[Congressional Record Volume 145, Number 89 (Tuesday, June 22, 1999)]
[Senate]
[Pages S7428-S7446]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




   AGRICULTURE, RURAL DEVELOPMENT, FOOD AND DRUG ADMINISTRATION, AND 
               RELATED AGENCIES APPROPRIATIONS ACT, 2000

  The PRESIDING OFFICER. The Senate will now resume consideration of 
the agriculture appropriations bill, S. 1233, which the clerk will 
report.
  The legislative clerk read as follows:

       A bill (S. 1233) making appropriations for Agriculture, 
     Rural Development, Food and Drug Administration, and Related 
     Agencies programs for the fiscal year ending September 30, 
     2000, and for other purposes.

  Pending:

       Dorgan (for Daschle) amendment No. 702, to amend the Public 
     Health Services Act, the Employee Retirement Income Security 
     Act of 1974, and the Internal Revenue Code of 1986 to protect 
     consumers in managed care plans and other health coverage.
       Lott amendment No. 703 (to Amendment No. 702), to improve 
     the access and choice of patients to quality, affordable 
     health care.

  The PRESIDING OFFICER. The Senator from Massachusetts.
  Mr. KENNEDY. Mr. President, what is the business before the Senate at 
this time?
  The PRESIDING OFFICER. The Senate is currently considering S. 1233, 
the agriculture appropriations bill and the pending amendment is 
amendment No. 703.
  Mr. KENNEDY. Mr. President, now we are back to where we were 
yesterday just about 24 hours ago. At the request of the Democratic 
leader, the

[[Page S7429]]

amendment on the Patients' Bill of Rights was submitted to the Senate 
as an amendment on the appropriations bill yesterday afternoon. The 
majority leader then offered an amendment to that amendment, which was 
effectively the legislation that was passed out of the Health and 
Education committee some 3 months ago and the tax provisions from the 
Senate Republican leadership proposal. That is an amendment to Senator 
Daschle's proposal.
  We have this measure now before the Senate. Many of us over the last 
2 years have tried to gain the opportunity to debate what we call the 
Patients' Bill of Rights. The underlying concept of the Patients' Bill 
of Rights is very simple and very straightforward. Our legislation has 
the strong and compelling support of over 200 organizations all across 
this country. Medical decisions that affect the members of our families 
ought to be made by doctors--by professional, trained medical 
personnel--and the patients. They ought to be the ones that make the 
decisions that are going to affect our lives and the lives of our 
families, our grandparents, and our children. Those decisions should 
not be made by an insurance agent, or by an HMO official.
  This is a very basic and fundamental concept, and all of the basic 
measures--the proposals--that are advanced in our Patients' Bill of 
Rights, which was introduced by Senator Daschle, reflect this concept. 
The Republican proposal does not address this critically important 
concept. I call the Republican proposal the ``patients' bill of 
wrongs.'' They use the right words in their title, but that's it. Their 
bill doesn't guarantee that these decisions are going to be made by the 
doctors and nurses and by the trained medical professionals.
  The Members of this body do not have to take what I say on this 
interpretation of the Republican proposal. The fact remains that we 
have been waiting and waiting and waiting for well over a year, or for 
close to 2 years, to hear from our Republican friends about the medical 
associations or the medical professionals that support their proposal. 
Let's be clear, we don't advance this proposal because we are 
Democrats. We advance it because it will protect consumers and families 
in this country.
  It isn't that I say it, or that Senator Daschle says it, or that any 
of our colleagues say it. It is because the doctors in this country say 
it. The American Medical Association says it. The American Nurses 
Associations says it. The consumer organizations that have been 
dedicated to protecting patients have said it.
  If you look over the list of those various groups that are supporting 
our particular proposal, you will find that virtually every 
organization that represents women's health care support our 
legislation, and for very good reasons, which we will outline today. 
Virtually every leading group that has dedicated itself to protecting 
the well-being of children in our society and the health care of 
children are supporting our proposal. Why? For very good reasons, which 
have been outlined before by Senator Daschle, Senator Reed and those of 
us who support helping children. You will find that virtually every 
organization in this country that is concerned about the needs of the 
disabled in our society is supporting our program. Virtually every 
group that is concerned about cancer and cancer research is supporting 
our particular proposal. And virtually none are supporting the 
opposition's proposal.
  This is something that the American consumers ought to understand. 
This is something the American consumers ought to realize.
  I see our leader on the floor at this time. I think all of us are 
looking forward to listening to his presentation.
  I yield the floor at this time and will come back and address the 
Senate.
  Mr. DASCHLE. Mr. President, if the Senator will yield, he was talking 
earlier about the amazing array of groups in support of our bill. I 
think I heard the Senator say it really represents virtually the entire 
universe of health care provider organizations that we know in this 
country. Certainly they are not all necessarily Democratic groups or 
progressive groups.
  Would the Senator comment on the diversity of the groups supporting 
our proposal? I think this is a point that is sometimes lost--the 
breadth of organizations that say this is a top priority as a 
legislative issue.
  Mr. KENNEDY. As the Senator knows full well, we can take one example. 
There are many, and we will come back to those later in the afternoon. 
But the Senator has been a strong supporter in terms of increasing the 
NIH research budget and has followed the various recommendations so 
that hopefully we are going to double the NIH research budget. Our 
Republican colleagues have supported this proposal. Senator Mack and 
Senator Specter have been leaders. Senator Harkin has been one of the 
important leaders. Many other Members have supported that proposal. 
Why? Because it is universally accepted that we are in the early 
morning sunrise period of major scientific breakthroughs on many of the 
kinds of diseases that affect millions of our fellow citizens.
  This year, more than 563,000 will die from cancer, and 1.2 million 
will be diagnosed. We have these enormous potential breakthroughs that 
can mean the difference between life and death. These breakthrough 
treatments allow individuals some degree of hope of being freed from 
Alzheimer's or Parkinson's disease or cancer. Every medical researcher 
understands that. That is why they support the access to clinical 
trials piece in our proposal. When they have the breakthrough in the 
laboratory, they want to get it to the bedside. The way that is done is 
through clinical trials.
  Under the Daschle proposal, we would continue the traditional support 
for clinical trials so that we can move these breakthroughs that are 
coming in the laboratory to the patients, to the mothers, and to the 
daughters, and to others.
  Mr. DASCHLE. Will the Senator explain the term ``clinical trials?'' 
The Senator has made such an important point about this issue. There 
are so many differences between the Republican and Democratic bills. 
One of the myriad of differences has to do with the so-called 
``clinical trial'' provision. The Senator has spoken on the floor so 
patiently and eloquently about the concept of clinical trials and 
access to them. When we talk about clinical trials, are we talking 
about innovative techniques to respond to health problems that take 
full advantage of research and the opportunities of medicine that this 
country provides? Are we talking about giving people access to that 
medicine and cutting-edge technology just as soon as it is available?
  Isn't that really what we are talking about?
  Mr. KENNEDY. The Senator is absolutely correct.
  If I could add to what the Senator has said, we have made great 
progress in dealing with cancer, especially children's cancers, over 
the last 10 years. The principal reason for this progress is the large 
number of clinical trials. We should take the time to spell out what 
has actually happened in the clinical trials and why that is an 
important provision of the leader's Patients' Bill of Rights.
  Mr. DASCHLE. We should talk about clinical trials and how critical 
they are.
  I ask the Senator if he could inform Members what impact it would 
have on an individual were he or she able to have access to clinical 
trials today under this bill?
  Mr. KENNEDY. Senator, I will speak from a personal point of view. My 
son was 12 years old when he was diagnosed with osteosarcoma, bone 
cancer. Chances of survival were 15 percent; the mortality rate was 85 
percent. We were able to enroll my son in a National Institutes of 
Health clinical trial, which only 22 children had gone through 
successfully. He was in that program for 2 years. By the time he 
finished, they had more than 400 children taking part in that program 
who survived osteosarcoma, with a breakthrough new treatment for 
osteosarcoma. Seven thousand children are affected every single year. 
At that time, the loss of a leg was a matter of course; it is not at 
the present time.
  There is no question that not only my son but many of the other 
children would not likely have survived had they not participated in 
the clinical trial. That treatment for osteosarcoma is now the standard 
treatment and is saving countless children's lives.
  There are many other examples. Our greatest progress in cancer 
research

[[Page S7430]]

and in treating cancer has been a direct result of clinical trials.
  Mr. DASCHLE. If the Senator would yield for a clarification, is the 
Senator saying that in many cases today insurance companies and managed 
care organizations are refusing to allow a patient access to the very 
kind of treatment that you say your son received? Is that what is going 
on?
  Mr. KENNEDY. Not only am I saying that, but most important is that 
the directors of the Lombardi Cancer Research Center, located here in 
Washington, DC, one of the major centers in the country in cancer 
research programs and clinical trials, is saying that as well. The 
director says they employ eight professionals who work 18 hours a day 
combating health maintenance organizations to help enroll women in 
breast cancer clinical trials. Doctors have recommended patients for 
clinical trials, with treatment that can probably save their lives, but 
due to resistance and denials by the health maintenance organizations, 
those women are effectively denied treatment that may save their lives. 
That is happening today.
  As the Senator knows, all we are trying to do with this particular 
proposal is follow sound medical guidelines, the medical guidelines 
that your doctor--who may be an oncologist acting on behalf of a victim 
of breast cancer--believes, given the clinical trials taking place, 
providing you a real chance of surviving if we enlist you in the 
clinical trial; this is in your medical best interest.
  Your bill says your physician's medical determination is going to be 
the controlling judgment. It isn't going to be an accountant in the HMO 
who says: We don't believe that treatment is justified and we are not 
prepared to pay for it; I am making the medical judgment--even though I 
am trained as an accountant.
  Mr. DORGAN. Will the Senator yield?
  Mr. KENNEDY. I am happy to yield to the Senator.
  Mr. DORGAN. The Senator is talking now about specifics, and Senator 
Daschle was asking about clinical trials.
  Let me ask another specific. Regarding emergency room treatment. 
Senator Kennedy makes the point there is the Patients' Bill of Rights 
on this side and the Patients' Bill of Rights on that side. But they 
are not the same. There is a big difference.
  Let me give an example regarding emergency room care. I told the 
story of a case of a woman named Jacqueline the other day. Jacqueline 
is a real person. She was hiking in the Shenandoah. While hiking in the 
Shenandoah, she slipped and fell down a 40-foot cliff. She fractured 
three bones in her body, including her pelvis. She was unconscious. She 
was medivac'ed by helicopter, taken to a hospital emergency room, and 
treated. She survived.
  The HMO said: We don't intend to pay for your emergency room 
treatment because you didn't have prior approval to go to the emergency 
room.
  This is a woman who was unconscious.
  The Patients' Bill of Rights that the AMA and so many other groups 
have endorsed--they have written in support--is different from the bill 
the majority party offers in the emergency room treatment in the sense 
that we require not only the ``prudent'' layperson standard in 
emergency care and emergency room, but we require also the 
poststability care that is necessary after you have been to an 
emergency room, and their bill does not do it.
  Mr. KENNEDY. The Senator is absolutely correct. We have had constant 
examples of abuses that have taken place. Senators have printed in the 
Record these human tragedies.
  The Senator understands fully that this is not only something from 
last year or something from last month. The situation the Senator has 
outlined is happening today. It has happened this morning; it has 
happened this afternoon; it will happen tomorrow. It will continue to 
happen unless and until we pass this legislation.
  Mr. DORGAN. I just described a case of a woman being hauled into the 
hospital unconscious and being told: We can't pay your bill because you 
didn't get prior approval for emergency room treatment.
  That is absurd. That is the kind of horror story that requires all 
Americans to believe we must pass a Patients' Bill of Rights that has 
teeth and works to solve real problems.
  Isn't it the case, with respect to emergency room care, that we in 
this Congress have already given all senior citizens in the Medicare 
program exactly what is proposed in our bill with respect to emergency 
room treatment and poststability care? Isn't it the case that every 
Member of the Senate has already voted for that in Medicare, saying 
yes, that is the right thing to do; but when it comes to the Patients' 
Bill of Rights they say: We want to have a Patients' Bill of Rights, 
but on our emergency room care, we don't intend to offer that 
protection on not only emergency room care but also poststability care 
in a hospital after you get out of the emergency room; we don't intend 
to offer that, even though we have already done that and voted for it 
for Medicare patients.
  I don't understand the contradiction; does the Senator from 
Massachusetts?
  Mr. KENNEDY. The Senator has correctly stated the current situation. 
It isn't only Medicare. It is also in Medicaid, as well as the Federal 
Employees Health Benefits Program. Every Senator has these protections.
  The interesting question I ask the Senator, if these protections were 
such burdens on the delivery system, doesn't the Senator think he would 
have heard? These protections are available today, for those who are 
covered with Medicaid or Medicare. The other side in opposition to the 
Daschle proposal is always saying these protections are burdening the 
system, and we can't protect all Americans because it will burden the 
system?
  The Senator has made the correct point. We do it today in Medicaid. 
We do it in Medicare. We do it for Federal employees. Most of the good 
HMOs do it. It is the bad apples that are threatening the well-being 
and the health of many of the citizens in our States whose procedures 
we need to address.
  Mr. DORGAN. I will respond, if the Senator will yield to me further, 
with the story I told on the floor of the Senate, about the woman who 
was also injured, whose brain was swelling and who was in an ambulance 
being taken to a hospital and who said to the ambulance driver, I do 
not want to go to X hospital. She named the hospital. I want to go to Y 
hospital farther down the road. This woman lying in the back of an 
ambulance with a brain injury said: I want to go to the hospital 
farther away. Why did she say that? Because she read that the hospital 
that was closest had made decisions about patients' care that were more 
a function of corporate profit and loss than they were about health 
care, and she did not want, with a brain injury, to be wheeled into the 
emergency room with the notion somebody was going to look at her and 
make a dollar-and-cents decision about her health care.
  Mr. DASCHLE. If the Senator will yield on that point, I would like to 
comment. I think what he has noted is exactly another reason why it is 
so important for us to have a debate about access to emergency rooms 
and other necessary care.
  I would note that just the opposite of what the Senator describes 
oftentimes occurs. A managed care company, or an HMO, actually will 
make you drive past the nearest hospital to go to a hospital farther 
away, where they have a contract.
  Sometimes a patient will choose not to use the nearest hospital, for 
a lot of reasons--better care, preferred specialists, different 
services. A patient may want to go farther away. But, in many cases, 
maybe a preponderance of cases, they actually have to drive past 
hospitals to go to the hospital the HMO has chosen, rather than the one 
they would choose for themselves.
  Again, I think the Senator makes a very good point.
  Mr. KENNEDY. May I just make this point? Access to emergency care, 
which is carefully protected in the leader's legislation, does the 
leader know that the provisions in his legislation were almost 
unanimously supported in the President's Commission on Quality Care? 
The one exception is the President's Commission did not make the 
recommendation that it be put in law, although they said every quality 
health maintenance organization ought to have it.
  Second, the American Association of Health Plans has recommended it.

