.
And I have here a letter from Therese M. Vaughan, the commissioner,
the State Insurance Commissioner from the State of Iowa, and she says:
Dear Representative Ganske: We want to alert you to
proposed legislation currently being discussed called
HealthMarts. HealthMarts pose a serious concern on several
levels . . . A few of our concerns are listed below for your
review: The impact of State insurance markets.
She goes on in some detail. Several provisions would allow a health
mart to cherry pick to ruin the risk pools. There are problems with
Federal enforcement of State law. There are conflicts of interest.
I have a similar letter from Consumers Union on the problems related
to health marts. Health marts, if you will remember, are very close to
what the Clintons proposed in 1993 with regional groups. So when
opponents to our Patient Bill of Rights have accused us of being
``Clinton Care'', I would sincerely hope that Republicans would not
come up with a proposal that is much, much closer to the Clinton plan.
And finally let me say I have a letter here from Blue Cross/Blue
Shield and the Health Insurance Association of America that says:
Dear Representative Ganske: We are writing to express our
opposition to proposals that would exempt certain health
insurance arrangements, such as association health plans and
multiple employer welfare arrangements, from State insurance
law and regulatory authority.
[[Page H5060]]
Mr. Speaker, insert these 3 letters into the Congressional Record.
The letters referred to are as follows:
Iowa Department
of Commerce,
Des Mones, IA, June 18, 1998.
Re HealthMarts.
Hon. Greg Ganske,
United States Representative, Washington, DC.
Dear Representative Ganski: We want to alert you to
proposed legislation currently being discussed called
``HealthMarts.'' HealthMarts pose a serious concern on
several levels. These concerns are similar to those we have
expressed in the past regarding other proposals that would
exempt certain health insurance arrangements (such as
association health plans (AHPs) and multiple employer welfare
arrangements (MEWAs)), from state law and regulatory
authority.
A few of our concerns are listed below for your review.
1. The impact of state insurance markets. HealthMarts would
undermine state health reforms by fragmenting the health
insurance marketplace. Recent reforms guarantee small
employers access to health insurance markets. While insurers
selling through HealthMarts would still have to pay premium
taxes, other state pooling laws and requirements would be
preempted. States require many different types of pooling
arrangements. These arrangements are primarily designed to
help spread risks through such mechanisms as reinsurance
pools, medically indigent pools, and high risk pools. Since
HealthMarts only have to meet the rating requirements of the
state in which the HealthMart is organized, a HealthMart
could organize itself in the state with the least restrictive
requirements in order to sell a particular benefit package at
a lower rate in a state with more restrictive requirements.
2. Cherry picking. Several provisions would allow a
HealthMart to choose which risks it wanted to accept.
A HealthMart is allowed to determine what geographic area
it will serve. This will allow a HealthMart to operate in
areas that contain healthier populations.
A HealthMart may market selectively within its geographic
limits, thus exacerbating the conditions established by
allowing the HealthMart to choose its own geographic
location.
With state mandated benefit requirements preempted, a
HealthMart would be allowed to design its own benefit
package. Benefit package design determines who will be
interested in purchasing a particular product.
3. Federal enforcement of state law. HealthMarts continue
to allow state officials to approve product offerings of
licensed insurance entities. If an insurance commissioner
denies the sale of a product offerings and the insurer,
selling through a HealthMart, disagrees with the decision of
the commissioner, the insurer could appeal to a federal
regulatory authority. The federal agency would then review
state law and determine if the insurance commissioner
properly interpreted her own state law. If, in the view of
the federal agency, the insurance commissioner did not make
the correct decision, the federal agency would allow the sale
of that product and enforce state law regarding that product.
This creates the unique situation where the federal
government enforces state law.
4. Conflict of Interest. Allowing sellers on the board of
an entity intended to act as broker between seller and buyer
creates a conflict of interest. HealthMarts will be accepting
bids from all insurers within a certain geographic location.
The insurers on the board will have access to those bids and
may also have access to proprietary information on how the
bids were put together. Board insurers would be able to
underbid those insurers who do not serve on the board.
HealthMarts undermine the recent efforts undertaken by
states to ensure their small business communities have access
to affordable health insurance. Iowa's success over the past
7 years in the area of health care reform will be greatly
diminished if this legislation is enacted.
We have supported purchasing pools through state
legislation that protects the consumer by providing coverage
within rate restrictions. We would be happy to work with you
on the development of legislation to continue to enhance the
ability of individuals and small groups to obtain adequate
and meaningful health care coverage.
If you have any questions, please do not hesitate to
contact me or my staff. We look forward to working with you
on any issues you may have concerning health insurance
coverage.
Sincerely.
Therese M. Vaughan,
Commissioner.
____
Blue Cross and Blue Shield Association, Health Insurance
Association of America.
June 4, 1997.
Hon. Greg Ganske,
United States House of Representatives, Washington, DC.
Dear Representative Ganske: We are writing to express our
opposition to proposals that would exempt certain health
insurance arrangements, such as association health plans
(AHPs) and multiple employer welfare arrangements (MEWAs),
from state insurance law and regulatory authority.
