[Congressional Record Volume 145, Number 28 (Tuesday, February 23, 1999)]
[House]
[Pages H682-H689]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                               HMO REFORM

  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 6, 1999, the gentleman from Washington (Mr. Baird) is 
recognized for 60 minutes as the designee of the minority leader.
  Mr. BAIRD. Mr. Speaker, I rise today along with many Members of my 
fellow freshman Democrats to address an issue that is central for the 
citizens of our country and to our State.
  As many of us have just finished long campaigns, we are firsthand in 
touch with the needs of the people of this country, and one of those 
crying needs is clearly the need for HMO reform.
  We are here today to talk about that issue and to talk about what we 
can do

[[Page H683]]

to solve this critical problem. The distinguished colleagues who have 
joined me today will talk about their perspective from firsthand 
experience with their constituents with people needing health care who 
have been prevented from getting the health care they need 
unfortunately by the current status quo. I would like to thank my 
colleagues in advance for their remarks.
  Several years ago, the health care industry launched a massive 
advertising campaign. There was a couple named Harry and Louise who 
threatened us that the sky was going to fall if the President's health 
care plan passed. Without commenting on the merits of that particular 
plan, I can comment on what Harry and Louise said.
  Harry and Louise said that, if we followed the President's plan, 
disaster would strike in the following way: people would lose their 
right to choose their own health care provider, they would have to wait 
for needed health care, that bureaucrats would make their health care 
decisions for them instead of their doctors.
  I am sorry to say that Harry and Louise were exactly right about what 
would happen, but the cause was the people who sponsored the Harry and 
Louise ads to begin with.
  The health insurance industry led consumers to believe they would 
have fewer choices of providers, that the type of care they receive 
would be decided by government bureaucrats and not their doctors.
  But it is the health insurance industry that profits while people are 
sick that has been responsible for limiting one's choice of doctors, 
that has been responsible for impeding the care health care providers 
would wish to provide that has caused long waits and unfortunately has 
deprived American people of the health care they deserve and have come 
to expect.
  But I am pleased to say that we now have an opportunity to correct 
many of those wrongs. With House bill 358, the Patients' Bill of 
Rights, this measure promotes common sense reforms, reforms that each 
and every consumer can understand and appreciate.
  Under this bill, the Patients' Bill of Rights, patients will be 
allowed to make medical decisions with their doctors without the 
interference from insurance company bureaucracies and accountants. Let 
me say again because it has to be underscored, patients and their 
doctors will make health care decisions under this bill, not insurance 
company executives and their accountants.
  As I travel through my district of southwest Washington, let me tell 
you that this is one of the things I hear most often.

                              {time}  1630

  The other thing I hear is that people want to choose their provider. 
They want to decide which physician they will be able to see or which 
nurse practitioner or clinical psychologist. The patient should have 
that right, and under this bill, H.R. 358, the patient will have that 
right.
  This measure also guarantees the patient the right to emergency 
treatment. The last challenge a patient should face, if they are facing 
an emergency medical decision, should be worrying about whether their 
insurance company will approve the procedure. And yet we have countless 
stories of precisely that happening.
  In rural areas this is particularly important, where patients may not 
be able to travel long distances to meet with the approved provider and 
they want to see the provider they have come to know and trust with 
their family over the years.
  So, Mr. Speaker, I urge this body, when the bill comes before us, to 
pass this important Patients' Bill of Rights. It is common sense, it is 
the right thing to do, and it is in the best tradition of American 
values of choice and respect for autonomy.
  With those initial comments, Mr. Speaker, I would like to yield to my 
good friend, the gentlewoman from Wisconsin (Ms. Tammy Baldwin).
  Ms. BALDWIN. Mr. Speaker, families in Wisconsin are anxious about the 
state of health care in this country. They are increasingly concerned 
that medical decisions are being made by accountants, managers and 
other insurance company employees instead of doctors and patients. Too 
often profit takes priority over patient need. Patients are losing 
faith that they can count on their health insurance plans to provide 
the care that they were promised when they enrolled and faithfully paid 
their premiums.
  I have heard from many of my constituents in Wisconsin on this issue. 
They do not want to see doctors spending hours filling out regulatory 
or administrative paperwork. They want them seeing patients. They do 
not want to pay for a layer of bureaucracy whose sole purpose it is to 
deny or reject payment for care already provided. They want their 
dollars paying for providing health care.
  We do not want decisions on how to treat a sick child to be based on 
profit. We want them based on sound medicine. I do not want the issue 
of whether my 92 year-old grandmother gets needed physical therapy at 
her nursing home to be based on profit. I want it based on sound 
medicine. We do not want the decision of which hospital accepts an 
emergency patient to be based on that patient's wealth. We want it 
based on sound medicine. We want doctors and nurses and other health 
professionals making those decisions based on their training and their 
commitment to saving lives, healing wounds, and treating illnesses.
  It is time for Congress and the health care industry to get their 
priorities straight. The Patients' Bill of Rights can head us in the 
right direction. For the millions of Americans who rely on health 
insurance to protect them and their loved ones when serious illness 
strikes, the Patients' Bill of Rights could be a matter of life and 
death. The Patients' Bill of Rights is a guarantee that medical 
decisions will be made by doctors and patients, not managed care 
accountants.
  All too often people who pay their premiums for years are denied care 
when they become seriously ill. Health plans should not be allowed to 
place arbitrary limits on covered services.
  We have all heard painful stories from our constituents who were 
denied care or services by managed care providers. I was deeply 
disturbed when I heard the account of one Wisconsin man in a hospital 
recovering from a serious operation. He received a telephone call in 
his hospital room from a representative of his HMO telling him that if 
he stayed in the hospital past midnight the insurance would not cover 
it. This gentleman had just gotten out of intensive care, and it was 
all he could do to reach for the telephone to take the call.
  How frightening an experience like that must be. This man filed a 
complaint with the State insurance regulator, accusing his HMO of 
playing doctor, but little was done. It is no wonder so many people 
feel anxious about their health care these days.
  Having a recourse when something goes wrong is vital. Unfortunately, 
ERISA preempts individuals in employer-sponsored plans from holding 
health plans legally accountable for decisions to limit care that 
ultimately cause harm. Health plans should not be allowed to escape 
responsibility for their actions when their decisions kill or injure 
patients. In our new managed care environment we have to do a better 
job of focusing on patients and not the bottom line.
  Six years ago we all in this country hoped for reform that would 
guarantee every American the health care they needed. That vision was 
never realized. In this time of economic prosperity, in this time of 
rapidly changing medicine, in this time of political opportunity it is 
time that we renew our commitment to health security for all. Many are 
still afraid to take on that task.
  The Patients' Bill of Rights is an important first step in protecting 
people who already have health insurance. No one should fear that their 
insurance company will abandon them when they need it the most. This 
reform is an important step in renewing our commitment to health care 
security for everyone.
  I urge my colleagues to support the Patients' Bill of Rights and I 
urge the leadership of this House to place a priority on real managed 
care reform that puts patients and doctors ahead of insurance company 
bureaucrats.
  Mr. BAIRD. Mr. Speaker, I thank my colleague for those very poignant 
and accurate comments. I think she summarized remarkably well the 
situations we face today and the needed remedies.
  Next I would like to yield to my good friend and colleague, the 
gentleman

