[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
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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
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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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