[Congressional Record Volume 144, Number 95 (Thursday, July 16, 1998)]
[House]
[Pages H5730-H5733]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                          MANAGED CARE REFORM

  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 7, 1997, the gentleman from New Jersey (Mr. Pallone) is 
recognized for half the time until midnight as the designee of the 
minority leader.
  Mr. PALLONE. Mr. Speaker, tonight, once again, I would like to take 
up the issue of managed care reform and particularly to draw a contrast 
which I think is very important between the Democratic bill, the 
Patient's Bill of Rights introduced by the gentleman from Michigan (Mr. 
Dingell) and the proposal that has been put forward by the Republican 
task force both here in the House and another one in the Senate.
  The Republican health care task force here in the House is supposed 
to release the language for their so-called managed care reform bill 
tonight or possibly tomorrow. We know from what the task force has 
already released publicly that this bill is essentially a response to 
polling that the Republicans have asked for and requested that shows 
that they will lose the majority in November if they do not address the 
issue of managed care reform.
  But their proposal is essentially a cosmetic fix, a farce, that lacks 
some of the most important patient protections that are included in the 
Democratic Patient's Bill of Rights.
  I also would mention that in the Senate, the Senate Republicans have 
responded to this overwhelming outcry by the American people for 
managed care reform, but they have responded with, again, with a 
rhetoric-laced, partisan proposal that places the interests of insurers 
far above the needs of patients.
  I think that the American people simply do not want a bill that does 
not measure up on the issue of managed care reform. They want an 
approach that is endorsed by not only most Americans but by the health 
care professionals, the doctors, the nurses, the Democratic proposal, 
the Patient's Bill of Rights that takes health care decisions away from 
insurance company bureaucrats and gives them back to doctors and 
patients where they belong.
  Let me just mention some of the faults in the Republican proposal and 
then give you some idea, if I can, of what is in the Democratic 
Patient's Bill of Rights.
  The Republican plan that has been announced, and we have not seen the 
language yet, but it lacks an enforcement mechanism. It denies patients 
the right to sue an HMO when they are denied needed care and actually 
expands the ERISA liability that does not allow those who are now in 
self-insured plans to sue the HMO.
  It expands this liability exemption to health insurance pools, 
private health insurance, that will now have the same basic liability 
exemption that now exists for self-insured organizations under ERISA.
  In addition, the Republican plan does not provide access to 
specialists. It allows insurance companies, not doctors and patients, 
to make medical decisions. And the Republican proposals contain several 
poison pills. In other words, these are added provisions unrelated to 
managed care reform but which are included because the Republican 
leadership knows that if they are included, a managed care reform bill 
will never pass and never get to the President's desk.
  These poison pills include medical malpractice damage caps and also 
an expansion of the medical savings accounts, two issues that are very 
controversial and could very easily lead to a situation where we do not 
get a bill, a managed care reform bill passed this session of Congress.
  Let me just mention some of the valuable patients protections that 
are in our Democratic Patient's Bill of Rights. This will apply to the 
majority of Americans, everyone who has health insurance, who has any 
kind of health insurance.
  The patient protections include the return of medical decisionmaking 
to patients and health care professionals, not insurance company 
bureaucrats. That would be, for example, the length of stay in the 
hospital or whether or not you would have access to certain procedures. 
Those decisions would be made by the patient and the doctor, not by the 
insurance company.
  The Democratic bill also includes access to specialists including 
access to pediatric specialists for children, includes coverage for 
emergency room care so that you can go to any emergency room when the 
need arises. It also eliminates the gag rule by saying that doctors and 
nurses can talk freely about every medical option. And it also includes 
an appeals process and real legal accountability for insurance company 
decisions.
  In other words, the Democrats would allow you to sue the HMO. They 
would allow a procedure where you could appeal your decision to an 
unbiased arbiter. It also, the Democratic proposal puts an end to 
financial incentives for doctors and nurses to limit the care that they 
provide. Today the CBO, the Congressional Budget Office, put out a 
study which I thought was very interesting, because many of my 
colleagues, I should say the Republican leadership and my colleagues on 
the Republican side that oppose the Democratic Patient's Bill of 
Rights, have talked about the cost and suggested that somehow patient 
protections are going to be very costly.
  The Congressional Budget Office released a report today or an 
analysis that says that the Democratic bill, the Patient's Bill of 
Rights, would have only a minimal effect on premiums with most 
individuals paying only $2 per month. In actuality, the cost would be 
even less than $2 per month for the many fortunate Americans enrolled 
in a responsible health plan that has already provided most of the 
patient protections. Again, cost is not a factor here. Even if it is as 
much as $2 a month, most Americans would not find that objectionable in 
order to have the valuable patient protections that increasingly they 
are demanding.
  I just wanted to mention, and then I would like to yield to my 
colleague from Texas who has joined me many times on this issue on the 
floor and talked about our own States where we have already enacted 
some of the Patient's Bill of Rights, yesterday we had a very important 
hearing of our House democratic task force on health care reform. And I 
would stress that the reason that we have to have Democratic hearings 
is because the Republican leadership that controls the process in the 
House has refused to have hearings on managed care reform, refused to 
have a bill brought up and marked up or considered in committee and 
refused so far to bring any bill to the floor. So the only way that we 
can hear the horror stories and the abuses from the American people and 
from some of our constituents is if we have our own hearings and hear 
from some of the people that have had problems.
  I will not mention too many of the witnesses that we had yesterday, 
but there were a couple that I think that were particularly important, 
I thought.

