[Congressional Record Volume 145, Number 79 (Monday, June 7, 1999)]
[House]
[Pages H3758-H3760]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                         HMO REFORM NEEDED NOW

  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 6, 1999, the gentleman from Iowa (Mr. Ganske) is recognized for 
60 minutes.
  Mr. GANSKE. Mr. Speaker, before I came to Congress I was a 
reconstructive surgeon. I took care of a lot of children who were born 
with cleft lips and pallets, similar to this little baby here. 
Unfortunately, Mr. Speaker, about half of the reconstructive surgeons 
in the country in the last couple of years have had proposed surgeries 
to correct conditions related to this birth defect turned down by HMOs 
because they are ``cosmetic.''
  Mr. Speaker, when you have a normal process like aging and you do an 
operation to make it better, that is cosmetic. But, Mr. Speaker, when a 
baby is born with a birth defect in the middle of their face, like 
this, that is not a cosmetic procedure. I can give you many functional 
reasons why this should be fixed. But there are children in this 
country in the last several years who have been denied medically 
necessary treatment by HMOs.
  Mr. Speaker, I closed my medical practice when I came to Congress, 
but I still go overseas to do surgeries to correct birth defects like 
this. I remember a few years ago I was down in Guatemala and a 30 year 
old man came in with an unrepaired cleft lip just like this. He lived 
all his life with an unrepaired cleft lip. So we fixed him the next 
day.
  He had come in with his mother, who was probably about 50, but she 
looked like she was about 80. They were of Indian extraction. When we 
took him back to the recovery area in this small hospital up in 
northeast Guatemala, his mother broke down and started crying. She said 
in Spanish, ``Ahora el va a Dios con felicidad,'' now he will go to 
heaven happy.
  Now, Mr. Speaker, one of the Members of this Congress, the gentleman 
from Texas (Mr. DeLay), should be commended, because he has helped 
raise funds for those surgical trips abroad, many of them done by Dr. 
Bill Riley, to help correct this type of birth defect. But we have a 
situation in this country where even if you are paying a lot of money 
for your insurance, you are getting turned down because your HMO 
arbitrarily declares this not medically necessary.
  When HMO reform comes to the floor, I hope my colleagues who have 
participated in helping children get charitable care to correct this 
type of birth defect will vote for legislation that makes it necessary 
for insurers in this country to cover correction of this type of birth 
defect.
  Mr. Speaker, the clock continues to tick. Another week has gone by 
without legislative action in the House on HMO reform. The gentleman 
from Virginia (Mr. Bliley), the chairman of the Committee on Commerce, 
has promised the gentleman from Georgia (Mr. Norwood) that we would 
have a subcommittee markup ``sometime in June.'' But where is a firm 
commitment to a date certain, and where is the commitment for a full 
committee markup, and where is the commitment from the Republican 
leadership in this House to move HMO reform to the floor? Or do we just 
continue to delay?
  Managed care reform should be on the floor by July 4th. There are 
four weeks until the July 4th recess. So, colleagues, let us get 
moving.
  Now, why is it so important to move this legislation in a timely 
fashion? Because, Mr. Speaker, people are being hurt every day by 
decisions by managed care health plans that they make when they know 
they cannot be held responsible for those decisions.
  I recently read an account of a gruesome crime, and I saw an analogy 
in that crime to what we have with Federal law as it relates to HMOs.
  Mr. Speaker, in late 1978 a woman by the name of Mary Vincent made a 
fateful decision. She jumped into a blue van on a freeway while 
hitchhiking in Berkley, California. Later the driver pulled off the 
highway and, in a flash, Mary saw a hammer swinging at her head. Her 
attacker then tied her hands behind her back and he raped her 
viciously, repeatedly. She screamed for her release. Finally, he untied 
her hands, only to sink an ax, an ax, into her left forearm. Then he 
did it again, and again, and her left arm was off in three blows. Four 
blows later, and he had cut off her other arm. This sadist then dumped 
her molested and violated and mutilated body into a culvert off of a 
lonely road, where she was found the next morning, miraculously, still 
alive.
  Mary was in the hospital for a month and was eventually fitted with 
prosthetic arms that have crab-like pinchers for her hands. She later 
testified against her attacker, and when she left the witness stand, he 
swore at her, ``If it is the last thing I do, I am going to finish the 
job.''
  Eight years later Mary was living in Puget Sound when she heard on 
her wedding day that her attacker had been freed from San Quentin after 
serving only eight years. She lived in fear for years that this rapist 
would return to finish the job.
  Finally, in February 1997, her mother called her with more bad news. 
Her attacker had killed a Florida woman. Last year she flew to Florida 
to testify against her attacker again.