[[Page S7431]]

 They do not mandate it, but they recommend it, saying it is essential 
in providing care.
  The National Association of Insurance Commissioners--not a Democratic 
group, the majority of Insurance Commissioners are probably 
Republicans--has recommended it for the States. They say, in the 
States, as a matter of good quality health care, they ought to have the 
provisions which are in our Patients' Bill of Rights. As the Senators 
have pointed out, it has been included in Medicare.
  So this proposal, which was offered and defeated in the Health, 
Education, Labor and Pensions Committee, should be a matter where we 
have an opportunity to present it and let the Senate make a judgment. 
As I mentioned, it has been recommended by the nonpartisan commission. 
It has been recommended by the independent insurance commissioners. It 
is in Medicare. We would like to hear on the floor of the Senate those 
individuals who are opposed, those individuals who say no to this 
particular protection. That is the kind of protection that is included 
in the Daschle proposal, which is of such importance.
  Mr. President, I see others want to speak on this proposal.
  In looking down this list of protections, you can ask yourselves: 
Where do these protections really come from? As I mentioned, the 
protections we have put into the Daschle proposal are effectively the 
ones supported by the President's commission, the American Association 
for Health Plans, and the Insurance Commissioners. It is in Medicare. 
It is working, and it is working effectively. We do not have examples 
that protecting those under Medicare is a burden, and I do not think 
those who are opposed to that particular proposal can make an effective 
case in opposition to this provision.

  I will take the time later to mention two or three more protections. 
Virtually every one of these protections is either part of a 
recommendation from the President's commission, part of the 
recommendations of the American Association of Health Plans, 
recommended by the state Insurance Commissioners, or is being 
implemented and protecting persons covered under Medicare.
  These are commonsense proposals. They are not protections we have 
suddenly grabbed from some way-out organization or group. They are 
fundamentally rooted in sound health care practices. That is the case 
we want to bring to the floor of the Senate.
  I see my colleague and friend on the floor now, wishing to speak. I 
will be back to address the Senate shortly.
  The PRESIDING OFFICER (Mr. Bennett). The Senator from North Carolina.
  Mr. EDWARDS. Mr. President, I thank my colleague from Massachusetts. 
First, on this issue of the Patients' Bill of Rights, I ran for the 
Senate in part so I could address this issue, which is of critical 
importance to the people of North Carolina and the people of America, 
in a completely nonpartisan way. I am not interested in engaging in 
partisan politics between Democrats and Republicans. What I am 
interested in is a real discussion about an issue that is absolutely 
critically important to the people of this country and the people of 
North Carolina. Let me talk briefly about one aspect of the Patients' 
Bill of Rights that I think is so important.
  Imagine there is a 29-year-old woman who lives in the Research 
Triangle of North Carolina which is between Raleigh-Durham and Chapel 
Hill, between Duke University Medical School and the University of 
North Carolina Medical School. Let's assume she is the mother of two 
children, having recently had a young child, born 6 months ago. She 
goes in for a postpartum checkup after the birth of her child, and the 
doctor looks at a mole on her back that seems suspicious. After some 
further testing, it is confirmed that her and her family's worst 
nightmare is true; she has a melanoma.
  After they do further investigation, they determine there are 
clinical trials going on at Duke University Medical Center, just down 
the road from where she and her family live, which could provide 
lifesaving treatment for her condition. So she goes to her HMO and 
says: I want to be part of this; I want to make sure I have access to 
the best health care available. Literally, her life is as stake. She 
finds out from her HMO, unfortunately, that Duke is not part of the 
network of her HMO. So, as a result, treatment for her melanoma, which 
is so critically needed, is not available.
  Here we have a situation where a simple thing is true. An HMO system, 
a health insurance system, a health insurance company, should not be 
able to stand between this woman and the lifesaving medical treatment 
she so badly needs and her family so badly needs for her. A real 
Patients' Bill of Rights would ensure that someone in her condition 
would have access to the best specialty care available, whether or not 
that care is within or without her HMO network. It would ensure, in my 
example, that she could, in fact, go 15 miles down the road to Duke 
University Medical Center and get the treatment that may well save her 
life--the life of a mother and a wife.
  This is the kind of thing we need to be doing something about in the 
Patients' Bill of Rights. She should not be confronted with an obstacle 
course in order to get the treatment she needs and deserves. She needs 
to have ready, direct access to the care she obviously needs under 
these circumstances. That was an illustration.

  I want to talk, secondly, about a real-life example. We received a 
phone call in my office from a young man who lives in Cary, NC, which 
is just outside of Raleigh. His name is Steve Grissom. Fifteen years 
ago, Steve Grissom was diagnosed with leukemia. The truth is, for most 
people, that would be an extraordinary life-altering and devastating 
thing to have occur. Unfortunately, that is not the end of the problem 
for Steve Grissom.
  In 1985, because of his leukemia, he was required to have a blood 
transfusion. Most folks who are listening to this story probably know 
where it is headed. As a result of this blood transfusion, which he had 
to get because of his leukemia, he now has AIDS. He got AIDS as a 
result of the blood transfusion.
  With the onset of AIDS, he had multiple medical problems. Included 
among those medical problems was the development of something called 
pulmonary hypertension which made it very difficult for him to breathe. 
The doctors who treated him prescribed oxygen 24 hours a day, 7 days a 
week to help him maintain his oxygen level. This prescription was made 
by a pulmonary specialist at Duke University, something that was 
clearly needed to save his life.
  He was doing fine. Then his employer changed health care companies, 
unbeknownst to him. When the new HMO took over, they cut off payment 
for the oxygen that Steve had been dependent on for a long time now--24 
hours a day, 7 days a week.
  Let me tell you how that decision was made. It was not made by some 
medical doctor who examined Steve and decided he did not need this 
treatment. It was not made by a specialist who had a different opinion 
than the pulmonary specialist at Duke University. Instead it was made 
by a clerical/bureaucratic person at the HMO sitting behind a desk 
looking at papers. The conclusion that person came to was that his 
oxygen saturation levels were not sufficiently low under their criteria 
to justify him receiving oxygen 24 hours a day, 7 days a week, even 
though the most highly trained medical specialist in the area at Duke 
University Hospital had prescribed this oxygen for him. He said it was 
lifesaving, absolutely critical.
  The result of all this was basically an insurance company bureaucrat 
sitting behind a desk overrode a doctor who has spent his life in this 
area, who had become one of the best known pulmonary specialists in the 
country at Duke University, who had prescribed this oxygen therapy for 
Steve. Here is a man who has been confronted with extraordinary 
setbacks in his life, the kinds of things that would put most of us 
under the ground.
  Here is the extraordinary thing about Steve Grissom. He has continued 
to fight. Even though his health insurance company now says they will 
not pay for the care he needs, he has managed to pay out of his own 
pocket for as much of this care as he can get.
  He has called my office and said: I want to come to Washington. I 
want to testify. I want to talk to Members of

[[Page S7432]]

the Senate, Members of the Congress. I want to tell them about the 
problem I am having getting any continuity of care which I so 
desperately need.
  The truth of the matter is, what Steve Grissom is doing is he is 
fighting in every way he knows how to cease being a statistic, to stop 
being a name and a number on a piece of paper on somebody's desk 
sitting in an insurance company office.
  He is an extraordinary example of heroism. He is the kind of person 
whom I think most of us would hold up to our children and members of 
our family as what we hope they will be when confronted with 
extraordinary, difficult setbacks.
  He fought back. He got the blood transfusion he needed in 1985. When 
he was then confronted with something that would absolutely overcome 
most people, which is AIDS as a result of the blood transfusion, he 
continued to do everything in his power to get the treatment he needed 
and go forward with his life.

  When he was on oxygen 24 hours a day, 7 days a week just to stay 
alive and his employer changed HMOs and they cut off payment for the 
treatment that kept him alive, he continued to fight. Here is the most 
extraordinary thing about it. Not only has he continued to fight, not 
only has he expressed a willingness to come and talk to Members of the 
Senate, to testify before this Congress about what he has been 
confronted with, there is absolutely no bitterness in this man. He has 
been kind and gracious. He has said: I want to do everything I can to 
ensure that what has happened to me does not happen to other Americans, 
does not happen to other North Carolinians. I want to explain to 
Members of Congress why it is so critically important that we pass a 
meaningful Patients' Bill of Rights, one that will protect people who 
are confronted with the kind of situation with which I am confronted.
  The truth of the matter is, it is extraordinary that he is still 
alive. He continues to be a huge part of his family's life. He is, by 
any measure, a hero. But to the insurance company, Steve Grissom is a 
liability. He is somebody who costs $515 a month to pay for the oxygen 
that is needed to keep him alive.
  The reality is that they made the decision about Steve Grissom for 
the same reason that HMOs and health insurance companies make these 
decisions all across the country, affecting children and adults and 
families all over this country every day. They did it based on the 
bottom line--profits. They had established an arbitrary criteria for 
what was necessary for somebody in Steve's situation to get oxygen 
therapy and treatment that he needed. Regardless of his individual 
situation, regardless of the fact that the doctors who were responsible 
for treating him, who are highly trained, highly specialized experts at 
Duke University Medical Center, had said he needs this treatment, they 
rejected it. They made the decision that no longer would he receive 
this oxygen, and they would not pay for it anymore.
  I cannot help but believe the majority of Americans think that what 
has been done to Steve Grissom is wrong; that the courage he has shown 
in the face of extraordinary adversity is something that should be 
admired and looked up to. He is absolutely entitled to the benefit of 
the doubt, to the extent there is any doubt, that a specialist at Duke 
University has determined that he is entitled to this treatment that he 
so desperately needs.
  Mr. KENNEDY. Will the Senator yield for a question?
  Mr. EDWARDS. Yes.
  Mr. KENNEDY. Given that this patient is denied the treatment that can 
make all the difference in restoring his health or well-being, and 
given that we have heard examples where, as a result of denying that 
treatment, a decision made by the health maintenance organization 
despite the recommendations of the medical professional--can the 
Senator tell me the remedies available? What remedies are available to 
a family whose loved one dies or whose loved one sustains a permanent 
injury because a judgment was made by the insurance company or the HMO, 
in conflict with the recommendation by the treating doctor. What remedy 
is available to that family that loses its breadwinner or has to care 
for an individual who is permanently injured for the rest of their 
life? What remedy is available for the family who loses a loved one due 
to the negligence or the clear malfeasance of the insurance company or 
the HMO?
  Mr. EDWARDS. The Senator's question highlights an enormous problem in 
existing law and a problem that we are trying to desperately cure in 
this Patients' Bill of Rights.
  Under the circumstance I have just described, if something happens to 
Steve Grissom, i.e., he suffers more serious injury or dies as a result 
of an arbitrary decision made by an insurance company bureaucrat, if 
that occurs, first of all, under the existing law, that HMO and that 
bureaucrat cannot in any way be held responsible. They are totally 
immune to responsibility, unlike every other American--you, I, any 
other American--who could be held accountable in court for that 
decision. They are totally immune from responsibility. They are 
protected.
  As a result, they only have one incentive for what they do, and that 
incentive is the green dollar bill, the profit, the bottom line. It is 
the only thing that matters to them. That is the basis on which these 
decisions are made.
  Not only that, not only can they not be held accountable in court, I 
say to the Senator, there is not even an independent review board that 
can look at this decision that has been made and determine whether it 
is unfair, whether it is unjust, and whether it is medically unsound.
  So basically, Steve Grissom and his family, in this life-threatening 
situation, are confronted with a circumstance where they have no remedy 
at all. They can do absolutely nothing.
  Does that answer the Senator's question?
  Mr. KENNEDY. Further, is the Senator suggesting that this is the only 
area in civil law that a remedy is really being denied on the basis of 
real negligence, malfeasance? Are these the only companies in America 
that have this sort of privileged position of being free from what I 
think most Americans would understand as accountability? Is that what 
the Senator is suggesting?
  Mr. EDWARDS. That is exactly what I am suggesting, I say to the 
Senator.
  I add, anecdotally, one of the things that the Senator knows, I have 
come from 20 years of having represented folks in court cases. One of 
the questions we always ask jurors in the process of jury selection is: 
Do you believe everyone should be treated exactly the same in this 
courtroom? Universally, the answer is yes. Because the American people 
are fairminded. They believe everyone should be treated equally, 
everyone should be treated the same. They believe in both personal and 
corporate responsibility, that everybody ought to be held accountable 
for what they do or do not do--the very same way we teach our children 
they should be held accountable for what they do or do not do.
  Instead, under existing law in this country, we have decided HMOs and 
health insurance companies are privileged characters. They get treated 
in a way that no other American business is treated, that no other 
American citizen--the people who are listening to this debate--is 
treated. They are held responsible for what they do.
  But for some reason, under the law, unless and until we are able to 
change it, HMOs and health insurance companies are treated in a very 
privileged way. They cannot be held responsible for what they do. 
Unfortunately, that has enormous consequences for people, for families, 
and for children. The consequence is they have no reason to do anything 
other than the profit motivation, and the bottom line, which is the 
dollar. That is one of the problems we are working desperately to cure 
in our Patients' Bill of Rights.
  Mr. KENNEDY. Finally--because I see others on the floor; and this 
issue is going to be addressed in the Daschle proposal--I am wondering 
whether the Senator would agree with Justice William Young, a Federal 
judge on the Federal bench in Massachusetts, who was appointed by 
President Ronald Reagan, who said, after a very tragic case--and I will 
not review all of the facts here, but it was quite clear that there was 
responsibility by the insurance companies; and it will be self-evident 
in his quote; and there was a real injustice done--this is what Judge 
William Young, appointed by President Reagan, who prior to the time he

[[Page S7433]]

served on the bench was a Republican, said:

       Disturbing to this Court is the failure of Congress to 
     amend a statute that, due to the changing realities of the 
     modern health care system, has gone conspicuously awry from 
     its original intent. This Court has no choice but to pluck 
     the case out of State court . . . and then, at the behest of 
     Travelers [Insurance Company]--

  That is effectively the culprit--

     slam the courthouse door in [the wife's] face and leave her 
     without any remedy. ERISA has evolved into a shield of 
     immunity that protects health insurers . . . from potential 
     liability for the consequences of their wrongful denial of 
     health benefits.