[[Page H5731]]

  I will just mention two of the witnesses who were physicians. One was 
a doctor, Tom Self, who is a pediatric gastroenterologist from San 
Diego, California. He won a lawsuit against a managed care group that 
fired him for refusing to curtail patient visits, for limiting 
diagnostic tests.
  They fired him because he refused to do these things, refused to 
curtail patient visits, refused to limit diagnostic tests, and required 
him to abide by a gag rule whereby he would not disclose recommended 
treatments to his patients.

                              {time}  1100

  But despite more than 28 years of experience and excellent 
credentials, the medical group attacked Dr. Self's reputation by 
fabricating charges of poor medical practice. Employees for the medical 
group told Dr. Self's patients he had left town and was no longer 
practicing, when in fact he had set up his own practice across the 
street. This is after they had fired him. Well, he won his lawsuit and 
he is now practicing again. But that is an example of the kinds of 
things HMOs do for practicing physicians.
  One other physician, Dr. Boyle, a trained emergency room physician 
from San Antonio, Texas, the home state of my colleague. He currently 
serves as the attending staff physician for Texas Trauma Rehabilitation 
Associates. He was treating a 49-year-old auto mechanic with a strong 
history of hypertension who had been rushed to the emergency room.
  After lengthy unsuccessful arguing with the HMO's utilization review 
physician, Dr. Boyle informed his patient that his HMO would not 
authorize his admission into the hospital. And despite his extreme 
condition, the patient left after hearing his care would not be 
covered. He then suffered a stroke on his way home that resulted in 
permanent paralysis and medical costs totaling more than $75,000 that 
the HMO had to later pay. But the patient can no longer work and 
survive on Social Security payments.
  Mr. Speaker, we can give endless stories and we already have about 
people that had been negatively impacted and abuses that many HMOs have 
actually committed on individuals as well. But I have to say that my 
concern tonight is that the Republicans will bring their sham managed 
care reform proposals to the floor next week.
  In fact, even though we do not have the language to the House bill, 
the Republican House bill, they have already noticed the bill to come 
to the floor at the end ever next week. And by noticing it and not 
allowing hearings, not allowing committee markups, not allowing really 
the American public to speak out on this legislation, what they are 
trying to do is simply railroad and bring up this cosmetic sham 
proposals for so-called managed care reform to the House and have this 
vote on it and be done with it.
  And what we have to do as Democrats, and we have some Republicans 
also who have joined us, is we have to demand that the Democratic 
proposal, which is really a bipartisan proposal now, the Patients' Bill 
of Rights, be considered on the floor of the House of Representatives 
next week at the same time as the Republican alternative.
  We have asked and we have I think well over maybe close to 200 
Members now who have agreed to sign a discharge petition next week that 
would allow the Patients' Bill of Rights to come to the floor when the 
Republican proposal alternative also comes to the floor. And I would 
simply urge my colleagues over the next few days and once this 
discharge petition is available this coming Monday to sign the 
discharge petition. Because we must allow a real managed care reform 
bill, the Patients' Bill of Rights, to be considered by the House of 
Representatives. The American people deserve no less.
  Let me yield now to my colleague the gentlewoman from Texas (Ms. 
Jackson-Lee) who has done such a wonderful job in bringing this issue 
to the attention of the American people.
  Ms. JACKSON-LEE. Mr. Speaker, I thank the gentleman from New Jersey 
(Mr. Pallone) for yielding.
  And, likewise, I think that it is very important to explain to the 
American people that the health task force, which I have worked with 
him on, to be one of the key elements to being able to draw these real 
issues and concerns about patients' rights and a Patients' Bill of 
Rights. We would have wanted to have had a process that went through 
the normal committee channels where hearings were open and that issues 
were addressed seriously.
  I think it is important the tone that we raise this issue so that it 
becomes what the American people want to hear and that is a nonpartisan 
debate but one that is full of passion. And I believe rightly the 
willingness to fight. Because we will have a fight on our hands, not 
for political purposes but because so many of us have gone into our 
districts and have heard some of the crises that our constituents are 
facing.
  One of the important points I think that was made this morning and 
this afternoon and I was delighted to join my colleague and join the 
gentleman from Michigan (Mr. Dingell) and to join the gentleman from 
Iowa (Mr. Ganske) and Steve Forbes, the president, so many 
representatives from the health profession.
  One of the points that was made was that this is not an attempt to 
indict all HMOs, that in fact when we began to assess this problem in 
1993, I had not come to Congress then, we knew that we had a system 
that was broken, that needed repair on many fronts.
  One of the reasons even earlier than that that the HMOs rose to 
prominence, of course, was everyone collectively said, let us try to 
bring health care costs into reality. We all joined on that issue. At 
least all of us, including consumers, said that we thought we needed to 
work on the question of health care costs hospitals physicians.
  But what happened was that all of a sudden the route that was being 
taken got misdirected. It either got accelerated on a high-speed chase, 
with HMOs way out front, and the consumers chasing after some good 
health care. The HMOs started to dominate. And the question was not 
making sure that we were responsibly economically or containing the 
cost. It began to be, we are going to make a huge, huge profit. We have 
no other concerns but a huge, huge profit. So the consumer got left 
behind.
  And I hope that, as we have this discussion, albeit soon but not in 
the context where we want it, I hope some HMOs will stand up and be 
counted and be recognized that as a parent tells a child, you 
brought this on yourself. Because the American public was not anti-HMOs 
to the extent that just because they were. They were for it. They were 
supporting it.