                              {time}  2115

  This time he got the treatment he deserved. He is now on death row.
  Parenthetically, Mr. Speaker, it is crimes like those done to Mary 
Vincent that caused me and many other of our colleagues to support the 
death penalty. Any person who is not criminally insane should be 
responsible for his or her actions.
  So what does the horrendous tragedy that befell Mary Vincent have to 
do with managed care reform? Mr. Speaker, unfortunately, it reminded me 
of an equally tragic event that happened to a little 6-month-old baby 
named Jimmy Adams.
  At 3:30 one morning Lamona Adams found her 6-month-old boy Jimmy 
panting, sweating, moaning, with a temperature of 104, so she phoned 
her HMO to ask for permission to go to the emergency room. The voice at 
the other end of the 1-800 number, probably 1,000 miles away, told her 
to go to Scottish Rite Hospital. Where is it, asked Lamona? I don't 
know, find a map, came the reply. It turns out that the Adams family 
lived south of Atlanta, Georgia, and Scottish Rite was an hour away on 
the other side of the Atlanta metro area.
  Lamona held little baby Jimmy while his dad drove as fast as he 
could. Twenty miles into the trip, while driving through Atlanta, they 
passed Emory Hospital's emergency room, Georgia Baptist's emergency 
room, then Grady Memorial's emergency room. But they still pushed on to 
Scottish Rite Medical Center, still 22 miles away, because they knew if 
they stopped at an unauthorized hospital, their HMO would deny coverage 
for any unauthorized treatment, and they would be left with possibly 
thousands of dollars of bills.
  They knew Jimmy was sick, they just didn't know how sick. After all, 
they were not trained medical professionals. While still miles away 
from Scottish Rite hospital, Jimmy's eyes fell shut. Lamona frantically 
called out to him, but she couldn't get him to respond. His heart had 
stopped. Can you imagine Jimmy's dad driving as fast as he can while 
his mother is trying to keep him alive?
  They finally pulled into the emergency room entrance. Lamona leaped 
out of the car. She raced to the emergency room with Jimmy in her arms. 
She was screaming, help my baby, help my baby. The nurse gave him 
mouth-to-mouth resuscitation while the pediatric crash cart was rushed 
into the room. Doctors and nurses raced to see

[[Page H3759]]

if modern medicine could revive this little infant. He was intubated, 
intravenous medicines were given, and he was cardiopulmonary 
resuscitated.
  This is little Jimmy Adams, tugging at his big sister's sleeve before 
he got sick. Well, little Jimmy turned out to be a tough little guy. He 
survived, despite the delay in treatment caused by his HMO. But he 
didn't survive whole. He ended up with gangrene in both hands and both 
feet, and doctors had to amputate both of Jimmy's hands and both of his 
feet.
  Now Jimmy is learning how to put on his leg prostheses with his arm 
stumps, but it is tough for him to get on both of his arm hook 
prostheses by himself. For the rest of his life this anecdote, quote 
unquote, as HMO defenders are so likely to call a victim like Jimmy; 
they just say, they are just anecdotes. Well, little Jimmy will never 
play basketball, and little Jimmy will never caress the face of the 
woman that he loves with his hands.
  A judge looked into this case of James Adams and he said that the 
HMO's margin of safety was ``razor thin.'' I would add it is about as 
razor thin as the scalpel that had to amputate little Jimmy's hands and 
his feet.
  What do little Jimmy's amputations have to do with Mary Vincent's 
amputations? The person responsible for cutting off her arms is now on 
death row. But if your child had an experience like little Jimmy's and 
you received your health insurance through your employer's self-insured 
plan, the health plan would be responsible for nothing.
  The health plan, let me repeat that as we look at little Jimmy, if 
Jimmy's parents received their insurance through their employer who has 
a self-insured plan, and that plan has made the medical decision that 
has resulted in a little Jimmy Adams losing both hands and both feet, 
under Federal law that plan is responsible for nothing other than the 
cost of care given; in this case, the amputations.
  We say, how can that be? How can a health plan that makes medical 
decisions that result in the loss of hands and feet be free of 
responsibility? We would say, that is an outrage. We do not allow that 
to happen with victims of crime like Mary Vincent. How do we let an 
insurance company off scot-free when they make the kind of medically 
negligent decision that results in this?
  Do not get me wrong, I am not advocating criminal prosecution of 
medical malpractice. But just as I, as a doctor, am responsible for my 
actions, HMOs should be responsible for their actions.
  There are many Members of Congress like myself who support the death 
penalty because we believe in personal responsibility. How can, I ask 
the Members, how can we not at least support financial responsibility 
for an HMO when they make a medically negligent decision that results 
in the loss of a limb like this? Should they not at least be 
responsible for damages?
  Under a current Federal law called ERISA, the Employee Retirement and 
Income Security Act, if you receive your insurance from your employer 
and you have a tragedy like Jimmy Adams, your plan which makes 
decisions is liable for nothing other than the care that was not given. 
Not only did Congress give HMOs legal immunity for their decisions, but 
ERISA allows those health plans to define as ``medically necessary'' 
any damned thing they want to say it is.
  Do Members not quite see the parallel between Mary Vincent and Jimmy 
Adams yet? Listen to the words of a former HMO reviewer as she 
testified before Congress. It was May 30, 1996, when a small, nervous 
woman testified before the Committee on Commerce. Her testimony came 
after a long day of testimony on the abuses of managed care.
  This woman was Linda Peeno, a claims reviewer for several health care 
plans. She told of the choices that plans are making every day when 
they determine the medical necessity of treatment options.
  I am going to recount her story for the Members as she testified: ``I 
wish to begin by making a public confession. In the spring of 1987, I 
caused the death of a man. Although this was known to many people, I 
have not been taken before any court of law or called to account for 
this in any professional or public forum. In fact, just the opposite 
occurred. I was rewarded for this. It brought me an improved reputation 
in my job, and contributed to my advancement afterwards. Not only did I 
demonstrate I could do what was expected of me, I exemplified the good 
company doctor. I had saved a half million dollars.''
  Her anguish over harming patients as a managed care reviewer had 
caused this woman to come forth and bare her soul in tearful and husky-
voiced account. The audience in that room shifted uncomfortably and 
they became very quiet as her story continued. Industry representatives 
averted their eyes.