[[Page H684]]

from the State of Pennsylvania (Mr. Hoeffel).
  Mr. HOEFFEL. Mr. Speaker, I thank the gentleman for yielding to me. I 
rise today to address an issue of critical importance to the people of 
this country and the 13th District of Pennsylvania.
  Mr. Speaker, it is time to change the way HMOs do business in this 
country. Health care quality is suffering because HMOs continue to seek 
to drive the cost of health care lower and lower. They have succeeded 
in cutting the cost of health care, but the pendulum has swung too far 
and we have to take action to protect the health of the American 
people.
  When I go home to my district I hear the growing chorus of 
complaints. It is increasingly difficult for patients to get to see 
necessary specialists. Patients are being forced to leave hospitals 
only hours after having complex procedures performed. Prescription drug 
policies seem to change like the weather. Plan provider networks are 
small, spotty and too restrictive. Little or no coverage is offered for 
clinical trials and experimental benefits.
  Last week in my district the League of Women Voters held a town 
meeting to discuss Medicare, but it turned into a session complaining 
about HMOs. The local newspaper, The Intelligencer-Record, covered the 
meeting the next day with a headline that says ``Crowd Tells of Health 
Care Horror Stories''. At the meeting Dr. Peter Lantos, of Erdenheim, 
Pennsylvania, described how he needed prostate surgery. His HMO was 
unwilling to provide any list of surgeons, making it very difficult for 
him to make an intelligent choice. He was also told he had to go to a 
specific hospital, not the one he preferred.
  Now, Dr. Lantos fought the system. He fought it and he won. But he 
should not have had to fight, and he certainly lost critical time. And 
Dr. Lantos is a professional; a physician. He knows how to fight the 
system. What about average Americans? What kinds of protection do they 
have?
  Something surely must be done, Mr. Speaker, for the children who are 
denied access to pediatric specialists; for the women who want to 
designate an obstetrician or gynecologist as their primary care 
provider; for all those suffering from cancer or serious heart disease 
who want to designate their oncologist or their cardiologist as their 
primary care provider; for all of those people and others who have been 
victims, not beneficiaries, of a managed care system that has lost its 
way. We must find an answer.
  Yes, we must continue to control costs, but we must achieve four 
critical reforms.
  First, we have to make sure that medical decisions are made by 
medical professionals, not by insurance company bureaucrats and 
accountants.
  Secondly, we have to lift the gag rule that is placed on doctors by 
many insurance plans that prohibit those doctors from describing the 
full treatment options that their patients have.
  Thirdly, we have to make sure that patients have the fullest possible 
choice of plans and providers.
  And, lastly, we have to make sure that HMOs are held accountable. 
And, as a last resort, that means giving patients the right to sue 
their HMOs if an arbitrary coverage denial leads to a bad medical 
consequence.
  Those are the steps we have to take. We have to make sure that we 
provide for good medical care for Americans, and the answer certainly 
is passage of the Patients' Bill of Rights. It is a bipartisan bill. It 
has broad appeal. We must answer the call of the American people and 
pass this legislation.
  Mr. Speaker, I am providing for insertion into the Record the article 
I referred to earlier from the Doylestown Intelligencer-Record.

               Crowd Tells of Health Care Horror Stories

                           (By Stephen Brady)