  But just like a good friend of mine who was a prominent member of my 
community rushed to an emergency room with a massive heart attack of 
which that person did not realize they were having, because there are 
times, as I understand, you can walk of your own abilities, what 
happened at the emergency room? They were checked at the door while 
they were checking for their HMO and their insurance.
  I need not say the great tragedy that occurred to that dear soul. 
When rather than taking care of his immediate emergency need, the 
question was, where is your card? And primarily because hospitals 
themselves find that they are under enormous pressure not to keep 
people in, not to take people in because of the fact of cost.
  So we have a situation that the American public has told us we need 
to fix this. And now we come to a point when we could have done this in 
a bipartisan manner we could have answered the American public's 
concern. But what do we have to do now? Rather than move in that 
direction, we have got to put the American people on notice buyer 
beware of the Republican plan.
  Read between the lines and read the fine print. For with, I 
understand, some grouping of HMOs that have now risen to the occasion 
of supporting the Republican bill, all with scenes from the same page 
and verse, singing beautiful music, would it not be great if they were 
singing the music that the American people could likewise join in?
  But, unfortunately, we have to sound the chord of not only confusion 
but opposition. And the reason being is the Republican plan does not 
answer the question. And what was most noteworthy of the idea of what 
we are planning and proposing. And someone offered to my friend from 
New Jersey

[[Page H5732]]