  That is the statement from the bench of a distinguished Federal judge 
who came down and eventually effectively testified about the injustice 
of this provision. As I understand it, the Daschle proposal addresses 
that inequity and unfairness, which the Senator has outlined.
  Mr. EDWARDS. May I respond to that briefly, I say to Senator Kennedy?
  I would ask for a comment from you on this issue. In terms of talking 
to your constituents in Massachusetts, can you tell me what response 
you have gotten, including from health care providers, on the issue of 
whether it is important to them, No. 1, that there be an independent 
review board so when folks' claims are denied, they have some ready 
process to use to get relief, and, secondly, whether they believe it is 
fair for HMOs and health insurance companies to be treated completely 
differently than every other segment of American society?
  Mr. KENNEDY. As the Senator knows, they have independent review. We 
have it under the Medicare proposal. It works. It works very 
effectively. It works pretty well. It is somewhat different in scope 
than was included in the Daschle proposal. I favor this one here, but 
there is an independent review. But not only in that measure, we have 
some 23 million Americans who are working for State and local 
governments that have the kind of protection that is favored in the 
Daschle proposal, and it is working very effectively.
  One of the very important programs that has the kind of protections 
the Senator has favored and that I favor is what they call the Calpurse 
Program in the State of California, which has well over a million 
individuals who are part of that program with the kind of protections 
that are supported by the Senator.
  What they have found out--we will have a chance to get into this, 
hopefully, at the time we get a debate on it--is that the cost of that 
whole program has not increased as much as the increase in health 
insurance nationwide, or even in the programs in California that do not 
have that protection.
  Do you want to know why, Senator, I believe that is so? For the same 
reason we had the expert witnesses who appeared before Senator 
Specter's Appropriations Committee; and that is, because the HMOs take 
more time and attention to make sure the patients are going to get 
better kinds of health care and health care coverage. That basically 
means they are able to get a better handle on the cost.
  So it makes a major difference in terms of the quality of health 
care, and it makes a major difference in terms of the protections of 
individuals.
  I thank the Senator for his response.
  Mr. SCHUMER. Would the Senator from North Carolina yield for a 
question?
  Mr. EDWARDS. Yes.
  Mr. SCHUMER. I thank the Senator.
  I have been very impressed with what he has said. As the Senator 
knows, I have been advocating the Patients' Bill of Rights for quite a 
while. Just this week I had traveled to different parts of my State--to 
Long Island, to New York City, to Syracuse, to Rochester. Everywhere I 
went, I found an amazing thing: The providers, the doctors, including 
the medical society, the AMA, the nurses, the hospitals are allied with 
the patients. Usually they are at loggerheads. But they were allied 
together in asking for a real Patients' Bill of Rights, not a Patients' 
Bill of Rights in name only.
  We do not want to go through putting something on the floor that 
says: Patients' Bill of Rights, and does not protect patients. We are 
worried about that.
  The reason I think we want an open debate and not just: Well, here is 
your version; we will vote for it. Here is our version; we will vote it 
down. We are finished with the Patients' Bill of Rights--we do not want 
that because we do not want to be able to just go home and say we 
passed something and then 3 months from now the very same doctors, and 
others, will say: It doesn't do any good. You didn't do anything.
  We went through this on guns. We were going to pass something in this 
body that did absolutely nothing. Then the very same people who say the 
gun laws do not work, or who tried to cripple and emasculate the 
provisions we passed, said the laws do not work.
  So the question I ask is--here are some examples of inequities that I 
have come across. I just would like to ask the Senator from North 
Carolina if he thinks the Patients' Bill of Rights would help in these 
instances; and they are just amazing.
  One, an HMO denies high-dose chemotherapy for a man with lung and 
brain cancer, stating it is experimental. What was the HMO's solution? 
The claim agent told his family to get in touch with organizations that 
have fundraisers for patients denied HMO coverage. Can you imagine the 
gall of that? A man is dying of cancer. They find a solution that might 
work. There is finally some hope in the family. Not only does the HMO 
say, no, we won't pay for it, but at the same time they say go have 
some fundraisers while the person has cancer. How about this one----

  Mr. DURBIN. I ask, if I might, will the Senator from North Carolina 
yield to me?
  The PRESIDING OFFICER (Mr. Gorton). The Senator from North Carolina 
has the floor.
  Mr. DURBIN. Will the Senator yield for the purpose of a unanimous 
consent request?
  Mr. EDWARDS. Yes.


                       Unanimous Consent Request

  Mr. DURBIN. Mr. President, I ask unanimous consent that the remaining 
65 minutes of debate before the vote at 5:45 on the motion to table be 
divided as follows: 40 minutes under the control of Senator Nickles on 
the Republican side and 25 minutes under the control of Senator Kennedy 
on the Democratic side.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  Mr. KENNEDY. I yield 5 more minutes to the Senator from North 
Carolina.
  Mr. EDWARDS. I thank the Senator. I will conclude my remarks. The 
point I make is so important, which is that this is not a partisan 
debate. This is not a debate and should not be a debate between 
Democrats and Republicans. I didn't come to the Senate to fight with my 
Republican colleagues. I came to the Senate to represent the people of 
North Carolina--Republicans, Democrats, Independents, whatever their 
politics. We desperately need to talk about the specific provisions of 
a real, substantive, meaningful Patients' Bill of Rights. That is what 
needs to happen. That is the reason we are on the floor today talking 
about this amendment. It is the reason this amendment has been attached 
to the agriculture appropriations bill.
  We need desperately to talk about these issues because they are so 
critically important to the people of my State--all of the people of my 
State--and they are important to all Americans. We have to make sure 
that folks have direct access to specialty care. It does absolutely no 
good for us to have the most advanced medical care and treatment and 
research in the world in this country if folks can't get to it. Folks 
have to be able to have access to the high-quality medical care that is 
constantly advancing on a daily basis in medical centers throughout 
this country, including medical centers in my home State, including 
Duke University Medical Center, University of North Carolina, Bowman 
Grey, and East Carolina University.
  We have great medical centers in North Carolina. But those folks and 
the care they can provide do no good whatsoever if they can't provide 
the treatment to the patients. That is where health insurance 
companies, HMOs, stand as a roadblock between the doctors and the 
health care providers who are spending their lives developing these 
lifesaving treatments and the patients who so desperately need them.

[[Page S7434]]

  Steve Grissom, the gentlemen I described with leukemia and AIDS, is a 
perfect example. There are heroes all over this country, all over North 
Carolina, who are standing up and fighting battles against health 
problems that are critical to them and their families. We have to give 
them direct access to the treatment and care that can save their lives 
and change the lives of their families.
  It is very simple. The bottom line is this: Patients, not profits, 
should be the bottom line in health care. That is what this Patients' 
Bill of Rights is about. We simply want an opportunity to talk about it 
to our colleagues, whom we respect, on the floor of the Senate, to talk 
about it to the American people. And I am telling you, the American 
people in their gut know that this is something that needs to be 
passed, needs to be done, and that health insurance companies and HMOs 
absolutely should not stand between children and families and the 
health care that, in many cases, can save their lives.
  With that, I yield the floor.
  Mr. NICKLES addressed the Chair.
  The PRESIDING OFFICER. The Senator from Oklahoma is recognized.
  Mr. NICKLES. Mr. President, I appreciate the accommodation and 
cooperation by my friend and colleague, Senator Durbin from Illinois. 
There are several on this side who wish to speak on this issue as well. 
We have been wanting to speak for about the last hour.
  I yield to the Senator from Vermont for 10 minutes.
  The PRESIDING OFFICER. The Senator from Vermont is recognized.
  Mr. JEFFORDS. Mr. President, this is an important time for America to 
listen to this debate because the lives and health of individuals 
throughout this Nation are at stake. It is interesting to note, looking 
back to last year when the Democratic proposal came forward, at first 
they wanted it to be voted on immediately. Then we worked together on 
this side of the aisle and worked up a bill that we find is superior to 
theirs in many respects, which I will talk about later, and all of a 
sudden they didn't want to bring it up without 100 amendments. We could 
not get a time agreement to get to the bill. Even though some of the 
things sound quite dramatic and wonderful, when we analyze them, we 
find that in many respects we believe the majority's bill is superior.
  First of all, the Patients' Bill of Rights Act addresses those areas 
of health care quality on which there is a broad consensus. It is solid 
legislation that will result in a greatly improved health care system 
for all Americans.
  The Committee on Health, Education, Labor, and Pensions has been long 
dedicated to action in order to improve the quality of health care. Our 
commitment to developing appropriate managed care standards has been 
demonstrated by the 17 additional hearings related to health care 
quality. And Senator Frist's Public Health and Safety Subcommittee held 
three hearings on the work of the Agency for Health Care Policy and 
Research (AHCPR).
  Each of these hearings helped us in developing the separate pieces of 
legislation that are reflected in our Patients' Bill of Rights Act.
  People need to know what their plan will cover and how they will get 
their health care. The Patients' Bill of Rights requires full 
disclosure by an employer about the health plans it offers to 
employees.
  Patients also need to know how adverse decisions by a plan can be 
appealed, both internally and externally, to an independent medical 
reviewer. That is a critical difference. We emphasize good health care. 
Under our bill the reviewer's decision will be binding on the health 
plan. However, the patient will maintain his or her current rights to 
go to court. Timely utilization decisions and a defined process for 
appealing such decisions are the keys to restoring trust in the health 
care system.
  Our legislation also provides Americans covered by health insurance 
with new rights to prevent discrimination based on predictive genetic 
information.
  It ensures that medical decisions are made by physicians in 
consultation with their patients and are based on the best scientific 
evidence. And it provides a stronger emphasis on quality improvement in 
our health care system with a refocused role for AHCPR.
  The other bill uses the generally accepted practice in the area which 
can deviate very strongly from best medicine. We give you best 
medicine.
  Some believe that the answer to improving our nation's health care 
quality is to allow greater access to the tort system. However, you 
simply cannot sue your way to better health. We believe that patients 
must get the care they need when they need it, not just after they go 
to court in a lawsuit to repair the damage.
  In the ``Patients' Bill of Rights,'' we make sure each patient is 
afforded every opportunity to have the right treatment decision made by 
health care professionals. In the event that does occur, patients have 
the recourse of pursuing an outside appeal. Prevention, not litigation, 
is the best medicine.
  Our bill creates new, enforceable Federal health care standards to 
cover those 48 million of the 124 million Americans covered by 
employer-sponsored plans. These are the very same people that the 
States, through their regulation of private health insurance companies, 
cannot protect.
  What are these standards? They include: a prudent layperson standard 
for emergency care; a mandatory point of service option; direct access 
to OB/GYNs and pediatricians; continuity of care; a prohibition on gag 
rules; access to Medication; access to Specialists; and self-pay for 
behavioral health.
  It would be inappropriate to set Federal health insurance standards 
that duplicate the responsibility of the 50 State insurance 
departments. As the National Association of Insurance Commissioners, 
put it: ``(w)e do not want States to be preempted by Congressional or 
administrative ac
tions. . . . Congress should focus attention on those consumers who 
have no protections in self-funded ERISA plans.''

  Senator Kennedy's approach would set health insurance standards that 
duplicate the responsibility of the 50 State insurance departments. 
Worse yet, it would mandate that the Health Care Financing 
Administration (HCFA) enforce them if a State decides not to adopt 
them.
  Those of us who have been involved with this know what happened 
during the recent past when the HIPAA bill was passed on to HCFA. It 
was a mess. Almost nothing was getting done.
  HCFA cannot even keep up with its current responsibilities. This past 
recess Senator Leahy and I held a meeting in Vermont to let New England 
home health providers meet with HCFA. It was a packed and angry house, 
with providers traveling from New Hampshire, Massachusetts, and 
Connecticut.
  It is in no one's best interest to build a dual system of overlapping 
State and Federal health insurance regulation.
  Increasing health insurance premiums causes significant losses in 
coverage.
  This is the main difference. You can promise a lot of things when you 
try to do them. But if the result of what you do is that up to 1 
million people lose coverage because of the increased cost, that is not 
the way we ought to go.
  The Congressional Budget Office (CBO) pegged the cost of the 
Democratic bill at six times higher than S. 326. Based on our best 
estimates, passage of the Democratic bill would result in a loss of 
coverage for over 1.5 million working Americans and their families. To 
put this in perspective, this would mean that would have their family's 
coverage canceled under the Democratic bill.
  Mr. KENNEDY. Mr. President, will the Senator yield on that point?
  Mr. JEFFORDS. On the Senator's time?
  Mr. KENNEDY. On my time.
  Mr. JEFFORDS. Yes.
  Mr. KENNEDY. The Senator has referred to the loss in terms of 
coverage by the General Accounting Office. Will the Senator share that 
letter which allegedly reached that conclusion? Will the Senator put 
that in the Record at this time so we have a full statement of the 
General Accounting Office rather than just using the figure that the 
Senator used? Will the Senator make that whole letter a part of the 
Record?
  Mr. JEFFORDS. I would be happy to make that a part of the Record, 
yes.

[[Page S7435]]

  I ask unanimous consent that the letter be printed in the Record at 
the conclusion of my remarks.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  (See Exhibit 1.)
  Mr. JEFFORDS. Let me repeat that. Adoption of the Democratic approach 
would cancel the insurance policies of almost a million and half 
Americans. I cannot support legislation that would result in the loss 
of health insurance coverage for a population the size covered in the 
combined states of Vermont, Delaware, South Dakota, and Wyoming.
  Fortunately, we can provide the key protections that consumers want 
at a minimal cost and without disruption of coverage--if we apply these 
protections responsibly and where they are needed.
  In sharp contrast to the Democratic alternative, our bill would 
actually increase coverage. With the additional of the Tax Code 
provisions to S. 326, the Patients' Bill of Rights Act, our bill allows 
for the full deduction of health insurance for the self-employed, the 
full availability of medical savings accounts and the carryover of 
unused benefits from flexible spending accounts. With the new Patients' 
Bill of Rights Plus Act we provide Americans with greater choice to 
more affordable health insurance.
  S. 326, the Patients' Bill of Rights Act, provides necessary consumer 
protections without adding significant new costs; without increasing 
litigation; and without micro-managing health plans.
  I also point out that under the law a doctor is still open to suit. 
Although they are prescribed health plans, the doctors are liable.
  Our goal is to give Americans the protections they want and need in a 
package that they can afford and that we can enact.
  This is why I hope the Patients' Bill of Rights that we are offering 
today will be enacted and signed into law by the President.
  I believe very strongly that the advantages we get, especially that 
we require, the standard of best medicine, and not just the medicine 
that is generally used in the area is by far a much better protection 
for the people we are trying to protect--the patients--than the 
Democrat's Patient's Bill of Rights.
  Mr. President, I yield the floor.

                               Exhibit 1

         General Accounting Office, Health, Education and Human 
           Services Division,
                                     Washington, DC, July 7, 1998.