       It's frightening to think that a doctor in this day and age 
     would have to see 20 patients an hour to make ends meet. And 
     how could this kind of schedule reasonably be called 
     ``care''?
       Dr. Peter Lantos of Erdenheim told this story about a 
     doctor friend. Lantos spoke during a public dialogue on the 
     future of Medicare, held last week at Jenkintown Borough Hall 
     and sponsored by the League of Women Voters of Abington-
     Cheltenham-Jenkintown.
       It was just this sort of horror story that motivated 
     Rochelle Sonnenfeld of Rydal, the league's chairwoman, to 
     organize the meeting.
       ``This is a nationwide project. We want to inform the 
     public about Medicare. We want to get legislation passed that 
     is worthwhile. This is a very important issue to millions of 
     people,'' Sonnenfeld said.
       While Medicare was the announced subject, many in the 
     audience vented about health insurance, especially managed-
     care providers, or health maintenance organizations.
       Lantos told his own personal horror story. ``I needed 
     prostate surgery. The surgeon that was recommended by my HMO 
     had a poor reputation, and they still wanted me to use him. I 
     found out they don't give out lists of good surgeons. I had 
     to go through several layers of management.''
       Dr. Todd Sagin, a family medicine and health-care policy 
     specialist, was the quest speaker at the dialogue. He 
     described Medicare, its history and development and explained 
     why there is a crisis and what solutions may lie ahead.
       ``The Medicare program hasn't changed in close to 35 years. 
     By today's standards, it's an inadequate packet,'' Sagin 
     said, adding ``Medicare is financed by employee payroll 
     taxes, and it's going bankrupt.''
       Sagin explained why hospital bills may seem inordinately 
     high and outlined the bills' hidden costs.
       ``Medicare only pays a certain percentage of the costs of a 
     hospital stay. You have the high charges on hospital bills 
     because the doctor is getting a percentage, and the hospital 
     has to pay its own bills. They have to charge more so all 
     their costs are covered.''
       In the matter of managed care, he tried to make sense of 
     the maze of contradictions that exist in the field.
       ``The crux of the matter is who decides what is medically 
     necessary. Medical necessity is in the eye of the beholder,'' 
     he said, adding, ``Most of us want the best technology, the 
     best medical care, and we want access to that care with the 
     least amount of red tape. And we want it at a low cost.''
       People who can least afford the medical bills are not the 
     only ones being hurt. ``Our government is being hurt by the 
     high cost of care. We are paying 15 cents on the dollar.
       ``The companies we work for have to pay the cost, and it 
     will eventually weaken them in the business world.''
       Elise Stern of Cheltenham had heard of another horror 
     story. A woman in her 80s was sent home just two days after 
     having a double mastectomy. ``The health-care system should 
     not be for-profit; it should be a social service,'' she said.
       She also felt that the taxpayers' money could be spent more 
     wisely. ``We are taking money away from the patients and 
     giving it to the stockholders.''
       Sagin agreed with her view. ``What degree should Wall 
     Street have in making decisions on health care?''
       Lantos agreed, adding, ``I was told I had the choice of one 
     hospital for my operation. I told the HMO I wanted to go 
     elsewhere and was told, `No, you can't.' I got treatment, but 
     I had to fight for it. You shouldn't have to fight for good 
     care.''

  Mr. BAIRD. If I might, Mr. Speaker, I know the gentleman from 
Pennsylvania has shared with me a personal story about a patient who 
faced some of the challenges he just described, and why that is 
important is behind the legislation are real world real lives of people 
who hurt and suffer every day because of the lack of this needed 
legislation. Could the gentleman take a few moments and relate that 
story to us?
  Mr. HOEFFEL. I would be delighted to. It is a sad story. I met with a 
woman from my district last year who reported to me that her husband 
had become very ill the year before with a head injury. He received 
care under his managed care plan. His primary care doctor wanted, once 
he was sent home from the hospital, to give him a very intensive course 
of therapy and the HMO would not pay for it, or would not authorize it. 
The family fought, the doctor fought, and they could not get approval. 
They gave him a lower level of therapy, not what the doctor ordered.
  Unfortunately, the husband died, and the wife wanted to hold that HMO 
accountable. She believes that the failure to authorize the more 
intensive level of therapy led to her husband's death. Now, I do not 
know if that is true. She does not know. But she wanted to test that. 
She wanted to hold that health care plan accountable for what she 
thought was an arbitrary decision, and the law does not allow her to do 
that today.
  Part of what the Patients' Bill of Rights would do is to make sure 
that people can go to court, if they have to, as a last resort, to hold 
their plans accountable. This bill would do it, and we ought to pass 
it.
  Mr. BAIRD. Mr. Speaker, I thank the gentleman very much and 
appreciate those great remarks.
  Mr. Speaker, I would like next to yield to my good friend, the 
gentleman from Colorado (Mr. Mark Udall).
  Mr. UDALL of Colorado. Mr. Speaker, I thank the gentleman from the 
State of Washington for yielding to me.

[[Page H685]]

  Mr. Speaker, at one time or another all Americans are faced with 
making tough choices about medical care for themselves and for their 
families. At those times, the last thing anyone wants to think about is 
whether their health plan will be there for them. They should know that 
access to vital services and information is guaranteed to them.
  Here is what is needed, I believe, to make sure that is in fact what 
we have in our medical care system.
  Patients should know that if they have an emergency they can go to 
the nearest emergency room without worrying if their plan will cover 
it. No one with a serious emergency should have to call an 800 number 
for permission to seek the emergency care that is needed.
  Patients also need access to clear and complete medical information. 
The reason for that is that informed decisions about health care 
options can only be made by patients who have full access to 
information about the options available to them. As a part of this, 
physicians should be able to advise patients of their options without 
restrictions from their health plan. Health care providers should know 
that they can give accurate medical advice without fear of retaliation 
by the health plan that is in order at that time.
  Patients need to know they can appeal plan decisions of denial or 
delay of care when a doctor feels that the care prescribed is medically 
necessary.