(Mr. Pallone) offered a question and said, ``well, you were 
presenting,'' when I say ``you,'' the Democrats and the President of 
the United States presented their proposal today, ``well, the 
Republicans will be in front of a hospital tomorrow.''
  Well, let me tell my colleagues who was joining Democrats today. 
Nurses and medical professionals and physicians, the American Medical 
Association were the ones that we were standing with. So standing in 
front of hospitals is not the answer the American people want.
  In fact, unfortunately, as I said earlier, many of those doors are 
closed. What the American people would like is a reemphasis of the 
physician-patient relationship, and that is what the Democratic bill 
ensures. They want to reemphasize of the right of women to select as 
their primary caretaker their OB/GYN. They want the right for 
physicians to tell the truth about their medical condition and to 
provide them with the opportunity to seek care from specialists.
  The Republican bill does not do any of that. And frankly, no, most of 
us do not want to be in the courthouse. And when it comes to a loved 
one, I can assure my colleagues that anyone would more apt to or let me 
just say they would choose the life and love of that loved one than to 
be in a courthouse for some faulting, some finding of fault and that 
loved one not be with them.
  For anyone to even dare suggest that our bill's anchor is something 
about lawsuits, it is something about enforceability and 
accountability. Because when the tragedy of that individual that my 
colleague mentioned that we all heard present their presentation from 
one illness to a stroke because they were denied, when the woman who 
was flying in or had to fly in from Hawaii that the gentleman from Iowa 
(Mr. Ganske) so eloquently and passionately discusses when she could 
have been cared for in Hawaii but was required by her HMO to fly all 
the way to Chicago and then because of that tragedy lost her life. Or 
when, as the doctor explained to us about the cleft palate and all of 
us viewed that tragedy of that kind of birth that so many American 
children and of course children across the world are born with. And do 
my colleagues believe that an HMO would then tell that poor baby, who 
deserves the right to have a full and happy life, that that subsequent 
surgery on that cleft palate is cosmetic?

                              {time}  1110

  The terminations being made by individuals who, as someone described, 
and would green eye shades. Again, this is not an overall attack or 
get-you on HMOs.
  I would simply say to them: Come go with us, come stand on the side 
of physicians and nurses, health care providers, health technicians, 
visiting nurses, home health care providers.
  You full well know that we had a problem and we re-did the Medicare 
provisions that venipuncture, of going home, on home care was being 
eliminated. All of that comes from the managed care problems, that they 
thought it was not necessary to provide that kind of home-care testing. 
It was the over burden, if you will, on some of the in putting into 
Medicare that you are not able to have all of this managed care, these 
HMO over hang. It is clouding what we should be about in this country, 
and that is good health care.
  And I have asked the gentleman this question because I think it is 
extremely important to emphasize. The Republicans say that they have a 
health care bill. I really do not understand how you can have a health 
care bill with all of the huge cry that we have heard from across 
America, and the figures suggest that the Republican plan that they 
will unveil tomorrow and that they have alluded to will only cover 50 
million people when right now we are looking at 140 million plus that 
our bill takes care of. And so there is already a 90 million plus gap.
  And I ask the gentleman because I think it is important to bring the 
facts to the table.
  Mr. PALLONE. Well, the gentlewoman has brought up and highlighted, I 
think, the biggest gimmick of all with regard to this Republican bill.
  Essentially my understanding is that at least on the Senate side, if 