     Subject: Private Health Insurance: Impact of Premium 
         Increases on the Number of Covered Individuals Is 
         Uncertain
     Hon. James M. Jeffords,
     Chairman, Committee on Labor and Human Resources, U.S. 
         Senate.
       Dear Mr. Chairman: Almost 150 million individuals obtained 
     health insurance through the workplace in 1996, either 
     through their own employment or the employment of a family 
     member. During the last several years, an increasing number 
     of individuals with employer-sponsored insurance have 
     enrolled in some form of managed care rather than in fee-for-
     service plans. Recently, concerns have grown regarding the 
     ways in which some managed care plans operate and the 
     adequacy of information shared between each plan, its 
     providers, and its members.
       In response to these concerns, several legislative 
     proposals have been made to require health insurance plans to 
     adopt specified operational practices. The proposals apply to 
     all types of plans, but would likely have their greatest 
     impact on health maintenance organizations (HMO). Other types 
     of plans, such as preferred provider organizations (PPO) and 
     indemnity, or fee-for-service, plans, will likely be affected 
     to a lesser degree. Included in various proposals are 
     requirements, for example, to disclose certain 
     information,\1\ guarantee patient access to emergency and 
     specialty services, implement internal and external grievance 
     policies, guarantee freedom of communication between 
     providers and patients, and eliminate the Employee Retirement 
     Income Security Act of 1974 (ERISA) restrictions on health 
     plan liability.
---------------------------------------------------------------------------
     \1\Footnotes at end of Report. (Figure not reproducible in 
     Record.)
---------------------------------------------------------------------------
       However, some lawmakers are concerned that these types of 
     mandates could increase the cost of health insurance and have 
     the unintended consequence of reducing the number of 
     individuals covered by private health insurance.
       This letter responds to your request for information on the 
     relationship between the amount charged for private health 
     insurance and the number of insured individuals. You also 
     asked us to analyze the basis for a widely cited statistic 
     from the Lewin Group, a private research and consulting 
     organization, that the number of insured individuals would 
     fall by 400,000 for every 1-percent increase in health 
     insurance premiums. Specifically, we (1) examined the trends 
     in employers' decisions to offer insurance and employees' 
     decisions to purchase it, (2) assessed the methodology used 
     by the Lewin Group to support its 400,000 coverage loss 
     estimate, (3) assessed the methodology used by the Lewin 
     Group to produce its most recent estimates, and (4) evaluated 
     conditions or factors that could affect the impact of premium 
     increases on insurance coverage. To conduct our study, we 
     reviewed relevant published research. We also evaluated the 
     applicability of the Lewin Group's estimates given the data, 
     methods, and assumptions it used to produce its estimates. We 
     performed our work between May 1998 and June 1998 in 
     accordance with generally accepted government auditing 
     standards.
       In summary, during a period of rising health insurance 
     premiums, the proportion of employees offered coverage rose, 
     while the share that accepted insurance fell. Between 1988 
     and 1996, health insurance premiums increased, on average, by 
     approximately 8 percent per year.\2\ During roughly the same 
     period, 1987 to 1996, the proportion of workers who were 
     offered insurance by their employers rose from 72.4 percent 
     to 75.4 percent, according to one recent study.\3\ The same 
     study found that the proportion of workers who accepted 
     coverage, however, fell from 88.3 percent to 80.1 percent. 
     This may be because employers required employees to pay a 
     larger share of the premiums.\4\ In 1988, employees in small 
     firms (fewer than 200 workers) paid an average of 12 percent 
     of single-coverage premiums. Employees in large firms paid 
     about 13 percent.\5\ By 1996, the employee share had risen to 
     33 percent in small firms and 22 percent in large firms. 
     Other factors, such as decreases in some workers' real 
     incomes, Medicaid-eligibility expansions, and changes in 
     benefit generosity, also may have contributed to the fall in 
     the acceptance rate.
       In November, 1997, the Lewin Group used published studies 
     to estimate that 400,000 fewer individuals would have health 
     insurance coverage for every 1 percent increase in insurance 
     premiums.\6\ Several of these studies had sought to quantify 
     the impact of subsidized insurance premiums on the increase 
     in the number of employers offering insurance. The Lewin 
     Group concluded from these studies that a 1-percent decrease 
     in premiums would likely induce an additional 0.4 percent of 
     employers to offer insurance. It then assumed that an 
     increase in premiums might cause a similar percentage of 
     firms to drop health insurance coverage and cause 400,000 
     individuals to be without coverage. The findings of more 
     recent studies, however, call into question the basis for the 
     Lewin Group's estimate. Although these studies did not 
     quantify the relationship between premium increases and 
     changes in the number of employees with coverage, they 
     clearly show that employers generally continued to offer 
     insurance during a period of rising premiums but that fewer 
     employees decided to purchase coverage. The estimate also 
     assumes equal premium increases for all types of insurance 
     products. If new federal mandates primarily affect HMO 
     premiums, some employees may switch to other types of 
     insurance--especially insurance with different benefit 
     packages--instead of dropping coverage entirely. Thus, the 
     Lewin Group's estimate may not be a good predictor of the 
     coverage loss that might be caused by new federal mandates.
       In January 1998, the Lewin Group lowered its estimate of 
     potential coverage losses by about 25 percent.\7\ It now 
     estimates that a 1-percent premium increase could result in 
     approximately 300,000 fewer individuals being covered by 
     private insurance. The new estimate is based on the Lewin 
     Group's statistical analysis of the relationship between how 
     much employees pay for insurance and the probability that 
     they, their spouses, and their dependent children have 
     employer-sponsored health insurance. However, it is unclear 
     how accurately the Lewin Group was able to measure the price 
     paid by the individuals in its sample. Moreover, the new 
     estimate applies to situations in which premiums for all 
     insurance types increase, on average, by 1 percent. If 
     premiums increase by 1 percent only for some insurance types 
     (for example, HMOs), then the coverage loss predicted by the 
     Lewin Group would be less than 300,000.
       Because many factors can affect the number of individuals 
     covered by private insurance, it is difficult to predict the 
     impact of an increase in insurance premiums. For example, new 
     mandates may increase premiums but may also change 
     individuals' willingness to purchase insurance. Individuals 
     may not mind paying higher premiums if they like the changes 
     brought about by the mandates. The extent to which employers 
     pass on premium increases to employees also can affect 
     coverage by influencing employees' purchasing decisions. 
     Another important determinant is the extent to which 
     employees switch from plans with high premium increases to 
     plans with no or low premium increases, or to less expensive 
     plans with more limited benefits. Finally, changes in other 
     economic factors, such as income, or changes in public 
     insurance program eligibility requirements can affect the 
     number of individuals with private health insurance.


                               background

       Between 1995 and 1997, real health insurance premiums 
     (adjusted for inflation) remained nearly constant or fell 
     slightly

[[Page S7436]]

     across all plan types. (See table 1.) This represents a sharp 
     decline from the previous 5 years, in which inflation-
     adjusted growth was as high as 11.6 percent for indemnity 
     plans and 10.6 percent for HMO plans in 1990.

                                 TABLE 1.--PERCENTAGE OF REAL ANNUAL GROWTH IN PREMIUMS BY TYPE OF HEALTH PLAN, 1990-97
--------------------------------------------------------------------------------------------------------------------------------------------------------
                        Plan type                            1990        1991        1992        1993        1994        1995        1996        1997
--------------------------------------------------------------------------------------------------------------------------------------------------------
Indemnity...............................................        11.6         7.8         8.0         5.5         2.5        -0.1        -1.8         0.3
PPO.....................................................         9.6         5.9         7.6         5.2         0.6         0.7        -2.4        -0.2
HMO.....................................................        10.6         7.9         6.8         5.3         2.7        -2.4        -3.4       -0.3
--------------------------------------------------------------------------------------------------------------------------------------------------------
Sources: GAO calculations based on data from KPMG Peat Marwick (1991-97); Health Insurance Association of America (1990), and Bureau of Labor Statistics
  Consumer Price Index. Includes employer and employee shares of premiums for workers in private firms with at least 200 employees.

       About 70 percent of the population under age 65 was covered 
     by health insurance purchased through an employer or union, 
     or purchased privately as an individual in 1996, according to 
     Current Population Survey (CPS) data. About 12 percent was 
     covered by Medicare, Medicaid, or the Civilian Health and 
     Medical Program of the Uniformed Services (CHAMPUS), and 
     about 18 percent was uninsured. From 1989 to 1996, the 
     percentage of the population covered by employer-sponsored, 
     union-sponsored, or individual insurance\8\ decreased 
     slightly, but these options still remained a dominant source 
     of coverage for people under age 65. (See fig. 1.) During the 
     same period, the proportion of the population covered by 
     Medicaid and the proportion without insurance both increased.


  more workers were offered insurance, but fewer accepted coverage as 
                           premiums increased

       Recent studies suggest that employers typically do not stop 
     offering health insurance when premiums increase. Between 
     1988 and 1996, health insurance premiums--unadjusted for 
     inflation--increased by about 8 percent per year, on average. 
     During approximately the same time period, one study\9\ found 
     that the fraction of workers offered insurance by their 
     employers grew slightly, from 72.4 percent to 75.4 percent. 
     The proportion of workers who had access to employer-
     sponsored insurance, either through their own job or the job 
     of a family member, remained essentially constant at about 82 
     percent. Another study\10\ reported that the fraction of 
     small firms (those with fewer than 200 employees) offering 
     insurance coverage grew from 46 percent in 1989 to 49 percent 
     in 1996. The study also found that 99 percent of large firms 
     offered insurance in 1996.
       Fewer workers, however, are choosing to accept employer-
     sponsored coverage for themselves or their dependents. In 
     1987, 88.3 percent of workers accepted coverage when their 
     employers offered it. In 1996, only 80.1 percent of workers 
     accepted coverage. The fall in the acceptance rate was 
     relatively large for workers under age 25 (from 86.5 percent 
     to 70.1 percent) and those making $7 per hour or less (from 
     79.7 percent to 63.2 percent). The fraction of workers who 
     accepted employer-sponsored insurance either through their 
     own job or that of a family member also declined, from 93.2 
     percent to 89.1 percent. Consequently, even though a greater 
     percentage of employers offered insurance, the acceptance 
     rate fell to such an extent that a smaller proportion of 
     workers was covered by employer-sponsored insurance in 1996 
     compared with 1997.
       The fall in the acceptance rate may be attributable partly 
     to required increases in employees' insurance premium 
     contributions. One study found that employees in small firms 
     paid an average of 12 percent of single coverage premiums in 
     1988 and employees in large firms paid 13 percent.\11\ In 
     1996, the employee share had risen to 33 percent in small 
     firms and 22 percent in large firms. According to the Lewin 
     Group, the combined effect of the increase in premiums and 
     the increase in the employees' share of those premiums 
     resulted in workers paying 189 percent more in real terms for 
     single coverage and 85 percent more in real terms for family 
     coverage in 1996 compared with 1988.
       Other factors also may have contributed to the drop in the 
     acceptance rate. A decline in real wages for some workers may 
     have made coverage less affordable. Expansions in Medicaid 
     eligibility provided a coverage alternative for some families 
     and may have decreased workers' willingness to accept 
     employer-sponsored insurance. Furthermore, possible changes 
     in benefit packages may have made coverage less desirable.


   lewin estimate of 400,000 coverage loss based on outdated studies

       In November 1997,\12\ the Lewin Group estimated that 
     400,000 fewer people might be covered by health insurance if 
     new legislation caused premiums to rise by 1 percent. Its 
     estimate was largely based on studies of the effects of 
     insurance premium subsidies on employers' decisions to offer 
     insurance. However, recent research casts doubt on the 
     applicability of these findings to other situations. 
     Furthermore, according to the Barents Group, a research and 
     consulting firm, the Lewin Group's coverage loss estimate may 
     be too high because some individuals may switch to other 
     types of health plans if new legislation causes HMO premiums 
     to rise.
       Few studies have analyzed the relationship between the cost 
     of insurance and the number of individuals covered. The 
     studies available to Lewin in November 1997 primarily focused 
     on employers' decisions to offer insurance. These studies 
     varied widely both in their research questions and their 
     findings. Several studies\13\ examined the effects of 
     programs designed to increase coverage by subsidizing the 
     premiums paid by employers--particularly small ones. The 
     estimates from this group of studies varied, with one 
     suggesting that between 0.07 percent and 0.33 percent of 
     small firms might begin to offer insurance if premiums were 
     reduced by about 1 percent. Some older studies, using data 
     from 1971 and before, found that between 0.6 percent and 2 
     percent of firms might stop offering health insurance 
     coverage if premiums increased by 1 percent.
       The Lewin Group selected a range of estimates, from what it 
     judged to be the best available, to predict that between 0.2 
     percent and 0.6 percent of firms would stop offering coverage 
     if insurance premiums increased by 1 percent. It then 
     selected the midpoint of this range (0.4 percent) as its best 
     estimate. To calculate the potential impact on coverage, the 
     Lewin Group multiplied 150 million--the number of workers and 
     their dependents covered by employer-sponsored health plans 
     in 1996--by 0.004--the percentage of firms expected to drop 
     coverage.\14\ This calculation suggested that 600,000 
     individuals would lose employer-sponsored health insurance if 
     premiums increased by 1 percent. However, on the basis of its 
     analysis of CPS data, the Lewin Group assumed that about one-
     third (or 200,000) of these 600,000 workers would obtain 
     insurance either through the policies of working family 
     members, the individual insurance market, or public insurance 
     programs.\15\ Consequently, it estimated that a 1-percent 
     premium increase might result in a drop in coverage of about 
     400,000 individuals.
       The Lewin Group's estimated potential coverage loss does 
     not consider the possibility that employers or employees 
     might switch to different types of insurance products if one 
     type becomes relatively more expensive. This is important in 
     the current context because many of the proposed federal 
     mandates are expected primarily to affect HMOs and have 
     little or no impact on PPOs and indemnity plans. The Barents 
     Group, a private research and consulting organization, 
     recently reported on the potential coverage loss that 
     proposed mandates could cause.\16\ The Barents Group used the 
     Lewin coverage loss estimate but reduced it by 25 percent to 
     allow for the possibility that some employees might switch 
     from HMOs to other types of insurance plans instead of 
     dropping coverage altogether.


     current Lewin Group coverage loss estimate lower by 25 percent

       Recent data analysis by the Lewin Group led it to revise 
     its estimate of potential coverage loss. The Lewin Group now 
     projects a loss of employer-sponsored coverage of 
     approximately 300,000 people for every one percent increase 
     in premiums. This estimate, reported in January 1998, is 
     approximately 25 percent lower than its November 1997 
     estimate. The new estimate is based on the Lewin Group's 
     statistical analysis of the relationship between what 
     employees pay for insurance and the probability that they, 
     their spouses, and their dependent children have employer-
     sponsored health insurance.\17\
       A key variable in the January 1998 Lewin Group study is the 
     price of insurance, but because of data limitations, this was 
     measured imperfectly. The study primarily used CPS data from 
     1989 to 1996. CPS data, however, do not contain information 
     on health insurance premium amounts. Lewin, therefore, used 
     three data sources to impute the amount employees paid for 
     insurance:\18\ the 1987 National Medical Expenditure Surveys 
     (NMES), the KPMG Peat Merwick employer surveys for 1991 
     through 1996, and the Health Insurance Association of America 
     (HIAA) employer surveys for 1988 through 1990. The authors of 
     the Lewis report acknowledged that these surveys were not 
     strictly comparable, and that the information used to measure 
     the employee share of health insurance may have been 
     different for 1988 through 1990 than for 1991 throgh 1996. 
     Another potential shortcoming related to premium amounts is 
     that the analysis did not allow for the possibility that some 
     workers may decline coverage from their own employers when 
     they can obtain it through a family members' employer-based 
     coverage.
       The Lewin Group's estimate is of the coverage decline that 
     would result from an overall average premium increase of 1 
     percent. Yet, the proposed federal mandates are expected 
     primarily to affect HMOs. If HMOs' premiums rise by 
     1 percent, then premiums for other types of insurance 
     would probably not increase as much. HMO enrollees, 
     therefore, would be affected most by the premium 
     increases. Under these circumstances, the

[[Page S7437]]