                              {time}  1645

  Plans must put into place an internal review process to address these 
concerns. But if that process fails, patients need to know that 
internal decisions may be appealed to an independent third party. They 
must have the ability to bring their grievances to a panel free of the 
health plan's influence.
  All patients also need to know that their medical plan has an 
adequate network of specialists available who can provide high quality 
care for those patients who need specialized treatments and, if 
necessary, patients need to have the right to seek specialists outside 
of their network.
  Mr. Speaker, our health care system is not as good as it should be 
and Americans need to know that this is not as good as it gets. The 
Patients' Bill of Rights is an important step in the right direction 
toward making these needed improvements and helping ensure that all 
Americans have access to quality health care.
  For those reasons, I am pleased to be a cosponsor of this important 
legislation. The Patients' Bill of Rights will put medical decisions 
back into the hands of doctors and patients, taking it out of the hands 
of the accountants and bureaucrats.
  Mr. BAIRD. Mr. Speaker, I might like to follow up if I might once 
again.
  I am sure that we can fill this room with people telling their 
stories, but they are important stories to hear. I know that my 
colleague also has talked to one of his constituents who shared with 
him the frustrations they felt under the current system, and I wondered 
if he might expand on that.
  Mr. UDALL of Colorado. Mr. Speaker, I have a constituent who was in 
the middle of chemotherapy for her breast cancer. Of course, this was a 
life-threatening situation. She was informed by her oncologist halfway 
through her chemotherapy treatment that she had to find another 
oncologist.
  Now, my colleagues can imagine the kind of turmoil and stress that 
that added to her situation where she was literally battling for her 
life. Now, she fought back hard and was able to get that care but only 
after a great deal of time had passed.
  My point in all of this is the Patients' Bill of Rights would make 
this a lot less likely to happen to the people who surround us in our 
communities, our families, our fellow citizens and our friends. I think 
it is important to remember the Patients' Bill of Rights is about 
people, it is not about regulations. It is about people. It is about 
providing the best possible health care for all Americans.
  Again, I would remind all of the Members here that the Patients' Bill 
of Rights is about putting those medical decisions back into the hands 
of patients and doctors and not allowing those decisions to be made by 
somebody who is maybe sitting 2,000 miles away in front of a television 
or computer screen.
  I urge adoption. This is a very, very important piece of legislation.
  Mr. BAIRD. Mr. Speaker, that element of the deeply personal 
relationship between a patient and his or her health care provider 
cannot be underscored too greatly. It is not that we are dealing with 
interchangeable parts of some machine, unfeeling beings. We are dealing 
with human beings who build a relationship of trust and respect and 
confidence and, most importantly, of caring with their health care 
provider. We have lost that under current HMO practices, and this bill 
will go a long way toward restoring that relationship.
  Next, Mr. Speaker, I would like to recognize my friend and colleague, 
the gentlewoman from Illinois (Ms. Schakowsky).
  Ms. SCHAKOWKSY. Mr. Speaker, I thank the gentleman for yielding to 
me.
  One of the real reasons that I wanted to come to this body as an 
elected Member of the House of Representatives and why I ran for office 
in my State legislature years ago is because I want to be able to 
provide accessible, affordable health care to people in my own family 
and to families around the State of Illinois and in this Nation.
  It is really a disgrace that in this country 44 million Americans 
have no health insurance at all. But even those that are insured, and 
that is what we are talking about today, cannot be certain that they 
are going to receive quality health care when they need it.
  What we need to know, and everyone has said it, my colleagues have 
said it, is that patients will get the health care they need based on 
medical decisions and not on arbitrary rules set by bureaucrats that 
are part of insurance companies or HMOs. That is why I am so proud to 
be a cosponsor of H.R. 358, the Patients' Bill of Rights, which is 
sponsored by the gentleman from Michigan (Mr. Dingell).
  This bill, which failed by only five votes in the last Congress, 
would establish critical protections for patients and medical 
practitioners; and it adopts the recommendations that were made by the 
President's Advisory Commission on Consumer Protection and Quality in 
the Health Care Industry.
  As a former State legislator, I sat on the Health Care Committee, and 
one day Ann Vaughn came to our committee to give testimony. Ann is a 
resident of the Springfield area in Illinois and came to tell us about 
what her experience was when she had a mastectomy. She said that it was 
really scary for herself and her family when she got that diagnosis. 
And my colleagues can imagine going to the hospital for the surgery.
  She said, but what was really unbelievable to her was when she woke 
up in the recovery room she was told that she would have to go home 
that day. An outpatient mastectomy, we are not talking about a 
lumpectomy, we are talking about a full mastectomy, tubes, grogginess 
from the anesthetic, that she was going to have to go home, that her 
HMO was not going to cover the overnight stay.
  Well, my colleagues can imagine, the members of the committee were 
outraged and decided we absolutely had to do something. So we did pass 
legislation that would say that doctors will decide how long someone 
stays in the hospital after a mastectomy, no discussion, no debate. It 
is not going to be whether the HMO says they are not going to cover it.
  Well, this is good. We got that bill passed. But at the time I said, 
look, we cannot go body part by body part. We have to have a 
comprehensive approach and get to the heart of who is going to make 
those medical decisions.
  Well, there is a lot of talk now about Patients' Bill of Rights, and 
everybody is for it. I really have not found anybody who is against it. 
But it is going to be very important as we get down to the nitty-gritty 
to look at what is in the legislation that is really going to guarantee 
that patients and doctors are going to be in the driver's seat.
  What I really like about H.R. 358 is three provisions that I want to 
focus on. The first is the whistle-blower provision. That is, 
protection for health care workers who see some kind of danger for 
patients in this medical setting.
  Recent surveys have reported alarming percentages of health care 
workers

[[Page H686]]

who believe that patient safety is in jeopardy. For example, a survey 
at a large Columbia HGA hospital found that 60 percent of workers 
reported dangerous delays in nursing response time relating to 
understaffing; 44 percent reported medication errors; and 37 percent 
reported lapses in infection control. However, only 13 percent were 
confident that they could honestly answer an inspector's question about 
the quality of care without risking reprisals, without, in quotes, 
risking reprisals. That is what they are afraid of.