not on the House side, that the Republican bill only applies to ERISA 
plans, and of course ERISA plans are those that are preempted by the 
Federal Government because they are self-insured essentially, and these 
are the very ones that we discussed earlier where there is no 
enforcement because the patient cannot sue the HMO if they have denied 
care.
  So what you have here is hollow patient protections. Not only does 
the Republican bill limit the patient protections and not include some 
of the most important ones that the Democrats have talked about, like 
access to specialty care, for example, but, in addition, by limiting 
the patient protections to ERISA plans they guaranteed that the patient 
protections would never be enforced, because if you are in ERISA, you 
will have the patient protections, albeit limited, but you will not be 
able to sue so there will be no guarantee of the patient protections. 
If you are outside of ERISA, you can theoretically sue, but you do not 
have the patient protections.
  So they have essentially guaranteed that the whole thing is a fraud 
by narrowing it, the patient protections, to ERISA where this is no 
effective enforcer mechanism.
  The other things that you brought up and spoke so well about:
  You mentioned the emergency room situation. Again there the 
democratic proposal uses what we call in legal terms a prudent lay 
person standard. In other words, the HMO cannot say that you can only 
use an emergency room at a particular hospital or that you have to have 
prior authorization to use the emergency room, which of course that, as 
you point out, is absurd. How can it be an emergency? I think most 
people would not believe that that is the case, and they are probably 
shocked if they go to an emergency room to think they need prior 
authorization.
  Our bill says that you can have access to emergency care, any 
emergency room, without authorization if a reasonable person would 
assume that it is an emergency. Even if it is not, if you can assume 
that based on your injury or whatever.
  The other thing that you mentioned with regard to the cost and how so 
many HMOs are simply prioritized cost savings without any reference to 
quality of health care, that was brought out so vividly in one of the 
other witnesses that I did not mention tonight but who testified 
yesterday before our Health Care Task Force hearing, and this was one 
of two individuals who had to disguise their voice. We just saw them 
over the TV monitor with their words sort of disrupted, if you will, so 
they could not be recognized because the HMO would retaliate against 
them if they knew that they were testifying.
  And this one woman, if I could just mention her, was announced as 
Case Manager X, and she is a mental health therapist for the mid-
Atlantic region, my region, with more than 10 years experience. In her 
role as a case manager she was forced to deny approval for mental 
therapy even though she knew it was medically necessary.
  Basically the document, the contract, for the HMO said that you would 
have 10 to 26 visits for a patient who needed some kind of mental 
health therapy, but they told her, the higher-ups in the insurance 
company, that she should not authorize any more than 3 to 5 visits. 
Sometimes they said 3, sometimes they said 5. And I asked her the 
question. I said:
  Well, you know, theoretically, because maybe I am being naive, but 
theoretically, you know, they must have some sort of theory as to why 
they are giving you only 3 to 5 visits, even though the contract 
requires 10 to 26. I mean how do they justify that?
  And she said:
  Oh, they came up with a model for mental health treatment known as 
ultrabrief therapy and told the case managers they should resign if 
they did not agree with this treatment policy.
  So because they wanted to save money, they came up with a new mental 
health therapy theory called ultrabrief therapy, and the theory was 
that that is all you needed was the 3 or 5 days because, if we did it 
this way, you would still have the same amount of therapy or the same 
impact on your mental health.
  Of course there is no clinical evidence to support the theory of 
ultrabrief therapy. It was just made up.