     Lewin Group's estimate could overstate the coverage 
     decline.
       The Lewin Group explicitly assumed that all observed 
     coverage changes were due to employees' decisions.\19\ 
     Consequently, it used the imputed employee contribution as 
     the relevant cost of insurance. This assumption is broadly 
     supported by the recent literature. However, if some 
     employees lost access to insurance because of their 
     employers' decisions to no longer offer it, the Lewin Group's 
     estimate may incorrectly predict employees' reactions to 
     changes in premiums.


       potential coverage loss uncertain, depends on many factors

       Insufficient information is currently available to predict 
     accurately the coverage loss that may result from health 
     insurance premium increases associated with new federal 
     mandates. One problem is that the potential cost of the 
     mandates and their impact on premiums is not yet known. 
     However, even if the premium increase was known with 
     certainty, previous research and economic theory suggest that 
     the impact on coverage depends on a number of conditions. 
     Coverage changes will depend on the extent to which premiums 
     rise for employees and whether they can switch to insurance 
     plans less affected by the mandates. The specific policy 
     adopted also can affect how employees respond to resulting 
     premium increases. Finally, changes in many economic and 
     other factors can cause coverage changes that mask or 
     exaggerate the impact of premium increases. The following 
     list describes several conditions that could affect observed 
     changes in health insurance coverage if new federal mandates 
     increase insurance costs.
       1. The percentage of premiums paid by employees and the 
     amount of any premium increase the employers pass on to 
     employees. If, as recent evidence suggests, employees' 
     decisions largely affect the extent of coverage, then the 
     relevant price increase is the percentage increase in their 
     contribution. For example, about two-thirds of employees in 
     small firms had to contribute toward premium costs in 1996. 
     Those employees paid about 50 percent of the total premium. 
     If total premiums rise by 1 percent and employers pass on the 
     full increase to employees, then the employees' contribution 
     would rise by 2 percent.
       2. The extent to which additional benefits are valued by 
     consumers. If higher insurance premiums are the result of 
     additional benefits that consumers value, then any coverage 
     loss will be less than the coverage loss that might occur if 
     premiums increased but benefits stayed the same (or the 
     additional benefits had little consumer value). In its 
     November 1997 letter, the Lewin Group notes that its 
     ``estimates of the number of persons losing coverage will 
     differ depending upon the health policy being analyzed.'' The 
     Lewin Group goes on to suggest that ``some proposals that 
     increase premium costs are often associated with other 
     provisions that may either lessen or intensify incentives for 
     individuals to drop coverage.''
       3. The extent to which some types of plans have no or low 
     premium increases and employees can switch to them. Proposed 
     new federal mandates are expected primarily to increase costs 
     of HMOs. Faced with a rise in HMO premiums, some employees 
     may switch to PPOs or indemnity insurance rather than drop 
     coverage entirely. The Barents Group assumed this switching 
     behavior might lower the Lewin Group's coverage loss estimate 
     by 25 percent.
       4. Changes in other insurance benefits. Instead of raising 
     premiums in response to new mandated benefits, insurance 
     companies and employers may find ways to reduce other parts 
     of the insurance package to keep premiums constant. It is 
     unknown how employees might respond to such changes in their 
     insurance plans.
       5. Changes in real wages and other factors. Changes in 
     economic conditions or eligibility for public insurance 
     programs can also affect private insurance coverage. For 
     example, the Lewin Group estimated that a 1-percent rise in 
     real incomes could increase private insurance coverage by 
     nearly 0.37 percent (about 550,000 workers and dependents). 
     Likewise, expansions in Medicaid eligibility could cause some 
     workers to substitute public insurance for employer-sponsored 
     family coverage.


                     comments from the lewin group

       In commenting on a draft of this correspondence, a 
     representative of the Lewin Group said that we had accurately 
     characterized its analysis and findings. The representative 
     suggested one technical clarification in our report's 
     characterization of the Lewin Group study that we adopted.
       As agreed with your office, unless you publicly announce 
     its contents earlier, we plan no further distribution until 
     30 days from the date of this letter. We will then make 
     copies available to others who are interested.
       Please call me or James Cosgrove, Assistant Director, if 
     you or your staff have any questions. Susanne Seagrave also 
     contributed to this letter.
           Sincerely yours,

                                           William J. Scanlon,

                                                  Director, Health
                                     Financing and Systems Issues.


                               footnotes

     \1\Legislative proposals would require each plan to disclose, 
     for example, information on appeal procedures, restrictions 
     on reimbursement for care received outside of the plan's 
     network of providers, and the location of plan providers and 
     facilities.
     \2\J. Gabel, P. Ginsburg, and K. Hunt, ``Small Employers and 
     Their Health Benefits, 1988-1996: An Awkward Adolescence,'' 
     Health Affairs, 16(5) (Sept./Oct. 1997). J. Sheils, P. Hogan, 
     and N. Manolov, ``Exploring the Determinants of Employer 
     Health Insurance Coverage,'' report to the AFL-CIO (Fairfax, 
     Va.: The Lewin Group, Inc., Jan. 20, 1998).
     \3\P. Cooper and B. Schone, ``More Offers, Fewer Takers for 
     Employment-Based Health Insurance: 1987 and 1996,'' Health 
     Affairs, 16(6) (Nov./Dec. 1997), pp. 142-49.
     \4\Private Health Insurance: Continued Erosion of Coverage 
     Linked to Cost Pressures (GAO/HEHS-97-122, July 24, 1997).
     \5\J. Gabel, P. Ginsburg, and K. Hunt, ``Small Employers and 
     Their Health Benefits, 1988-1996: An Awkward Adolescence,'' 
     Health Affairs, 16(5) (Sept./Oct. 1997), pp. 103-10.
     \6\John F. Sheils, Vice President, The Lewin Group, letter to 
     Richard Smith, American Association of Health Plans, Nov. 17, 
     1997.
     \7\J. Sheils, P. Hogan, and N. Manolov, Exploring the 
     Determinants of Employer Health Insurance Coverage, report to 
     the AFL-CIO (Fairfax, Va: The Lewin Group, Inc., Jan. 20, 
     1998).
     \8\Individual insurance is coverage that an individual 
     purchases directly from an insurer or through a broker.
     \9\See P. Cooper and B. Schone, ``More Offers, Fewer Takers 
     for Employment-Based Health Insurance: 1987 and 1996,'' p. 
     144.
     \10\See P. Ginsburg, J. Gabel, and K. Hunt, ``Tracking Small-
     Firm Coverage, 1989-1996,'' p. 168.
     \11\J. Gabel, P. Ginsburg, and K. Hunt, ``Small Employers and 
     Their Health Benefits, 1988-1996: An Awkward Adolescence,'' 
     p. 107.
     \12\John F. Sheils letter to Richard Smith, Nov. 17, 1997.
     \13\See K. Thorpe, and others, ``Reducing the Number of 
     Uninsured by Subsidizing Employment-Based Health Insurance: 
     Results From a Pilot Study,'' The Journal of the American 
     Medical Association, 267(7) (1992), pp. 945-48; Statement of 
     Nancy L. Barrand and W. David Helms for the Robert Wood 
     Johnson Foundation, before the Subcommittee on Health, 
     Committee on Ways and Means, House of Representatives, Health 
     Insurance Options: Reform of Private Health Insurance 
     (Washington, DC: May 23, 1991), pp. 125-61. W. Helms, A. 
     Gauthier, and D. Campion, ``Mending the Flaws in the Small-
     Group Market,'' Health Affairs (Summer 1992), pp. 7-27; C. 
     McLaughlin and W. Zellers, ``The Shortcomings of Voluntarism 
     in the Small-Group Insurance Market,'' Health Affairs (Summer 
     1992), pp. 28-40; J. Gruber and J. Poterba, ``Tax Subsidies 
     to Employer-Provided Health Insurance,'' Working Paper No. 
     5147, Cambridge, Mass.: National Bureau of Economic Research, 
     June 1995.
     \14\The studies' findings applied to the percentage of firms 
     that might change their behavior. The Lewin Group, however, 
     applied this percentage to individuals. This implicitly 
     assumes that all sizes of firms would react similarly. If 
     large firms are less responsive to premium increases than 
     small firms, then the percentage of workers affected by a 1-
     percent increase in premiums could be less than 0.4 percent.
     \15\Lewin's November 1997 letter did not discuss how many of 
     the 200,000 individuals might enroll in public insurance 
     programs and how many might obtain other private coverage.
     \16\Impact of Legislation Affecting Managed Care Consumers: 
     1999-2003, report for the American Association of Health 
     Plans (Washington, DC: The Barents Group, LLC, Apr. 21, 
     1998).
     \17\Lewin used complex statistical models to estimate the 
     proportion of the population covered by employer-sponsored 
     insurance grouped by a number of demographic characteristics, 
     including race, age, income, full-time/part-time status, 
     occupation, industry, firm size, and the imputed employee 
     share of the premium costs, among others.
     \18\Lewin focused on the employee share of the insurance 
     premium as the most appropriate cost affecting the employee 
     decision to participate in employer-sponsored health plans.
     \19\The data used in the Lewin study do not indicate whether 
     observed coverage losses are the result of employers' 
     decisions not to offer insurance or employees' decisions not 
     to accept it.

  Mr. JEFFORDS. Mr. President, the GAO report examines two reports done 
by the Lewin Group on the impact of premium increases on coverage.
  A 1997 report by Lewin indicates that a 1% increase will result in 
400,000 losing coverage.
  A 1998 report by Lewin for the AFL/CIO indicates that a 1% increase 
will result in 300,000 Americans losing coverage. It is this lower 
number that I used.
  The PRESIDING OFFICER. Who yields time?
  Mr. KENNEDY. Mr. President, I will just take a moment.
  The PRESIDING OFFICER. The Senator from Massachusetts.
  Mr. KENNEDY. Mr. President, with regard to just one fact that the 
Senator has mentioned, I have the GAO report to which the Senator 
refers. The fact that the Senator refers and is talking about is on 
page 4 of the report. It says:

       If premiums increase by 1 percent only for some insurance 
     types (for example, HMOs), then the coverage loss predicted 
     by the Lewin Group to . . .

  Not the GAO, it is the Lewin Group that makes the estimate referred 
to in the GAO letter.
  To the contrary, if you read on, GAO says:

       Because many factors can affect the number of individuals 
     covered by private insurance, it is difficult to predict the 
     impact of an increase in insurance premiums. For example, new 
     mandates may increase premiums but may also change 
     individuals' willingness to purchase insurance.

  Therefore, there might be more people covered.
  This is the kind of thing we ought to be debating out here. This is 
just the type of thing we ought to be debating. We have a lot of 
distortions and misrepresentations. The insurance companies themselves 
have spent $100 million

[[Page S7438]]

in distorting our proposal. What we want to do is to try to clarify the 
Record on this.
  Mr. DURBIN. Will the Senator yield?
  Mr. KENNEDY. If I could just mention one other point, the Senator 
talked about what we wanted to do last year with regard to the 
Patients' Bill of Rights.
  I have in my hand the majority leader's unanimous consent request. 
Here it is. This is an offer from last June 18, a little over a year 
ago, when we were trying to bring this legislation up.

       I ask unanimous consent that prior to the August recess . . 
     .

  Isn't that interesting? June of last year; they are saying ``prior to 
the August recess.''

       . . . the majority leader after notifying the minority 
     leader shall turn to the consideration of the bill to be 
     introduced by the majority leader . . .

  It doesn't tell us what that is going to be.

       . . . or his designee regarding health care. I further ask 
     that the Senate proceed to its immediate consideration.

  And following the report by the clerk that Senator Daschle be 
recognized to offer as a substitute the text of S. 1891, which really 
wasn't the all-inclusive legislation, the majority leader is trying to 
tell the Democratic leader which bill he ought to put in.

       I further ask that during the consideration of the health 
     care legislation it be in order for Members to offer health 
     care amendments in the first and second degree. I further ask 
     consent that the Chair not enter a motion to adjourn or 
     recess for the August recess prior to a vote or in relation 
     to the majority leader's bill and the minority leader's 
     amendment, and following those votes it be in order for the 
     majority leader return to the legislation to the calendar.

  To the calendar--not send it over to the House of Representatives--to 
the calendar.
  Let's be clear about who is serious about bringing this up. Here is 
their consent request. They are going to return it to the calendar. 
Even if we win the vote, under their proposal, that could be the end of 
it.
  Then it says:

       Finally, I ask consent that it not be in order to offer any 
     legislation, motion, or amendment relative to health care 
     prior to the initiation of this agreement and following the 
     execution of the agreement.

  Therefore, you can't offer a health care measure for the rest of the 
Congress.
  If the Senator from Vermont can say with a straight face that it is 
the Democrats who are trying to lock this thing up when the Senator has 
his own leader making a proposal like this, he is defying any kind of 
rational understanding of what a unanimous consent rule is.
  Mr. DURBIN. Will the Senator yield for a question?
  Mr. KENNEDY. I would be glad to yield for a question.
  Mr. DURBIN. I am going to ask a very brief question. Is it not true 
that at 5:45--in 45 minutes--there will be a motion by the Republicans 
to table the Democratic version of the Patients' Bill of Rights without 
further debate, without further amendment, and to bring to an end this 
debate about whether families across America will have the stronger 
voice in terms of their health insurance protection?
  I ask the Senator from Massachusetts, who has been here for a few 
months, to respond, if he will. Why is it that the Republican majority 
is so concerned about or afraid of the idea of actually debating or 
deliberating something which is so important to American families, 
their health care?
  Mr. KENNEDY. We will have to listen to the explanation coming from 
the other side. We know what the spokesman for the health insurance 
industry has said. We know what their answer has been, and that is to 
virtually instruct the Republican leadership just to say no. We know 
what the leadership on the other side has said about this: We are not 
going to get a chance to debate this issue.