  A Peter Hart poll found that one out of every four health care 
professionals was afraid to speak out on the job even to superiors. 
Now, think about it. If my colleagues or their family member goes to a 
hospital, wouldn't they want their nurse or doctor to be able to raise 
quality problems? Wouldn't they like to know that those professionals 
who are on the front line every day, whose job it is to take care of 
them, have the ability to improve whatever health or safety problems 
that they see, that they are not going to be afraid to report it 
because they are afraid that they are going to be fired?
  So protection for whistle-blowers, for people who want to raise 
legitimate concerns has to be in the legislation. It is in this bill.
  Second is the question of their right to sue an HMO. Over 85 percent 
of those of us with private insurance are in some kind of managed care, 
where HMOs and insurance companies have the ability to deny, to limit 
or to terminate medical care in addition to denying payment. They have 
the ability to override medical decisions of medical professionals even 
though they have never laid eyes on the patient. And when they do so, 
they are exempt from accountability for their actions.
  Now, again, we dealt with this issue in Illinois. And we had 
representatives of the HMO industry, and they sat before us in 
committee and they said, no, we do not make care decisions; we only 
make coverage decisions.
  Well, I said, ``Fellows, in the real world there is no difference 
here. If you are not going to pay for the care that I need, I cannot 
get the care that I need. I am not going to be able to afford to go out 
and buy it by myself. And so, if you said, I will not pay for it, that 
is as good as saying I am not going to allow you to have it.'' That is 
a medical decision.
  We heard a story from an emergency physician who was telling us about 
a patient who had come in with symptoms, he thought, of a heart attack, 
pain in the chest, some pain in the arm. Went to the emergency room. Lo 
and behold, they found it was not a heart attack. It was some kind of 
gastric distress. Home he went. The insurance company said, we are not 
going to pay for that; it was not a real emergency.
  Well, this emergency physician was telling us, the next time this 
patient had the same symptoms, he said, heck, no, I am not going to be 
able to go to the emergency room because I am not going to get it paid 
for. This person had a heart attack, and this person is dead.
  Well, come on, this is a care decision that is made by the HMO. If 
something goes wrong, we should have the ability to sue.
  And, finally, we have to address the question of what we call medical 
necessity. Who decides what is a medical necessity? Is it going to be a 
doctor or is it going to be an HMO, a person who has never met them, 
and yet the person who is going to determine how they can stay in the 
hospital, whether a service is provided on an inpatient or outpatient 
basis, if home care will be available, what prescription drugs they 
get, whether they get a lab test or follow-up visit, and other key 
decisions.
  Do they want someone who is hundreds of miles away from them, who 
does not know them, who may not be a qualified physician to be making 
decisions about their care? The answer is obvious. Medical necessity 
needs to be decided not by HMO bureaucrats but that they should be made 
based on generally accepted principles of good professional medical 
practice.
  This bill says the health plan should not be allowed to place 
arbitrary limits on covered services. It says that doctors should be 
able to prescribe the drugs that their patients need. It gives patients 
the assurance that their doctors will not be helpless bystanders as a 
bureaucrat goes ahead and makes all the decisions.
  So those are the three things that I would like to see that really 
are in H.R. 358. That is whistle-blower protections, HMO 
accountability, the right to sue, and medical decision-making by 
medical professionals.
  Mr. BAIRD. Mr. Speaker, I want to thank my colleague particularly for 
raising some issues that we had not addressed before and also for 
raising the important point about how much it costs us in our efforts 
to constrain costs when people are forced to go home from the hospital, 
where they do not get the care they need, they develop infections and 
then are forced to come back, or when medication regimens are cut off 
in the middle of someone's prescribed treatment regimen and they worsen 
in their illness.
  When physicians or other health care providers are forced to spend 
their days on the phone begging for the treatment that they know their 
patient needs, that costs. When hospitals are understaffed and when the 
staff that is there it is not at the level of professional training, 
that costs.
  When everybody talks about, those on the other side, on the Patients' 
Bill of Rights against it, they say it might raise costs. We need to 
counter, there are costs associated with the status quo and those costs 
are the cost in people's lives, the cost in the quality of care. The 
reason people oppose this is because the costs are borne by the 
providers and by the public while the profits are privatized. That is 
the problem with it.
  Ms. SCHAKOWSKY. Mr. Speaker, if the gentleman will continue to yield, 
that is absolutely right. And my colleague is talking about dollars and 
cents cost, and I think we have to have a much broader view on how we 
calculate that.
  My colleague also talks about the human cost. My father lived with me 
for 6 years before he died and was part of an HMO, and I cannot tell my 
colleagues the hours that I spent on the phone, the letters that I 
wrote, and I was writing as a State representative so it presumably was 
even easier for me, just trying to get him the care that he needed, 
getting them to cover what I thought that he needed that they 
eventually did and that anyone with common sense would see needed to be 
covered.

                              {time}  1700

  What if I was not there to advocate for him? How much shorter would 
his life have been? How much more difficult would his life have been? 
These all have to be part of our larger calculation.
  Mr. BAIRD. I thank the gentlewoman very much for raising those 
issues.
  Mr. Speaker, I yield to the gentlewoman from California (Mrs. 
Napolitano).
  Mrs. NAPOLITANO. Mr. Speaker, I am here because I am very concerned 
specifically on this issue of the Patients' Bill of Rights bill that is 
going to be coming before us. My constituency is a working-class 
constituency. I have been in that particular area for over 40 years, so 
I know that the people that I represent are people who have generally 
some coverage, not all of them have coverage, and it has become a great 
issue for all of the people that I represent. That includes some of my 
businesses, because they have no choice in some areas.
  The gentlewoman from Illinois (Ms. Schakowsky) talked about some of 
the things that she would like to see included in the bill. I agree. 
The whistle-blowers is a very inherent part, an oversight, if you will, 
directly by either the providers or the people who see the abuse or are 
able to articulate where we need to make a change or how we can address 
it to make it better to provide the protection for the patients. The 
accountability has sort of been overshadowed in the growth of the HMOs.
  Consider some of the facts that we are now looking at currently and 
that is that HMOs have witnessed considerable growth through the 1990s. 
By 1996, 60 to 70 million people were enrolled in HMOs. That is about 
20 percent of the U.S. population or, put another way, it is one of 
five Americans.
  HMOs started off in my era back 30 some odd years ago to be a good 
thing, and I belonged to one of them for over 35 years. They have made 
the medical