We remain very concerned about proposals to preempt state
regulation of federally certified association health plans,
including many MEWAs (e.g. H.R. 1515/S. 729). These proposals
would undermine the most volatile segments of the insurance
market--the individual and small group markets. AHPs could
siphon off the healthy (e.g., through selective marketing or
by eliminating coverage of certain benefits required by
individuals with expensive illnesses), thus leading to
significant premium increases for those who remain in the
state-regulated pool. The ultimate result: an increase in the
uninsured and only the sickest and highest risk individuals
remaining in the states' insured market.
We have similar concerns regarding a proposal to create a
new type of purchasing entity, called HealthMarts, which has
not been reviewed via the committee hearing process. This
proposal would exempt health plans offered through a
HealthMart from state benefit standards and requirements to
pool all small groups for rating purposes. As with AHPs, this
proposal raises serious concerns regarding market
segmentation and the ability of states to protect their
residents. The combination of these two proposals could lead
to massive market segmentation and regulatory confusion.
Moreover, these proposals, over time, would lead our nation
toward increased federalization of health insurance
regulation. Preemption of state regulatory authority would
create a regulatory vacuum that would necessitate an
exponential increase in federal bureaucracy and federal
regulatory authority.
As representatives of the health insurance and health plan
community, we are concerned about the issue of access to
health coverage for small firms. However, we urge legislators
to avoid legislation that unravels the market by helping a
limited group of small employers at the expense of other
individuals and small groups.
We look forward to an opportunity to work with you
regarding proposals that expand coverage without damaging the
small group and individual markets.
Sincerely,
------ ------
____
Congress of the United States,
House of Representatives,
Washington, DC, June 4, 1998.
Blue Cross/Blue Shield and HIAA Oppose Republican ``HealthMart''
Proposal
Dear Colleague: It's not often that I think the advice from
HIAA and Blue Cross/Blue Shield bears repeating, but this
time they got it right.
In a letter to Chairman Bliley of the Commerce Committee,
the Blue Cross/Blue Shield Association and the Health
Insurance Association of America have made clear their
opposition to the ``HealthMart'' proposal being circulated by
Rep. Bliley as a potential component of the upcoming
Republican health reform proposal.
Their letter states that the HealthMart proposal ``would
exempt health plans offered through a HealthMart from state
benefit standards and requirements to pool all small groups
for rating purposes.'' For those reasons, HealthMarts raise
``serious concerns regarding market segmentation and the
ability of states to protect their residents.''
They conclude their letter by urging ``legislators to avoid
legislation that unravels the market by helping a limited
group of small employers at the expense of other individuals
and small groups.''
I urge my colleagues to heed their advice.
Sincerely,
Pete Stark.
There are a number of proposals that I am concerned will be in the
GOP Health Task Force plan that are not well-thought-out, that are even
opposed by the industry, at least as much as some of the patient
protection legislation. I am afraid that if you add a number of these
additional controversial items to a patient bill of rights type
protection, that they will in effect act as poison pills and ensure the
defeat of this legislation.
And I would not gainsay anyone's motives on this, but I would simply
ask my Republican colleagues to be aware of this potential problem when
they put forth their GOP task force.
Mr. PALLONE. Again, if I could ask you to elaborate a little more on
this, one of the concerns that I expressed earlier this evening is that
the Republican Task Force would come out with patient protections that
are less than what is in the Patient Bill of Rights or the PARCA bill,
and that is still a concern. But I think what you are voicing now is an
additional problem which is not only the possibility of not including
some of these patient protections that we would like to see, but also
the possibility of adding other things unrelated to patient protections
that would sort of muddy the water, if you will, and maybe confuse what
goes on here and take away from this issue of patient protection which
we are trying to bring forward.
And I know that one of the things I believe you mentioned was the
medical malpractice cap, I guess, that we have
[[Page H5061]]
discussed in the past, and that is something that would.
Mr. GANSKE. If the gentleman would yield, I have argued on the floor,
I have encouraged my colleagues, Republican and Democrat, to vote for
medical malpractice reform. In fact, the House of Representatives
passed that legislation in the last Congress, but we found out that we
could not get that through the Senate, and the administration is
opposed to it. To put that into a Patient Bill of Rights, a consumer
protection bill, would be to realize fully that that bill could not
pass, it could not become law.
I continue to be in favor of that legislation, but what I want to see
is, I want to see a Patient Bill of Rights passed and become law this
year. I think most of the major medical organizations, including the
American Medical Association, recognize by loading up other issues into
a Patient Bill of Rights you are working to defeat a Patient Bill of
Rights, not to advance it.
Mr. PALLONE. Did not the AMA, which has been the biggest supporter of
this medical malpractice reform, even say at one point that they did
not want to deal with it this year in the context of the patient
protections for the exact reason that you just cited, which is very
amazing to me because this was always their biggest, one of their
biggest, concerns.
Mr. GANSKE. I cannot speak. I am not a representative for that
organization. All I can say is I am sure that that organization would
like to see those provisions become law at some point in time, but the
recognition is there that on this piece of legislation that will be
considered a poison pill. We have broad bipartisan consensus and
support for a limited Patient Bill of Rights like is in the Patient
Bill of Rights bill, 3605, or Patient Access to Responsible Care Act.