  People can draw their own conclusions. They have indicated this will 
not be permitted to come up, even though it is the people's business.
  I see the Senator from Rhode Island on the floor. I yield 5 minutes.
  The PRESIDING OFFICER (Mr. Smith of Oregon). The Senator from Rhode 
Island.
  Mr. REED. Mr. President, as I look at the Republican proposals, they 
are deficient in many ways. Of particular concern to me is the way this 
proposal mistreats children.
  The Democratic proposal, the proposal we would like to not only 
debate but also to vote on, emphasizes the need to protect the children 
of America. I hope we all can agree that at the end of this Congress at 
least we can provide adequate protections in managed care for children.
  Don't just take my word for it. Take the word of organizations 
including the American Academy of Pediatrics, the American Association 
of Children's Residential Centers, the American Academy of Child and 
Adolescent Psychiatry, the Children's Defense Fund, the Child Welfare 
League of America. All of these organizations support unequivocally the 
Democratic Patients' Bill of Rights. This is the legislation we know 
and they know will protect the children of America.
  There are three key points that are terribly important with respect 
to the differences between the Republican proposal and the Democratic 
proposal.
  First, our legislation will assure access to pediatric specialists. 
In the world of medicine today, it is not just sufficient to visit an 
oncologist if you have cancer and you are a child, because pediatric 
oncology is a particular specialty that is necessary for children who 
have serious cancers.
  Second, our legislation provides clearly expedited review procedures 
if child development is threatened--not just their life but their 
development. This is a critical issue that is virtually unique to 
children. This is something we have to protect and ensure.
  Third, we also have provisions within our legislation that will 
measure outcomes in terms of children, so that when parents are trying 
to determine what plan is best for their child, they can actually look 
at measured results: How well this particular plan did--not with a 
large population of adults, but particularly with respect to children.
  The Republican plan has some fuzzy language regarding pediatricians 
and specialists.
  Clearly and unequivocally, there is language in the Democratic 
legislation that guarantees children access to providers who are 
trained to take care of them, access to pediatric specialists, 
expedited review procedures in the case of developmental difficulties 
for children, and also outcome measures that actually take children 
into consideration. These are critical issues that have to be included 
in any managed care legislation we pass on the floor of the Senate.
  What did the American people think about that? I have listed August 
organizations like the American Academy of Pediatrics in support of 
this measure. Let me tell Members what the American people think.
  In February of 1999, a survey by Lake Sosin Snell Perry and 
Associates and the Tarrance Group--one a Democratic polling firm, the 
other a Republican polling firm--revealed 86 percent of voters surveyed 
favored having Congress require health plans to provide children with 
access to pediatric specialists and hospitals that specialize in 
treating children.
  That is an overwhelming example of what the American people are 
asking: Protect their children, and give them access to pediatric 
specialists. Let them choose, as mothers and fathers, pediatricians to 
be primary care providers for their sons and daughters.
  Not only do the American people demand these provisions, they will 
also pay for them. Seventy-six percent of the voters surveyed said they 
would pay for these protections, ``even if it increased health 
insurance costs for families with children by $100 a year.''
  They want these protections. Only the Democratic version gives them 
these protections.
  Mr. NICKLES. I yield myself a couple of minutes, and then I will 
yield to my colleague from Maine.
  Our colleague from Massachusetts said there was a unanimous consent 
request last year; we were talking about doing this last June and July. 
That is correct. We offered several unanimous consent requests, from 
June 18, July 15, and July 25, to bring this bill up to allow both 
sides to have a chance to vote on their proposals. We offered a number 
of amendments before the August break. Those were not agreed upon.
  Everyone has had a chance to offer their bill and to have it voted 
on. We

[[Page S7439]]

would have a package, we would have a bill, before the Senate that 
possibly could pass. That was not agreed upon last year. I don't know 
if it will be agreed upon this year. I told the Democratic sponsors we 
are willing to come to some time agreement, some limit on amendments, 
but we are not just going to have the bill on the floor for an 
unlimited number of amendments with unlimited debate.
  Somebody asked, Why haven't we done this?
  The Kennedy bill increased health care costs a lot. It is estimated 
that health care costs will increase 4.8 percent in addition to 
whatever health care increases are already scheduled. Increases are 
scheduled to be 7 to 9 percent. Take the average of that, 8 percent, 
and add 4.8 percent. That is a 13-percent increase in health care 
costs. That will increase the number of uninsured by at least 1.5 
million.
  I am going to work energetically to see we don't pass any bill that 
increases people's health care costs by 13 percent in 1 year. 
Certainly, I will work energetically to see we don't pass a health care 
bill that increases the number of uninsured by 1.5 million. That would 
be a serious mistake.
  Whatever the Senate does, it should do no harm. If we increase health 
care costs in double digits and increase the number of uninsured by 
over a million, we have done a lot of harm. Some Members will not do 
that.
  We should make some needed reforms. One of my colleagues worked 
energetically to put together a good package that makes needed reforms.
  I yield 7 minutes to our colleague from Maine, Senator Collins.
  Ms. COLLINS. Mr. President, there is growing unease across this 
Nation about the changes in how we receive our health care, which has 
prompted the current debate on managed care. People worry, if they or 
their loved ones become ill, that their HMO may deny them coverage and 
force them to accept either inadequate care or financial ruin--or 
perhaps even both. They believe vital decisions affecting their lives 
will be made not by a supportive family doctor but by an unfeeling 
bureaucracy.
  All Members agree that medically necessary patient care should never 
be sacrificed to the bottom line and that health care decisions should 
be in the hands of medical professionals, not in the hands of insurance 
accountants.
  We do, however, face an extremely delicate balancing act as we 
attempt to respond to concerns without resorting to unduly burdensome 
Federal controls and mandates that will further drive up the costs of 
health insurance and cause some people to lose their coverage 
altogether. That is the crux of this entire debate.
  I am very alarmed by recent reports that American employers 
everywhere, from giant multinational corporations to the small corner 
store, are facing huge hikes in their medical insurance coverage for 
their employees, averaging over 8 percent, and sometimes soaring to 20 
percent or more. This is a remarkable contrast to the past few years 
when premiums rose less than 3 percent, if at all.

  We know for a fact that increasing health insurance premiums cause 
significant losses in coverage. That is the primary reason why I am so 
opposed to the approach offered by the Senator from Massachusetts. Even 
if we discard CBO's previous estimate that the Kennedy bill would 
increase premiums by 6.1 percent and accept the newly revised estimate 
of 4.8 percent, the fact is the CBO score for the Democratic bill is 
six times higher than the cost for the bill we are proposing.
  Moreover, the Lewin Associates, in a study for the AFL-CIO, has 
estimated that for every 1-percent increase in premiums, we are 
jeopardizing the insurance coverage of as many as 300,000 Americans. 
Based on these projections, the passage of the Kennedy legislation 
could result in the loss of coverage for more than 1.4 million 
Americans. That is more than the population of the entire State of 
Maine. This is a significant cost.
  If you look at the CBO estimate of the revised Kennedy bill, CBO 
estimates it will impose additional costs to the private sector of 
nearly $41 billion over the next 5 years. That is a cost that is going 
to cause employers to drop insurance altogether or employees to be 
unable to pay their share of the premium. At a time when the number of 
uninsured Americans, unfortunately, is increasing with every year, we 
should be acting to decrease the number of uninsured Americans, not 
impose costly new burdens that are going to cause some of the most 
vulnerable working Americans to lose their coverage altogether.
  Our approach, on the other hand, provides the key protections that 
consumers need and want without causing costs to soar. It applies these 
protections responsibly, where they are needed. Our legislation does 
not preempt, but rather builds upon the good work the States have done 
in the area of patients' rights and protections. States have had the 
primary responsibility for the regulation of health insurance since the 
1940s. As someone who has worked in State government for 5 years 
overseeing a Bureau of Insurance, I know State regulators and State 
legislators have done an excellent job of responding to the needs and 
concerns of their citizens.
  Let me give you just a few examples. Mr. President, 47 States have 
already passed laws prohibiting gag clauses that restrict 
communications between patients and their doctors; 40 States have 
requirements for emergency care; all 50 States have requirements for 
grievance procedures; 36 require direct access to an obstetrician or a 
gynecologist.
  The States have acted, without any prod or mandate from Washington, 
to protect health care consumers. That is why the National Association 
of Insurance Commissioners supports the approach we have taken in our 
bill.
  In a March letter to the chairman of the Committee on Health, 
Education, Labor, and Pensions, the NAIC pointed out:

       It is our belief that states should and will continue the 
     efforts to develop creative, flexible, market-sensitive 
     protections for health consumers in fully insured plans, and 
     Congress should focus attention on those consumers who have 
     no protections in self-funded ERISA plans.

  That is exactly the approach we have taken. Currently, Federal law 
prohibits States from regulating the self-funded, employer-sponsored 
health plans that cover 48 million Americans. Our legislation is 
intended to protect the unprotected. We would extend many of the same 
rights and protections to these consumers and their families that those 
in State-regulated plans already enjoy.
  For the first time they will be guaranteed the right to talk freely 
and openly with their doctors about their treatment options. We would 
ban the gag clauses. They will be guaranteed coverage for emergency 
room care that a ``prudent layperson'' would deem medically necessary 
without prior authorization. They will be able to see a pediatrician or 
an OB/GYN without a referral from their plan's ``gatekeeper.'' They 
will have the option of seeing a doctor who is not part of the HMO's 
network. They will be guaranteed access to nonformulary drugs when it 
is medically necessary. They will have an assurance of continuity of 
care if their health plan terminates its contract with their doctor or 
hospital.
  The opponents of our legislation contend that the Federal Government 
should simply preempt the States' patient protection laws unless they 
are virtually identical to what the Federal Government would require. 
But the States' approaches to these patient protections vary widely. 
For example, States may have emergency requirements, but not exactly 
the same standard that the Democrats in Senator Kennedy's bill would 
impose on everyone. States that have already acted in this area would 
have to make extensive changes to their laws, if they are forced to 
comply with the one-size-fits-all model.
  Moreover, what if the State has made an affirmative decision not to 
act in one of these areas? What if the bill failed in the legislature 
or was vetoed by the Governor? Let me give you a recent example from my 
State. Maine law requires plans to allow direct access to ob/gyn care--
without a referral from the primary care physician--but only for an 
annual visit. Maine also requires plans to allow ob/gyns to serve as 
the primary care provider. Our State Legislature recently decided that 
the current provisions provide sufficient protection and rejected a 
bill that would have expanded the direct access

[[Page S7440]]

provision, primarily out of concern that it would drive up premium 
costs. I would note that this decision was made by a legislature 
controlled by the Democratic Party. In cases like these, the Kennedy 
proposal for a one-size-fits-all model would be a clear pre-emption of 
State authority.
  Other provisions of our bill provide new protections for millions 
more Americans. A key provision of our bill builds upon the existing 
regulatory framework under ERISA to give all 124 million Americans in 
employer-sponsored plans assurance that they will get the care that 
they need when they need it. The legislation will enhance current ERISA 
information disclosure requirements and penalties and strengthen 
existing requirements for coverage determinations, grievances and 
appeals, including the addition of a new requirement for independent, 
external review.
  All 124 million Americans in employer-sponsored plans will be 
entitled to clear and complete information about their health plan--
about what it covers and does not cover, about any cost-sharing 
requirements, and about the plan's providers. Helping patients 
understand their coverage before they need to use it will help to avoid 
coverage disputes later.
  The goal of any patients' rights legislation should be to resolve 
disputes about coverage up front, when the care is needed, not months 
or even years later in a court room.
  Our bill would accomplish this goal by creating a strong internal and 
an independent external review process. First, patients or doctors who 
are unhappy with an HMO's decision could appeal it internally through a 
review conducted by individuals with ``appropriate expertise'' who were 
not involved in the initial decision. Moreover, this review would have 
to be conducted by a physician if the denial is based on a 
determination that the service is not medically necessary or is an 
experimental treatment. Patients could expect results from this review 
within 30 days, or 72 hours in cases when delay poses a serious risk to 
the patient's life or health.
  Patients turned down by this internal review would then have the 
right to a free, external review by medical experts who are completely 
independent of the health plan. This review must be completed within 30 
days--and even faster in a medical emergency or when the delay would be 
detrimental to the patient's health. Moreover, the decision of these 
outside reviewers is binding on the health plan, but not on the 
patient. If the patient is not satisfied, he or she retains the right 
to sue in federal or state court for attorneys' fees, court costs, the 
value of the benefit and injunctive relief.

  Our bill places treatment decisions in the hands of doctors, not 
lawyers. If your HMO denies you treatment that your doctor believes is 
medically necessary, you should not have to resort to a costly and 
lengthy court battle to get the care you need. You should not have to 
hire a lawyer and file an expensive lawsuit to get the treatment.
  Our approach contrasts with the approach taken in the measure offered 
by Senators Daschle and Kennedy that would encourage patients to sue 
health plans. I do not support Senator Kennedy's approach. You just 
can't sue your way to quality health care.
  We would solve problems up front, when the care is needed, not months 
or even years later after the harm has occurred. According to the GAO, 
it takes an average of 33 months to resolve malpractice cases. This 
does nothing to ensure a patient's right to timely and appropriate 
care. Moreover, patients only receive 43 cents out of every dollar 
awarded in malpractice cases. The rest winds up in the pockets of trial 
lawyers and administrators of the court and insurance systems.
  I met with a group of Maine employers who expressed their serious 
concerns about the Kennedy proposal to expand liability for health 
plans and employers. The Assistant Director for Human Resources at 
Bowdoin College talked about how moving to a self-funded, ERISA plan 
enabled them to continue to offer affordable coverage to Bowdoin 
employees when premiums for their fully-insured plan skyrocketed in the 
late 1980s. Since they self-funded, they have actually been able to 
lower premiums for their employees, while, at the same time, enhance 
their benefit package with such features as well-baby care, free annual 
physicals, and prescription drug cards with low copayments. They told 
me that the Democrats' proposal to expand liability seriously 
jeopardizes their ability to offer affordable coverage for their 
employees. Similar concerns were expressed by the Maine Municipal 
Association, L.L. Bean, Bath Iron Works, and other responsible Maine 
employers.
  And finally, our amendment will make health insurance more affordable 
by allowing self-employed individuals to deduct the full amount of 
their health care premiums. Establishing parity in the tax treatment of 
health insurance costs between the self-employed and those working for 
large businesses is a matter of basic equity, and it will also help to 
reduce the number of uninsured, but working, Americans. It will make 
health insurance more affordable for the 82,000 people in Maine who are 
self-employed. They include our lobstermen, our hairdressers, our 
electricians, our plumbers, and the many owners of mom-and-pop stores 
that dot communities throughout my state.
  Mr. President, I believe that this amendments strikes the right 
balance as we effectively address concerns about quality and choice 
without resorting to unduly burdensome federal controls and mandates 
that will further drive up costs and cause some Americans to lose their 
health insurance altogether, and I urge all of my colleagues to join me 
in supporting it.
  Mr. NICKLES. Mr. President, how much time remains to both sides?
  The PRESIDING OFFICER. The Senator from Oklahoma has 19 minutes and 
the Senator from Massachusetts has 9.
  Mr. NICKLES. I yield my colleague from Tennessee 8 minutes.
  Mr. FRIST. Mr. President, there has been a lot of misinformation and 
I am sure a lot of confusion on the part of many because of allegations 
that have gone back and forth because of the rhetoric, so I think I 
will use my few minutes to outline what is in the Patients' Bill of 
Rights Plus Act; that is, the Republican leadership bill we have been 
discussing for the last several days.
  I am very proud of the bill we have put forward. I am proud of it as 
a physician, as a member of the task force that helped put this bill 
together, and as a Senator, because I believe with passage of this bill 
we can do what I think everybody in the body wants to do, and that is 
to improve the quality of care for individuals across this country, 
their children, and on into the next generation.
  The bill we put forward has really six major components with three 
objectives. The three objectives are to enhance health care quality, to 
enhance access, and to provide consumer protections. We do that through 
six components.
  First, as the Senator from Maine has just gone through, strong 
consumer protection standards. The second way of achieving that is that 
we offer good, comparative information among plans, at a time when it 
is very confusing to the beneficiary, to the individual patient, what 
plan offers what, and what benefits are covered.
  Third--and I am proud of this--we have a strong internal, and even 
more important, I believe, external appeals process establishing these 
rights for 124 million people. We are talking about scope in a lot of 
these discussions, but let's remember this applies to 124 million 
Americans who are covered both by the self-insured and fully insured 
group health plans.
  Fourth, we have in our bill a ban on the use of genetic information 
by insurance companies for underwriting purposes. It is very important, 
as we look at the human genome project, which is producing 2 billion 
bits of information, all of which can be to the benefit of mankind if 
it is used appropriately.
  Fifth, we have a quality focus in our bill which is lacking in other 
bills and other proposals. We have expanded quality research activities 
through the Agency for Health Care Policy and Research. We address 
issues of access. This is in contrast to the bill on the other side, 
because we have a major problem in this country today of about 41 
million people who are uninsured. You are not going to find this 
Senator voting for a bill that drives people to the ranks of the 
uninsured and expands that 41 million to 42 million.