[[Page H687]]

profession a must-do. And I will not name it, but they have been very 
receptive to the needs of my family and to other people around us, but 
there are very few who put the patients' needs ahead of profits.
  Now, another statistic. The for-profit HMOs enroll 60 percent of all 
HMOs. That means the other 40 percent are the HMOs who are doing it 
because they want to provide a service for their community, and they 
much of the time are being bought out by the for-profit HMOs. So that 
means that my area alone I am seeing a lot of change and a lot of the 
closure to some of the access for some of my working-class folks.
  Another statistic. Two-thirds of the persons under 65 are covered by 
employer-sponsored insurance. Of these two-thirds under 65, 73 percent 
are HMOs. That means most big companies or most employers are using 
HMOs. That means they have captured most of the constituency that has 
to have insurance.
  Another statistic. A number of States have enacted various laws that 
regulate the practices to a varying extent. California was one of them, 
and specifically because of the outcry of the general populace of the 
need of reform in that particular area. They did not go far enough, as 
far as some of us were concerned, but at least it was a start to be 
able to bring some sanity to the addressing of the HMO's heavy-handed 
efforts to limit the amount and number of visits, the services of 
people who are in need of some very, very critical coverage.
  Another statistic. There has been little national legislation to 
regulate HMOs and ensure that patients receive quality care. Now, we 
know that is a fact because even the press brings that out, that some 
of the HMOs are making exceedingly high profits. That is one of the 
areas that certainly they are entitled to make a profit but not at the 
expense of human life which as we have heard some of my colleagues 
point to that fact.
  In 1998, Democrats fought for the enactment of the Patients' Bill of 
Rights that would have ensured medical decisions are made by doctors 
and patients and not by the insurance company bureaucrats, a person who 
has no credibility in the medical world to be able to determine whether 
or not that patient should have that coverage or that care.
  It would have also ensured direct access to specialists. Now, we 
might say, well, that is up to the HMO to determine, but where are the 
bureaucrats' credentials to say that they can determine what kind of 
service or what special service they need so that they would deny that 
to them?
  It would also have ensured the continuity of care. I have just 
recently had a doctor tell me that he is leaving an HMO because the HMO 
has placed caps on the number of visits that he is allowed to see his 
patients. He refuses, because of this, the Hippocratic oath that he 
took, to not render care where it is needed, so he is going into 
private practice. That tells me something, what has happened to some of 
the HMOs that we are dealing with.
  My Republican colleagues blocked those efforts in 1998. Hopefully, we 
will be able to ensure joint work together, our New Member Caucus and 
some of the other persons who are interested, because the Republican 
legislation does not ensure that we put medical decisions in the hands 
of the doctors and the patients. We want to put it in the hands of 
those doctors and patients, not in the bureaucrats. And we want to 
ensure that that weak legislation which did not ensure the direct 
access to specialists is changed so that anybody who has a requirement, 
a medical requirement, and medical need does get assurance that they 
will be referred to the specialist necessary.
  And also that legislation that was passed did not give the patients 
the right to sue HMOs liable for making decisions leading to serious 
injury and/or death. To me, if my family member were affected, I would 
certainly want to hold the right to be able to sue an HMO if they did 
not do their best to take care of my family member or my friend or my 
colleague. I think all of us feel that way.
  There is still a pressing and dire need for a meaningful Patients' 
Bill of Rights so that, for example, in emergencies, patients can go to 
the nearest emergency room and that the HMOs who feel that the 
emergency rooms do not pay off and close them, especially to urgent 
care, that we are able to have at least geographically accessible 
emergency rooms so that we can take care of that need.
  We also would like to see in that Patients' Bill of Rights we will 
include that the patients are guaranteed continuity of care. When their 
employer switches plans or when their doctors are dropped or resign 
from that network, the need for that care does not go away. I think it 
is incumbent upon us to realize that more and more we are going to be 
faced with individuals in our own backyard who are going to come to us 
and request that we extend that.
  It also should include that the patients can be part of approved 
clinical trials if no other treatment is available.
  Mr. Speaker, our constituents await our leadership to ensure that all 
their needs are addressed in this 106th Congress. I plead that we need 
to work together and not let our American working class down.
  Mr. BAIRD. I thank the gentlewoman very much. She raised two points 
that I think were absolutely critical.
  First, and I commend her for it, distinguishing between the for-
profit versus the not-for-profit HMOs. In our State, some of the 
pioneers of health maintenance organizations were not-for-profit 
organizations, voluntary cooperatives that have in fact voluntarily 
adopted many of the standards we are fighting to enact now through law, 
but they saw the need to do the right thing, to voluntarily allow 
patients to choose their providers, to create an appeal structure, and 
they have done the right thing. So I really think we need to emphasize 
that distinction between the for-profit and the not-for-profit.
  The other thing I want to compliment you on is the observation of the 
toll this system takes on health care providers. The gentleman you 
spoke about, have you talked to any others who raised these kinds of 
issues, other providers who said the stress of the HMO, dealing with 
those is burning them out, so to speak?
  Mrs. NAPOLITANO. Yes, very much so. As a matter of fact, recently one 
constituent told me, and he was a doctor, that they have been told that 
they must have something like 15 patient visits a day at 15, 20 minutes 
apiece. You really cannot provide the kind of care, especially in the 
specialist area like a heart doctor. To me it just indicates that these 
people are being put under pressure to move on to the next customer. It 
is like it is an assembly line.
  We cannot treat human beings that way. We need to ensure that those 
doctors and those plans that are not for profit, that we provide them 
with the assistance that is necessary to be able to render a service 
and increase their ability to do it at a local level where there is no 
HMO, even a for-profit. Unfortunately, that is not happening. I think a 
lot of people are being disheartened.
  Mr. BAIRD. I thank the gentlewoman very much for her comments.
  Mrs. NAPOLITANO. I thank the gentleman for the opportunity.
  Mr. BAIRD. Mr. Speaker, I yield to the gentleman from Washington (Mr. 
Inslee).
  Mr. INSLEE. Mr. Speaker, it is a delight to address this topic today. 
The reason is, when I think about the topics we sometimes talk about in 
this Chamber sometimes they are a bit obtuse, a bit theological, a bit 
arcane, but this is one that cuts right to the heart of why we come 
here to serve, because this issue is one of justice for Americans in 
getting medical treatment.
  This is not a matter of how many angels can dance on the head of a 
pin. It is not a matter of what is good or bad tax policy. It is a 
matter of whether you will live or whether you will die in the certain 
circumstances that people face in real life. For that reason, it is 
time for the U.S. Congress to get off the dime and act on this, to pass 
a strong Patients' Bill of Rights. It has dithered, it has dallied, it 
has debated for years and not acted, and it is time for action.
  Mr. Speaker, what particularly motivated me on this subject, during 
this last campaign I met lots of folks but the one that perhaps sticks 
in my mind