[[Page H5733]]

  And she said that the reason why the HMO was really totally getting 
out of hand was because for the last 6 months they knew that there was 
a possibility of being bought out by a larger HMO, and so they wanted 
to prove that, you know, they were really cost-conscience and they were 
really cutting costs so that the larger HMO would buy them out.
  So you talk about cost cutting, that was the only thing that was 
motivating this agent.
  Ms. JACKSON-LEE of Texas. If the gentleman would yield, these are the 
kinds of ludicrous, everyday examples that everyday people experience, 
and I think that is the distinction between the Republican bill which 
plays, if you will, at patients bill of rights and plays more with the 
HMOs and insuring their rights than what the Democrats have offered, 
and let me say this, what in a bipartisan way we have offered I am very 
proud of and very pleased with the bipartisan support that this 
legislation has garnered and, I expect, will garner even more because 
one key element that the President made very clear today: this is an 
American issue. And for your example you add to that insult, if you 
will, the whole idea that mental health has suffered in terms of parity 
issues anyhow, and for those who suffer from mental illness, mental 
dysfunctions, you tell those families that they can get the necessary 
care and that concept of abbreviated care of 3 days or free treatment 
time frame, and you have them tell you the truth.

                              {time}  2320

  Just have them look at you in outrage or complete amazement. But the 
fact that it is utilized shows in greater evidence than we could ever 
manage to show that clearly it is a question of cost.
  I have another example of a gentleman I have mentioned, a veteran who 
I had the pleasure of providing him assistance and helping to secure, 
along with our United States military, one of his lost medals.
  He was a participant, a fighter in World War II. He marched the 
Japanese death walk, the episode of a march when they had captured the 
Americans and they were held in Japanese prison camps. So he was 
recently awarded one of his medals.
  He was involved, in a plan, in a health system. He is an elderly 
gentleman. Because of some paperwork snafu, when he left his house on a 
hot, hot, hot Texas day to go and pick his prescription up at the place 
where he needed to pick it up, he did not get a positive response such 
as, ``Let's go find your medication.'' It was, ``You don't have the 
right paperwork.''
  ``Well, I sent the paperwork in.''
  ``Well, you don't have the right paperwork.''
  Everyone operates in such fear. I would think that a very logical 
response would have been, he is 77, he has been documented for the 
eight years preceding in this particular plan with his paperwork, 
``because care is more important to us than cost right now, we will 
work on the cost element. We will allow him to get his prescription 
that he needs to survive.''
  Well, that constituent of mine was sent home, and not in a very 
friendly manner. He went home to suffer alone, and by some means that 
it came to our office's attention. But it was the intervention of an 
office that has nothing to do with HMOs or health care, but working on 
it from a constituent perspective, where this gentleman was restored 
his prescriptive rights, if you will, or the right to get the 
prescription, and it was acknowledged that a mistake had been made.
  This is an isolated incident that is reflective of incidents 
happening all over the country, where, many circumstances like this, 
there is no intervention, none, no intervention, and you have cited 
some of those where they have resulted in someone's death.
  Mr. PALLONE. I just wanted to mention again, because the gentlewoman 
brings up these cases, and you stated it, these are not isolated 
incidents. When we had the hearing yesterday, again, we asked each of 
the health care professionals who testified, whether they were the case 
managers or the physicians, the kinds of stories you tell us, how often 
do they happen?
  Generally they would say at least once a week. Once a week each of 
these individuals, whether they were a doctor or a caseworker who was 
detailing, working for the HMO, had to face a situation where they felt 
there was clear abuse and the patient was going to suffer.
  So we are not talking about a few horror stories, we are talking 
about things that occur on a regular basis throughout the country, and 
that is the reason I think why so many people now all over the country 
are demanding the kind of reform that the Democrats are putting 
forward.
  I agree with the gentlewoman, it is bipartisan. I do not mean to 
suggest that we do not have Republicans with us. We have the gentleman 
from Iowa (Mr. Ganske), and we have quite few people with us on the 
other side. But it is the Republican leadership that refuses to bring a 
good bill it to the floor, actually refused to bring any bill to the 
floor.
  Now we hear they are willing to bring up their sham bill and have 
that voted on as possibly as early as next week. But it is their 
control of this house and their unwillingness, if you will, to bring up 
the Democratic proposal, the Patient Bill of Rights, that I think we 
have to continue to speak out against, because I believe, I am 
optimistic, and I know the gentlewoman is, if we keep demanding that 
the Patient Bill of Rights come to the floor, and if we get enough 
people to sign the discharge petition, we will have the opportunity to 
vote on that bill.
  I just want to say one last thing, because I think we are almost out 
of time. The gentlewoman mentioned the enforcement again. Again, I do 
not want people to think the distinction between these two approaches, 
Democrat versus Republican, is based on litigation and the ability to 
sue, because it is not.
  There are many differences, important differences. But the ability to 
sue is an important part of the ability to enforce your rights, and if 
you have patient protections, but you do not have ultimately the right 
to bring suit for damages, then you know that the HMOs are not going to 
be held accountable. They will say that is fine that these rights 
exist, but what do we care if you cannot enforce them ultimately in a 
court of law?
  So, again, we are not trying to be litigious or whatever, but we have 
to demand that ultimately there is some way for the people to enforce 
these patients' protections. Otherwise they are false, they do not 
exist, and are not real.
  Ms. JACKSON-LEE of Texas. Mr. Speaker, the gentleman has aptly 
brought us to a close this evening, and I appreciate very much the 
long, arduous journey I think that we have traveled on to bring this 
issue to a head.
  The devastation of what we see in the landscape of health care is so 
overwhelming that something has to be done. As we were deliberating 
over this legislation, I really felt we were moving to a point where we 
would have the entire House embracing this one issue as a bipartisan 
issue, because the stories are not respecting whether you are a 
Democrat or a Republican.
  So I would simply say the gentleman is so right, we should emphasize 
this idea of enforcement. But it is not the anchor of this bill. The 
anchor of this bill is patient protection.
  The last point that I think is extremely important, as our Chairman 
of the American Medical Association said, Dr. Smoke, doctors were 
rising up around the Nation, in State capitals all over the Nation, 
arguing for the Patient Bill of Rights on the patient-doctor 
relationship. I think that should be a signal as to which direction 
this house should go in voting for a real bill that protects those who 
cannot speak for themselves.
  Mr. PALLONE. Mr. Speaker, I thank the gentlewoman for her 
participation in this special order.

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