[[Page S7441]]

  As my colleague from Maine just pointed out, every 1-percent increase 
in premiums drives about 300,000 people to the ranks of the uninsured. 
I doubt one will find very many Senators on our side in favor of 
increasing that number of uninsured.
  We addressed the issue of access through two means: No. 1 is medical 
savings accounts expansion, and No. 2 is to have availability of a full 
deduction for health insurance benefits for the self-employed.
  As the Senator from Maine pointed out, States already regulate 
insured health plans. Thus, our bill addresses the unprotected with the 
protections. We do it through emergency care. A prudent layperson, 
somebody in a restaurant has some chest pain--is it indigestion or a 
heart attack? You go to the emergency room and are reimbursed, because 
a prudent layperson standard is used and, therefore, that service is 
covered.
  Choice of plans: In our bill, we make sure those plans that offer 
network-only plans are required to offer what is called point-of-
service options.
  Consumer protections: Obstetricians, gynecologists, pediatricians--we 
have heard these words used a lot. Who are these physicians? Do you 
have access? Under our bill, health plans would be required to allow 
direct access to obstetricians, to gynecologists, and to pediatricians 
for routine care without referrals, without gatekeepers.
  Continuity of care: Under our bill, plans that terminate or nonrenew 
doctors or providers from their networks would allow continued use of 
the provider for up to 90 days or, if someone is pregnant, up through 
the postpartum period.
  Access to medication: We all know that formularies are used 
increasingly by people broadly because of the cost of prescription 
drugs. In our plan, we make sure physicians and providers and people 
with clinical experience are on those boards that put together these 
formularies. In our bill, we make sure that nonformulary alternatives 
are available when medically necessary and when appropriate. 
Physicians, pharmacists, not just bureaucrats, will be putting these 
formularies together.
  Access to specialists: I am a heart and lung transplant surgeon. I 
have had the opportunity to transplant hundreds of hearts and lungs and 
do hundreds of heart operations, and I know the importance of access to 
a specialist. Under our bill, health plans would be required to ensure 
that patients have access to covered speciality care within the network 
or, if necessary, provide that access through contractual relationships 
if heart surgeon Bill Frist happens not to be inside that network.
  Gag rules: We all know that physicians should not have gags placed on 
them when they talk to patients. We have a strong gag rule prohibition 
in our bill. No more gag rules.
  A second approach is that we require comparative information be given 
to individuals so they can compare one plan to another so they will 
know what services are covered and what services are not.
  I mentioned grievance and appeals. All group health plans would be 
required to have written grievance procedures and have both an internal 
appeals process as well as an external appeals process if there is some 
disagreement as to what is covered and what is not covered.
  Timeframes--we address it in our bill. Expedited requests for care, 
if there is any question of jeopardizing the patient's health, is 
allowed.

  Qualification of reviewers: This is a significant improvement in our 
bill compared to last year. We make absolutely sure that an 
appropriately qualified external reviewer; that is, a provider who has 
expertise in the field where there is some question. If it is a 
question about heart surgery, you have a heart surgeon, somebody 
familiar to heart surgery as the reviewer. The external appeals process 
is, I believe, greatly strengthened by having this independent--and 
those are the words we use--``external medical reviewer where 
necessary.''
  We allow in those cases where a treatment is considered experimental 
that that also can be handled in this external review process. We 
require that external reviewer to have ``relevant expertise.''
  My time is just about out. There are three other issues.
  Genetic information: Our bill recognizes that ``predictive genetic 
information'' can be used against you by an insurance company, either 
raising premiums or denying coverage. We prohibit it.
  Our bill focuses on quality improvement by taking the Agency for 
Health Care Research and Quality and focusing on health service 
delivery and training scientists, providing information systems to 
improve quality, and, lastly, our bill invests in the infrastructure 
necessary to measure quality.
  Medical savings accounts and full health insurance deduction for the 
self-employed are a part of our bill.
  That is our bill in a nutshell. It looks at consumer standards. It 
looks at improved quality, it looks at improved access. It is a bill of 
which I am proud. It is a bill I know all of us can support. It is a 
bill that will improve health care in the United States of America.
  Mr. President, I yield back my time.
  Mr. SCHUMER addressed the Chair.
  The PRESIDING OFFICER. The Senator from New York.
  Mr. SCHUMER. I have been yielded 4 minutes by the Senator from 
Massachusetts.
  The PRESIDING OFFICER. The Senator from New York is recognized.
  Mr. SCHUMER. I thank the Chair, and I thank the Senator from 
Massachusetts not only for yielding but for his leadership over many 
years on this issue. Let me make a couple of points.
  First of all, the Senator from Tennessee has outlined his bill, and 
it is a different approach. I ask Americans to ask: Why do all of the 
leading doctors' groups, including the American Medical Association, 
why do the leading consumer groups up and down the line, support our 
approach? If the bill on the other side is so good for consumers and so 
good for physicians and providers, then why are they all supporting 
this bill? And if, as the Senator from Tennessee believes, all of these 
are worthy goals--specialists, appeals processes, et cetera--then why 
not go all the way? Why not do it right? Why not do it in a way that 
the AMA and all the consumer groups and all of those that both sides 
are talking about protecting choose? The bill they choose is our bill.
  Second, on cost, because I know the Senator from Maine mentioned 
cost, the most recent estimates by CBO said that the Daschle-Kennedy 
bill, at the end of 5 years, would cost $2 extra a month a person. Ask 
Americans: Would they pay that to have access to specialists, to have 
emergency room treatment, to have the kinds of things we have been 
talking about? You bet. They would pay it in a New York minute. So if 
cost is the concern, it is not much, and you get a lot. If helping 
providers and consumers is the concern, our bill prevails.
  What we are going to do tonight is table any proposal. That is not 
adequate, nor is it even adequate, at least from my point of view as a 
freshman Senator, to try to deal with this issue and just push it away. 
We believe passionately that patients need help, that consumers need 
help, that physicians and nurses and hospitals need help.
  We believe the HMOs have swung too far in their ability to police the 
basic patient-doctor relationship. We do not think that a quick ``let's 
get rid of this, let's have a quick vote and say it is over'' serves 
the American people.
  What we will be doing on this side is continuing to fight until we 
can get a full and open debate. I want to debate the Senator from 
Tennessee on whether the Daschle bill or his bill really gives access 
to specialists. I want to debate the Senator from Tennessee on whether 
the appeals process in our bill or in his bill is the most open.
  I want to debate the Senator from Tennessee on every one of the 
issues that has been mentioned. The process that we are going through 
now does not allow that debate. I do not know where it will come out. 
My guess is it may come out similar to the last debate we had where a 
number of people, in a bipartisan way, come together for a stronger 
bill. But that may not happen.
  But at the very least, in conclusion, we should have a full and open 
debate. And a motion to table and a vote on one bill and then the other 
to get rid of this is not fair to the American people.
  Thank you.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. NICKLES. Mr. President, how much time remains?

[[Page S7442]]

  The PRESIDING OFFICER. Eleven minutes for the Senator from Oklahoma.
  Mr. NICKLES. On the other side?
  The PRESIDING OFFICER. Four minutes 46 seconds.
  Mr. NICKLES. I yield the Senator from Pennsylvania 5 minutes.
  Ms. SANTORUM. Thank you, Mr. President.
  I thank the Senator from Oklahoma for yielding me time. I 
congratulate him and the entire working group on the Republican side of 
the aisle--Senators Jeffords, Collins, Frist, and Gramm for putting 
together what I believe is a bill that this Senate should embrace. I 
think America, if they were given the choice between what is being 
offered on the Democratic side and what is being offered on the 
Republican side, would quickly embrace this plan for many reasons.
  No. 1, it is a much more comprehensive plan. This is the Patients' 
Bill of Rights Plus. It is not just some consumer protection measures 
which Democrats have put forward--and we have, to some degree, done the 
same--but it goes much farther. By looking at the health care picture 
in America, on a comprehensive basis, we took a step back and said, 
what can we do to improve quality, to improve access, to reduce costs--
not responding to hot button poll issues?
  It seems to be the popular move around here--when something polls 
well, we rush out here and try, with legislative fixes, to pass 
something that sounds good to the American public.
  We did not take that approach. We took the approach of how, from a 
public policy point of view, we are going to solve real problems in 
America--not real problems that maybe poll well but real problems that 
solve structural problems, structural problems in the health care 
system, which will end up benefiting millions of people.

  One such area is that of access. Much has been talked about in 
relation to patients' rights. We have not heard a lot of talk on the 
other side about access to insurance. There are a couple of components 
to that.
  No. 1, keep the costs down. We have heard a lot of talk about how the 
other bill, the Kennedy bill, dramatically increases costs. Our bill 
does not do that. So in that respect, we already, by virtue of not 
driving up health care costs, improve access. But we do more than that.
  We do two specific things in the tax portion of this bill. First, we 
increase the deductibility of insurance for the self-employed up to 100 
percent. So we put them on an even playing field with those who have 
employer-provided health care. We give 100 percent deductibility, 
thereby increasing the desirability of owning health care insurance, of 
buying that insurance for yourself as a self-employed individual, 
thereby getting more people into the health care system, which is 
something everybody believes is necessary and desirable.
  Second, we provide for medical savings accounts. Medical savings 
accounts have gotten, from a public policy perspective, a little bit of 
a bad rap based on what was passed here a few years ago. What was 
passed here a few years ago was a program that was designed to fail. 
Those who designed it got exactly what was predicted--failure.
  It is a program that is very limited. Very few taxpayers can 
participate in it. It is time limited. It does not allow you to carry 
contributions from year to year. It is a program that has very little 
in the way of a design that would be attractive. In fact, what would 
attract people to MSAs is the ability to control their own health care 
costs, which is the ability to profit personally--instead of the 
insurance companies managing your health care, doing things that keep 
you healthy. Those are some of the attractions of MSAs that are the 
control element, all of which are forfeited under the existing MSA 
proposal.
  The bill that we are offering removes all these restrictions--
artificial--to dampen the enthusiasm for the program, to make it less 
attractive and less workable, and allows a full-blown medical savings 
account proposal to go forward and to put it into the mix of health 
care delivery options, insurance options, again, creating more choices, 
creating, in this case, a high deductible insurance option that is very 
attractive to people who we have a very difficult time bringing into 
the insurance system but are very important to get in there, and those 
are younger workers, in particular.
  We have a very difficult time convincing younger uninsured people 
that it is maybe worthwhile to go out and buy insurance coverage. Most 
young people think they are infallible, that they cannot be hurt, that 
they do not need insurance. What we do is create a savings component to 
health insurance which is a very attractive thing, particularly for 
younger people and yet, at the same time, very useful for everyone--
once people understand how the dynamics of medical savings accounts 
work.
  So it has the dual components of attracting those very desirable 
people into the insurance pool--younger workers who have, in fact, less 
health care costs--and at the same time provides the kinds of choices 
and quality and the proper incentives to the rest of the population in 
the health care system through these medical savings accounts.

  So I am very excited that what we have been able to accomplish in 
this bill is not just to provide some hot button issues with regard to 
HMOs which poll well--and I understand that----
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. SANTORUM. We have provided a comprehensive approach to health 
care reform and one that I think we can all be very proud of.
  I thank the Senator from Oklahoma for yielding me time.
  Mr. KENNEDY. I yield 2 minutes to the Senator from Illinois.
  Mr. DURBIN. I thank the Senate for yielding.
  You know what this reminds me of? This reminds me of the Senate. 
Imagine, both sides of the aisle--Republican and Democrat--on the floor 
discussing and debating an issue which counts with American families--
health insurance.
  Is it going to be there when we need it? Will it be affordable? Can 
we trust our doctors not to be overruled by insurance company 
bureaucrats?
  I like this debate. That is why I ran for the Senate. But in 10 
minutes there will be a vote on a Republican motion to table to end 
this debate, to stop it, to say that there is going to be no further 
debate, no future amendments--it is over.
  I do not think that makes sense. Weren't we sent here to enter into 
this debate? To face these issues on an up-or-down vote? I am prepared 
to do that.
  I know that some of the votes on these amendments will not be easy, 
but I think we have an excellent bill in the Democratic Patients' Bill 
of Rights, a bill that has been endorsed by every major health 
organization, children's advocacy groups, and labor-business across the 
board.
  I am prepared to stand and defend this bill, offer amendments that 
give to families the assurance they are going to get quality health 
care. But the Republican side does not want this debate. They do not 
want to vote on these amendments. They called it ``health care-plus.'' 
It is ``health care-minus.'' Every day they are taking away from 
American families their power to choose a doctor, their power to have 
the right specialist, their willingness, I guess, to sit down with 
their doctor and realize they are getting an honest answer.
  It is a shame that in 10 minutes this motion to table is going to 
come before us. This really resembles the Senate--deliberation on an 
issue that counts. I hope the motion to table is defeated. Let's have 
the real debate on this issue.
  I yield back my time.
  Mr. BINGAMAN. Mr. President, I rise to today to ask my colleagues to 
consider several intriguing questions. What would we do if I told you 
that Americans were deliberately being denied access to our country's 
greatest technologies and developments? What if I told you that there 
is a business in this country that is permitted to make any kind of 
business decision they want and potentially adversely effect millions 
of consumers' lives and not be held accountable? What if I told you 
that Congress has had the answer to these questions and, most 
importantly, the solutions to these problems but because of a few 
people and a great deal