  She continued: ``Since that day, I have lived with this act and many 
others eating into my heart and soul. For me, a physician is a 
professional charged with the care of the healing of his or her fellow 
human beings. The primary ethical norm is, do no harm. I did worse. I 
caused death. Instead of using a clumsy, bloody weapon,'' those are her 
word, ``Instead of using a clumsy, bloody weapon, I used the simplest, 
cleanest of tools, my words. This man died because I denied him a 
necessary operation to save his heart.
  ``I felt little pain or remorse at the time. The man's faceless 
distance,'' remember that 1-800 number that Lamona Adams, little 
Jimmy's mother, had to phone, ``because of that faceless distance, it 
soothed my conscience. Like a skilled soldier, I was trained for the 
moment. When any moral qualms arose, I was to remember I was not 
denying care, I was only denying payment.''
  She continued: ``At the time, this helped me avoid any sense of 
responsibility for my decisions. Now I am no longer willing to accept 
the escapist reasoning that allowed me to rationalize this decision. I 
accept my responsibility now for this man's death, as well as for the 
immeasurable pain and suffering many other decisions of mine caused.''
  At this point, Mrs. Peeno described many ways that health care plans 
deny care, but she emphasized one in particular, the right to decide 
what care is medically necessary.
  She said, ``There is one last activity that I think deserves a 
special place on this list, and this is what I call the smart bomb of 
cost containment, and that is medical necessities denials. Even when 
medical criteria is used,'' she continued, ``It is rarely developed in 
any kind of standard traditional clinical process. It is rarely 
standardized across the field. The criteria are rarely available for 
prior review by the physicians or the members of the plan. And we have 
enough experience from history to demonstrate the consequences of 
secretive, unregulated systems that go awry.''
  Mr. Speaker, the man who cut off Mary Vincent's arms sits on death 
row, but HMOs which deny care with similar consequences, what happens 
to them? They increase their profits. Under Federal laws, HMOs can 
cause a Jimmy Adams to lose his hands or his feet, and then they can 
justify their decision by defining ``medically necessary'' any way they 
choose.
  When I think of Mary Vincent and Jimmy Adams, I rail at the injustice 
of their pain, but at least in Mary Vincent's case we know that her 
attacker is getting his just due, his just desserts.
  But does it not send a chill up our spine to hear an HMO medical 
reviewer describe how she caused the death of a man, and then got 
rewarded for it? Does it not cause a sense of outrage to find out that 
for years Congress has been shielding health plans from the 
consequences of their decisions like those that affected Jimmy Adams?
  It is time for Congress to defuse the smart bomb of HMOs. It is time 
for Congress to repeal the liability protection for ERISA health plans. 
They should function under the same liability that insurers in the 
individual market operate under, under regulations that would prevent 
tragedy like this.

                              {time}  2130

  Those protections should apply, Mr. Speaker, to everyone.
  Now, Mr. Speaker, personal responsibility has been a watchword in 
this Republican Congress and should be applied to this issue. Health 
plans that recklessly deny needed medical service should be made to 
answer for their conduct. Laws that shield entities from their 
responsibility only encourage them to cut corners. Congress created the 
ERISA loophole, and Congress should fix it.

[[Page H3760]]

  So I have now come full circle to what brings me to the floor 
tonight. I find us at a crossroads. HMO reform will either suffer slow 
legislative death as the House continues to do nothing, or we will take 
our responsibility for past congressional mistakes and pass a bill like 
my Managed Care Reform Act of 1999, H.R. 719.
  I urge my colleagues to cosponsor H.R. 719, the Managed Care Reform 
Act of 1999. It would fix the type of conditions that have caused this 
type of loss to a little boy.
  This bill is endorsed by the American Cancer Society and other 
consumer groups. It is endorsed by many professional groups, including 
the American Academy of Family Physicians. This weekend, it was 
endorsed by the American College of Surgeons.
  Mr. Speaker, I beg my colleagues, no I implore my colleagues, we 
cannot let even one more little boy or girl become a victim for the 
sake of making profits for an HMO. Let us have a fair debate under an 
open rule on the floor of this House by the July 4th recess. We should 
all be for the little guy. We should not be in the pockets of the HMO 
corporate CEOs.

                          ____________________