It is not like you have to reinvent the wheel. These bills have been
out there for some time. They already have broad bipartisan support. It
is simply a matter of bringing them to the floor for a debate under a
fair rule in a timely fashion before this session runs out.
Mr. PALLONE. Can I just ask you one more thing about the health
marts, because I was not sure I understood.
You said that your concern is that ERISA exemptions would be expanded
beyond what they already are now to cover health marts? In other words,
we would actually have to deal with this exemption from liability in an
even broader fashion?
Mr. GANSKE. That would be my understanding, and let me just read from
this letter from Blue Cross/Blue Shield Association and the Health
Insurance Association of America.
``As representatives of the health insurance and health plan
community, we are concerned about the issue of access to health
coverage for small firms. However, we urge legislators to avoid
legislation that unravels the market by helping a limited group of
small employers at the expense of other individuals and small groups.''
And I can assure you, as somebody that speaks to a number of
insurance companies located in my own district that still provide
insurance to individuals outside of the employer market, that if you
created this health mart idea, what you would be doing is you would be
taking the healthy individuals out of that individual market, thereby
making the individual market more sick. That would, therefore, have the
effect of raising the premiums significantly for those who still
purchase their own health insurance.
And there are a lot of people like that; farmers, for example. I
represent a lot of farmers.
So I would certainly advise the GOP Task Force not to include this
type of proposal in their health care legislation, but simply to stick
with the gentleman from Georgia (Mr. Norwood) who has worked on that
task force so strongly in terms of a Patient Bill of Rights.
And you need to remember also that there are a number of HMOs that
are trying to do an ethical, good job on providing care for their
constituents, and many of them have already called upon Congress to
pass Federal legislation for a Patient Bill of Rights. We have Kaiser,
for instance, or the Health Insurance Plan, HIP, and others. They see a
benefit in having some federally-enforceable minimum standards.
It is very similar to what we see if you were buying an automobile.
Gee, I mean when you buy an automobile, you know that you are getting
headlights that work, brakes that work, turn signals, a seat belt.
Those are all a product of Federal and State law for minimum safety
standards, and yet there continues to be a great deal of competition in
the auto industry. By having some uniform rules on that, we certainly
have not moved to a nationalized auto industry any more than by passing
a Patient Bill of Rights and having some uniform safety standards would
we ever be moving towards a nationalized health insurance system. It is
just a matter of common sense.
Mr. PALLONE. I think there is no question that, you know, what we are
really talking about here are just basic protections, common sense
protections, and as the gentleman has pointed out, the not-for-profit
HMOs actually from the very beginning of this year when the President
first came out with his patient bill of rights in, I guess it was in
his State of the Union address, and there were I think 18 points at
that stage or 18 types of protections that were being discussed by the
White House, and actually we had many of the not-for-profit HMOs
supporting those principles because they are really a floor. They are
just a floor of basic protections.
And what happens is, and again I think you mentioned this at some
point in the past, is that if the not-for-profit or the good HMOs,
whatever their characterizations would be, adhere to these patient
protections and then the other ones that are for-profit or for whatever
reason do not, it basically creates a noncompetitive situation, becomes
cheaper, if you will, for the ones that are not providing the
protections to operate.
Mr. GANSKE. And if the gentleman would yield, we have our July 4th
recess coming up soon. I would hope that organizations like some of the
ones that I have read tonight, all the other organizations that are
signed on to passing this type of legislation this year would contact
their Congressman and Congresswoman back in their districts and express
to them the importance and how this affects real people a lot of the
time and how Congress should do something about this this session and
not allow this legislation to be bottled up.
Mr. PALLONE. And following up on your comments, and I guess I will
close with this:
We know that during this 2-week recess that many Members, including
myself, will be having town meetings and forums at which time there
will be opportunities for groups or individuals to go to those town
meetings and express to their Member of Congress their support and ask
them to support the Patient Bill of Rights, or actually ask them to
support the discharge petition that you and the gentleman from Michigan
(Mr. Dingell) have now introduced. We need to get as many Members as
possible on this discharge petition because, if we can get a majority
on the discharge petition by the time we come back or soon after that
in the weeks that follow, we can finally bring the Patient Bill of
Rights or the PARCA bill, these types of managed care reforms, to the
floor.
And again I just want to commend you for your effort in moving in
that direction because this is the time. If we are not going to pass
this now when there is so much support for it, we are never going to
pass it, and we have got to try and get more and more of our colleagues
on board.
Mr. GANSKE. If the gentleman would yield, I appreciate the courtesy
of being able to do these special orders with you. As I said before
earlier in this special order, I would sincerely hope that a discharge
petition is not necessary, that the Republican leadership in the House
would set a date certain for bringing this legislation to the floor and
make sure that it is with a rule that is fair and not a rule similar to
the one that we have seen on campaign finance reform.
Mr. PALLONE. Mr. Speaker, I agree with the gentleman and thank him
again.
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