[[Page H688]]

the most is a woman named Katy Slater. Katy is from Issaquah, 
Washington. I did not know her before the campaign. I happened to meet 
her on the campaign trail.
  She told me her story. It was a story that, unfortunately, has become 
to maybe not be typical but not atypical. She got breast cancer. She 
had the trauma that would be associated with breast cancer.
  She went to her physician. Her physician told her, this is a serious 
case; but her physician held out one branch and light of hope for her. 
That was to have a stem cell transport. They told Katy Slater that if 
she had a stem cell transport, there was a good chance that she would 
survive and that if she did not, she would die.
  So she did what we would do, Mr. Speaker, in this case. She went to 
her insurance company to whom she had been paying premiums on a 
regular, timely basis for 30 years. She told them that the doctors had 
suggested she have her stem cell transport, and they said no. And she 
said, this can't be right. I have the physicians who have said I need 
this. But they said no.
  When she asked them, why do you say no when my physicians have said 
this is medically necessary, there is a medical necessity for this, how 
can you tell me I can't have this procedure, her insurance company to 
whom she had been paying premiums for 30 years said, no, ma'am, you 
don't understand, we make the rules, we decide what is medically 
necessary.
  When Katy Slater needed her transplant, she did not have an appeals 
tribunal to whom she could go to get a third party to resolve this. She 
did not have that. She did not have a legal right of recourse against 
her insurance company. She did not have that. She did not have the 
Congress of the United States saying to that insurance company that the 
physicians, the medical community should decide what is medically 
necessary, not the insurance industry. She did not have that. And she 
should have had that.
  Katy Slater, I will give the happy ending, Mr. Speaker, to this 
story. She, unlike many Americans, had a retirement plan. She had to 
cash it in, every single penny she had. She got her stem cell 
transplant 4 years ago, and she is alive today because of the stem cell 
transplant that her insurance company refused to provide for her. But, 
to her credit, she told me to come to this body and try to fight for 
the next Katy Slaters, the people who are going to have this problem in 
the future because she cares about them as much as she cared about 
herself.
  We need to pass this bill, Mr. Speaker, to prevent physicians from 
being gagged by insurance companies. An important provision of this, 
and the gentleman from Washington may have touched on this already, 
this antigag provision where insurance companies now can gag physicians 
to prevent them from telling their patients about life-saving 
treatment, that is an abominable practice, that is an absurdly unjust 
practice, and this body and Chamber ought to say so dramatically, and 
they ought to say so soon.
  And they ought to say it, too, Mr. Speaker, and I will make a 
particular entreaty. We are new Members. If I can, this ought to be a 
bipartisan effort, an effort where we work across the aisle together to 
make sure this gag rule is ended, to make sure that we have physicians 
decide medical necessity, not the insurance industry.

                              {time}  1715

  Mr. Speaker, the reason I say it should be bipartisan is we have just 
come through this political civil war, and this would be a really good 
place for us to start on a bipartisan basis to pass a bill that is 
meaningful to real Americans in their real life. And I would suggest we 
new Members work across the aisle to do that; and I say that when I 
address the insurance industry, too.
  And I think it is a good point the gentleman from Washington (Mr. 
Baird) raised: Not all insurance companies are guilty of the same sin 
here. Many, many insurance companies have provided fully adequate and 
comprehensive and quality care paid for by their insureds, but some 
have not, and it is for those good insurance companies, those who act 
in a fair and just way, that this bill will protect so they do not have 
to compete with the outliers who refuse to respect honesty and decency. 
This bill protects good insurance companies as well as the insureds.
  Mr. Speaker, I hope that we will work together to pass this bill.
  Mr. BAIRD. Thank you very much, Congressman Inslee. You know, I 
sometimes think we are here in this body for the Katie Slaters of the 
world.
  Mr. INSLEE. She told me to say this piece, and I have.
  Mr. BAIRD. I am grateful, and I am sure many other Americans are as 
well.
  Mr. Speaker, next I would like to recognize my colleague from the 
State of Nevada, Congresswoman Berkley.
  Ms. BERKLEY. Mr. Speaker, I rise today to tell you a story that 
explains why I am a passionate supporter of the Patients' Bill of 
Rights. This story, which is only one of many that I heard during my 
campaign, illustrates why health care plans must be held accountable if 
their financial decisions overrule the sound medical decisions of a 
doctor.
  This story is about a constituent who lives in my Las Vegas district. 
The man is a dialysis patient. He was scheduled for dialysis treatments 
twice a week, but over time he became toxic in between treatments and 
was continually sent to the emergency room during treatments. A third 
session became critical for his very survival.
  Rather than dealing with the ordeal of gradually becoming toxic and 
rushing to the emergency room because two treatments a week simply were 
not enough for him, the patient's doctor determined that without a 
third dialysis treatment the patient would be faced with a life-
threatening situation.
  But the patient was told by his insurance company that his diagnosis 
called for only two treatments per week. The patient was basically 
told: Tough luck, pal. Even though your doctor has diagnosed that there 
are three dialysis treatments necessary for your survival, we will only 
cover two of them.
  So the doctor called the health plan; he explained the situation. He 
graphically described how the health of the patient was in serious 
jeopardy without another dialysis treatment. Over the phone the doctor 
told a health care plan manager that the quality of the patient's life, 
in fact the patient's very life itself, was at issue.
  The HMO said no to the doctor's request. They said the diagnosis 
called for only two dialysis treatments and that that could not be 
changed.
  The doctor said, ``How can you say that? I am the diagnosing 
physician. The patient is standing right in front of me. My diagnosis 
calls for three dialysis treatments a week in order to save this 
patient's life.''
  In this case, the doctor prevailed. The patient got the necessary 
treatment, and the story had a happy ending. But there is a lesson to 
be learned here. A doctor should never have to argue to be allowed to 
provide critical care to his patient.
  In too many cases the balance has swung too far in favor of the 
bottom line. It has been said that there is too much emphasis on dollar 
signs rather than vital signs. I agree. The Patients' Bill of Rights 
holds health plans accountable legally if they reject sound medical 
diagnoses and treatment plans in order to boost profits. We owe this 
fundamental protection to our constituents, and I urge that we pass the 
Patients' Bill of Rights as soon as possible.
  Mr. BAIRD. Thank you very much.
  Mr. Speaker, I would like to finally recognize our final speaker for 
this afternoon, Congressman Holt from the State of New Jersey.
  Mr. HOLT. Mr. Speaker, I thank my colleague from the State of 
Washington. I am pleased to join today in the fight for passage of the 
Patients' Bill of Rights.
  My colleagues, the gentleladies from Nevada and Illinois and 
California and the gentleman from Washington have ably presented 
arguments in favor of this bill. I would like to address one of the 
fundamental, one of the fundamental features of the issue here, that 
is, the doctor-patient relationship, something I have observed closely. 
Few things are more fundamental, Mr. Speaker, more fundamental or more 
personal, than the relationship between a patient and her or his 
doctor.
  My wife is a physician, and the bond between her and her patients is 
something important, even sacred. It is a

[[Page H689]]

bond cemented by honesty and time and, importantly, by trust. The 
doctor-patient relationship is the bedrock of the entire health care 
system, and it is one of the main reasons that people choose to go into 
medicine in the first place. That relationship between doctors and 
their patients is under threat, and all too often in our Nation today, 
Mr. Speaker, the bond is being jeopardized by HMOs who are more 
interested in their profit statement than their mission statement.
  Mr. Speaker, there are insurance companies that are trying do a good 
job and many compassionate people working for those companies, but 
frankly the focus on profits taken by some HMOs makes you think they 
have more in common with Neiman Marcus than Marcus Welby.
  All of us have heard the stories, all of us here have, all of us on 
both sides of the aisle, families who worry that an insurance company 
clerk rather than their doctor will decide what treatment they get, 
providers who are afraid to tell their patients all of the health care 
options available to them because some might cost more, doctors who are 
restricted in what medicines they can prescribe and families who have 
to go through endless appeals and mountains of paperwork just to get 
the care they deserve.
  Just yesterday my colleague, Frank Pallone, and I met with 
constituents at Centrist State Medical Center in Monmouth County, New 
Jersey, to discuss this issue. We heard from people, a variety of 
people involved in health care: doctors, nurses, patients, hospital 
administrators and consumer advocates, men and women who serve every 
day on the front lines of health care. They had one message for us here 
in Washington, Mr. Speaker: Pass a Federal Patients' Bill of Rights, 
legislation that will ensure that medical decisions are not held 
hostage to business decisions.
  House Speaker Hastert recently said that he is willing to bring 
single-issue patients' rights bills to the House floor, bills dealing 
with issues like gag rules, emergency room standards and direct access 
to specialists. There is no doubt that these are issues that we need to 
address, but we cannot, we must not use them as an excuse to avoid 
tackling comprehensive patients' rights or we should not use them to 
dodge the important questions, issues of accountability and liability.

  As soon as we raise the question of liability, people say, oh, we 
should not let lawyers run this. Of course we do not want a health care 
system run by lawsuits, driven by lawsuits, but the question is: Who 
has the last word on medical decisions? That is what we have to 
protect.
  HMO horror stories are not isolated incidents. They are happening to 
families every day in my district and in yours, people who work hard 
and thought they were protected, people who see their loved ones denied 
the care they need and are powerless to do anything about it.
  We need to act in a bipartisan way to see that insurance companies 
are held accountable for their decisions, their medical decisions, and 
that they start to think twice before they deny payment for needed care 
and, in effect, deny the care. Mr. Speaker, we need to pass the 
Patients' Bill of Rights now.
  Mr. BAIRD. Thank you very much, Congressman. I appreciate those 
remarks.
  Mr. Speaker, I would like to conclude with just a few final comments. 
I, first of all, want to express my gratitude for my colleagues, 
particularly the fact that they are from the freshman class. These are 
folks who have just been on the front lines of often very difficult and 
challenging campaigns, but in the middle of those campaigns they 
listened to their constituents, they listened to their needs, and they 
carried those needs here to this body, and I hope this body will act on 
those needs.
  So I am very proud to serve as president of our freshman class, and I 
want to thank again my colleagues. I want to also make just a couple of 
final remarks.
  I asked to fill this role today because, in addition to being a 
Member of Congress, I am a health care provider myself. As a licensed 
clinical psychologist, I work with cancer patients, with head injury 
patients, with people dying of a number of terminal illnesses and with 
patients facing severe depression. I know firsthand the toll it takes 
on patients and the toll it takes on our providers and on our families 
and, frankly, on this country as a whole to have the current system.
  There is a common saying, and the saying is: If it ain't broke, don't 
fix it.
  Mr. Speaker, I would assert to you and the people we represent would 
assert to you and to this body that this system is broke and it is 
incumbent upon us as their elected representatives to fix it. I believe 
the Patients' Bill of Rights that gives you the right to choose your 
provider, gives your provider the option, the responsibility to 
determine your health care needs and that holds HMOs and managed care 
firms accountable is the solution to this system which is broken.
  Thank you very much.

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