[[Page S7443]]

of money from one special interest group, the American people have been 
denied a substantially better quality of life? Well, unfortunately, all 
this is true.
  Over 200 organizations representing doctors, nurses, patients' right 
advocates, consumer organizations and labor groups and American people 
everywhere have all spoken loud and long: The time is now to pass a 
meaningful patient's bill of rights. My Democratic colleagues stand 
ready, once again, to engage in a discussion with our Republican 
colleagues so that we can finally put the American people's interest 
before health insurance company profits.
  Over 100 million workers who labor hard and pay health insurance are 
being denied critical medical services. We are led to believe by some 
that the health care system under managed care is working just fine. In 
our own circles of friends and family, we know that this is simply not 
true. The numbers are staggering. I have a chart here that will not 
surprise anyone.
  In 1998, 115 million Americans either had a problem or knew someone 
who had a problem with managed care and that number is dramatically on 
the rise. Let me say that again. At least, 115 million people in this 
country are experiencing difficulties obtaining medical services for 
which they pay for every month. The issue is clear. Managed health care 
reform is long overdue.
  First and foremost, we need a managed health care system that is 
inclusive, providing the best health care for everyone that spends 
their hard earned dollars on health insurance. The Republican managed 
care bill leaves out over 100 million Americans: two-thirds of those 
that have private health insurance. Let me be even more specific using 
my own State, New Mexico, as a example of what I am referring to.
  There are approximately 900,000 privately insured patients in the 
State of New Mexico. Without passage of the Democratic Patients' Bill 
of Rights, look at the list of major patient protections that over 
900,000 New Mexicans will not have.
  Under the Republican bill, almost 700,000 New Mexicans will not have 
substantive protections and 350,000 will not be covered at all if the 
Republicans pass their bill. The Democratic Patients' Bill of Rights 
will assure that 900,000 New Mexicans will receive all these 
protections that I have listed on this chart.
  These numbers represent real people with real health concerns. These 
numbers represent people who expect Congress to put the health 
interests of Americans first.
  Let me address just a few of the basic protections that I believe a 
managed care system should provide and that, in fact, the Democratic 
Patient's Bill of Rights includes.
  We need a managed care health system that does not financially 
penalize health care professionals who try to provide the best care for 
their patients. We can no longer permit managed care companies to fire 
providers who report quality concerns or who speak up on behalf of 
their patients and assist their patients when their HMO denies care.
  We need a managed care health system that does not allow HMO's to 
operate with few providers and long waiting periods for appointments, 
and that force patients to drive long hours to get needed care, even if 
there are qualified providers nearby. Where you live in our country 
should not be reason enough to exclude you from the best medical care 
available. In a state such as New Mexico this is a critical concern.
  We need a managed care health system that does not prohibit health 
plans from excluding non-physician providers such as nurse 
practitioners, psychologists, and social workers from their networks. 
Under the Republican bill, patients, especially those in rural and 
other areas without an adequate supply of physicians, could be left out 
in the cold. Once again, in the State of New Mexico these are critical 
concerns.
  Simply put, we need a managed health care system that puts patient 
protections first before insurance company profits.
  Let me also address one other issue. I have heard concerns from some 
of my Republican colleagues regarding the impact that reforming health 
insurance might have on small businesses. I too have long been 
concerned with the effect of federal policy on this part of the 
business sector. New Mexico relies significantly on the innovation and 
hard work of the small businessperson and I have consistently worked to 
protect their interests. But instead of trying to scare small 
businesses with inadequate information that seemingly threatens their 
livelihoods as some might do, let's take a look at the facts.
  In a recent study by the Small Business Alliance and the Kaiser 
Family Foundation, the overwhelming majority of small businesses would 
continue to provide health insurance after managed care reform and the 
majority of these business endorsed key elements of the Democratic 
Patient's Bill of Rights including real independent appeals, access to 
speciality care, and direct access to OB/GYN services, as well as the 
patient's right to hold insurance companies accountable for their 
decisions.
  I began my comments asking several fundamental questions about 
consumer rights. I would like to conclude by encouraging all of my 
colleagues to consider the issues which I have raised and I look 
forward to substantive debate on these critical matters that have such 
a profound effect on the health of this Nation.
  We have an opportunity to stand up for American families, protect 
American children and respond to the needs of American workers. I urge 
all of my colleagues to stand together with the overwhelming majority 
of the American people and begin a discussion that will ultimately lead 
to the passage of a meaningful patient's bill of rights for all 
Americans. The American people have waited long enough.
  Mr. CHAFEE. Mr. President. I would like to clarify my position on 
these procedural votes regarding managed care reform legislation.
  I think Senators on both sides of the aisle are familiar with my 
position on the need for managed care reform legislation to ensure that 
health care consumers are treated fairly by their HMOs and other 
managed care plans.
  Indeed, I have authored bipartisan legislation--both in this Congress 
and the last--to provide a basic floor of federal protections for all 
privately insured Americans. And, I am pleased to be joined in that 
endeavor by Senators Bob Graham, Joe Lieberman, Arlen Specter, Max 
Baucus, Chuck Robb and Evan Bayh.
  Though I will vote not to table the Republican bill, I want to make 
clear, I do not think this bill goes far enough in protecting 
consumers. Nor am I entirely comfortable with the Democratic bill. Let 
me cite just a few examples.
  In the Chafee-Graham-Lieberman bill, our patient protections would 
extend to all privately insured Americans--not just to the self-funded 
component of the ERISA population, as is the case with most of the 
patient protections in the Republican bill.
  A credible enforcement mechanism is also critical to ensuring that 
any patient protections we adopt here in the Senate are taken seriously 
by managed care plans. The Chafee-Graham-Lieberman bill contains a 
strong enforcement mechanism which would permit injured parties to seek 
redress in federal court. Here the Democratic bill goes too far in 
exposing health plans to state tort liability, while the strengthened 
ERISA remedy contained in the Republican bill does not go far enough.
  Our bipartisan bill also contains very strong internal and external 
appeals provisions to ensure that patients get their appeals heard in 
an expeditious and equitable manner. I am not convinced the Republican 
bill does enough in this area.
  Regardless of our legitimate differences, I am not in favor of trying 
to force the debate on managed care in this manner. I respectfully urge 
both sides to work in good faith to arrive at a reasonable time 
agreement to facilitate an orderly debate as soon as practicable on 
this very important legislation.
  In that regard, I do not think 40 amendments on either side is 
realistic given all of the other matters competing for the Senate's 
attention; nor, for that matter, do I think 3 amendments would give the 
Senate the opportunity to fully debate these issues.
  If we are serious about Senate consideration of managed care 
legislation--as I believe both sides are--I see

[[Page S7444]]

no reason why we cannot come to an agreement on a date certain for 
taking up this legislation, and a date certain for completing it. I 
believe the Senate could complete consideration of this legislation 
within a period of five or six days.
  So, let us proceed in a timely manner to debate these differences and 
to vote to resolve them. That is our task, and I am willing to help in 
whatever ways I can to ensure a full and meaningful debate.
  Mrs. MURRAY. Mr. President, I rise today to express my frustration 
and outrage with the inability of the Republican leadership to allow a 
fair and open debate on a real Patients' Bill of Rights. I do not like 
the idea of tying up must do appropriations bills to try and force a 
fair and open debate on access to health care services. However, due to 
the inability to find a reasonable compromise on the number of 
amendments, we have been forced to bring this issue to every possible 
vehicle.
  There are many things we do here that simply do not have the impact 
we seem to think they do. We spend more time debating a constitutional 
amendment to balance the budget instead of simply doing the hard work 
to balance the budget. We proved that despite weeks of debate all we 
needed to do was make the tough choices and balance the budget. Yet 
when it comes to something like access to emergency room treatment or 
access to experimental life saving treatments, we can't find three days 
on the Senate floor. This is the kind of legislation that really does 
impact American working families. I would argue that it deserves a full 
and open debate on the Senate floor.
  The pending amendment before us is not, and let me repeat, is not a 
Patient Bill of Rights. Oddly enough it excludes most insured Americans 
and in many cases, simply reiterates current insurance policy. It does 
not provide the kind of protections and guarantees that will ensure 
that when you need your insurance it is there for you and your 
families. Let's face it, most people do not even think about their 
health insurance until they become sick. Certainly insurance companies 
do not notify them every week or month when collecting their premiums 
that there are many services and benefits that they do not have access 
to. It is amazing how accurate insurance companies can be in collecting 
premiums, but when it comes time to access benefits it becomes a huge 
bureaucracy with little or no accountability.
  The Republican leadership bill is inadequate in many areas. Let me 
point out one major hole in this legislation. During markup of this 
amendment in the HELP Committee I offered a very short and simple 
amendment to prohibit so-called ``drive through mastectomies.'' My 
amendment would have prohibited insurance companies from requiring 
doctors to perform major breast cancer surgery in an out patient 
setting and discharging the woman within hours. We saw this happen when 
insurance companies decided that there was no medical necessity for a 
woman to stay more than 12 hours in a hospital following the birth of a 
child. They said there was no need for follow up for the newborn infant 
beyond 12 hours. There was no understanding of the effects of child 
birth on a woman and no role for the woman or physician to determine 
what is medically necessary for both the new mother and new born 
infant.
  I offered the drive through mastectomy prohibition amendment only 
because an amendment offered earlier in the markup would continue the 
practice of allowing insurance personnel to determine what was 
medically necessary. Not doctors or patients, but insurance company 
bean counters. I offered my amendment to ensure that no insurance 
company would be allowed to engage in drive through mastectomies. My 
amendment did not require a mandatory hospital stay. It did not set the 
number of days or hours. It simply said that only the doctor and 
patient would be able to determine if a hospital stay was medically 
necessary. The woman who suffered the shock of the diagnosis of breast 
cancer; the woman who was told a mastectomy was the only choice; the 
woman who faced this life altering surgery. She decides.

  Unfortunately, my colleagues on the other side did not feel 
comfortable giving the decision to the woman and her doctor. They did 
not like legislating by body part. Neither do I. But I could not sit by 
and be silent on this issue. Defeating the medically necessary 
amendment offered prior to my amendment, forced me to legislate by body 
part. I would do it again to ensure that women facing a mastectomy are 
not sent home to deal with the physical and emotional after shocks.
  For many years I have listened to many of my colleagues talk about 
breast cancer and breast cancer research or a breast cancer stamp. When 
it sometimes to really helping breast cancer survivors, some of my 
Republican colleagues vote ``no.'' I hope we are able to correct this 
and give all of my colleagues, not just those on the HELP Committee the 
chance to vote ``yes.''
  I also want to remind many of my colleagues who support doubling 
research at NIH, that we are facing a situation where we have all this 
great research and yet we allow insurance companies to deny access. 
Today we heard testimony at the Labor, HHS Subcommittee hearing about 
juvenile diabetes. It was an inspiring hearing with over 100 children 
and several celebrities. Yet as I sat there listening to testimony from 
NIH about the need to increase funding and how close we are to finding 
a cure, I was struck by the fact that the Republican leadership bill 
would allow the continued practice of denying access to clinical 
trials, access to new experimental drugs and treatments, access to 
specialities and access to speciality care provided at NIH cancer 
centers.
  It does little good to increase research or to find a cure for 
diabetes or Parkinsons disease if very few can afford the cure or are 
denied access to the cure. We need to continue our focus on research, 
but cannot simply ignore the issue of access.
  I urge my colleagues to join with me in supporting a real Patient's 
Bill of Rights that puts the decision on health care back into the 
hands of the consumer and the physician. It does not dismantle managed 
care. But it ensures that insurance companies managed care, not 
profits.
  I do not want to increase the cost of health care costs, I simply 
want to make sure that people get what they pay for. That they have the 
same access to cure that we as Members of the Senate enjoy as we 
participate in the Federal Employees Health Benefit Plan. The President 
has made sure that we have patient protections. Our constituents 
deserve no less.
  Mr. SPECTER. Mr. President, I am voting against tabling both 
competing versions of the Patient's Bill of Rights because I believe 
both should be considered by the Senate. I oppose any proposal to limit 
amendments on either bill and then have just an up or down vote on each 
Bill.
  I believe a bill should be considered in regular order in the usual 
manner subject to the Senate rules which would permit amendments and 
debate under our rules without a unanimous consent agreement limiting 
amendments or debate.
  My own preference for the Patient's Bill of Rights is the bipartisan 
proposal S. 374 sponsored by Senators Chafee, Graham, Lieberman, 
Baucus, and myself.
  If any bill is called up subject to regular order, the various 
provisions could be considered and voted upon and the Senate would work 
its will on the competing provisions.
  Mr. KENNEDY. How much time do I have?
  The PRESIDING OFFICER. Two minutes 50 seconds.
  Mr. KENNEDY. Two minutes 50 seconds?
  The PRESIDING OFFICER. Yes.
  Mr. KENNEDY. I would like to reserve the last 20 seconds, Mr. 
President.
  Mr. President, to listen to my friends on the other side, you would 
think that you were hearing the talking points written by the insurance 
industry: It costs too much.
  Here is the CBO report: 4.8 percent for average premiums for 
employer-sponsored health insurance over 5 years. For the sake of this 
exercise, call it 5 percent. Say a families' premium is $5,000. That is 
$250 over 5 years. Allocate that in terms of employer-employee, and you 
will find that the cost paid by an employee is around the cost of a Big 
Mac each month. This

[[Page S7445]]

is a buy to ensure that you are going to have the protections in our 
legislation.
  We hear about all the things that their program is doing. But the one 
thing that Senator Frist left out is that they are only covering a 
third of all of Americans. They are leaving out more than 110 million 
Americans. If this plan is so good, why not include everyone?
  For those that are so concerned about the cost, I hope they are going 
to explain where they are getting the money that the Joint Tax 
Committee says their proposal will cost. Their medical savings accounts 
alone--which are little more than a tax shelter for the rich--are $4.2 
billion over the next 7 years. But they don't say how they will pay for 
it in their proposal.
  They are concerned about cost? Why are they expanding that tax 
loophole? Why aren't they at least jawboning the insurance companies to 
hold down the 6 to 10 percent increase that we see in the insurance 
premiums every year just to increase profits?
  Every single provision of the Republican bill is riddled with 
loopholes. It is a bill that only an insurance company accountant could 
like. As this debate proceeds, we will expose those loopholes.
  Mr. President, one of the ways you know a person is by who their 
friends are. Our friends in this debate are the 200 groups that 
represent the doctors and nurses--the health delivery professionals--
and consumers. Not a single organization supports the opposition.
  If our amendment is tabled, it is a vote against children, a vote 
against families, a vote against women; it is a vote against every 
individual with a serious health problem, and it is a vote in favor of 
mismanaged care and a vote in favor of placing insurance company 
profits ahead of patient care. I hope the motion to table Senator 
Daschle's amendment is defeated.
  I yield the remainder of my time.
  Mr. NICKLES. Mr. President, how much time remains?
  The PRESIDING OFFICER. The majority has 5 minutes 4 seconds, and 
Senator Kennedy has 20 seconds.
  Mr. NICKLES. Mr. President, I yield 3 minutes to the Senator from 
Maine.
  Ms. COLLINS. Mr. President, I thank the assistant majority leader.
  The goal of any patients' rights legislation should be to resolve 
disputes about coverage, about access to treatment upfront when the 
care is needed, not months or even years later in a courtroom. That is 
a fundamental difference between the bill supported by Senator Kennedy 
and the proposal that we have advanced.
  Our legislation would accomplish this goal by creating a strong 
internal and external review process. If a patient or a physician is 
unhappy with an HMO's decision, the patient or the provider can appeal 
it internally for a review. If they are unhappy with the review 
decision, the internal review, they have the right for a free and quick 
review by an external panel. The goal of our legislation is to ensure 
that people get the treatment they have been promised.
  Moreover, the decision of the outside reviewers is binding on the 
health plan but not on the patient. If the patient is still not 
satisfied, he or she retains the right to sue in Federal or State court 
for attorneys' fees, court costs, value of the benefit, and injunctive 
relief.
  Our bill places treatment decisions in the hands of physicians, not 
trial lawyers. If your HMO denies you the treatment your doctor 
believes is medically necessary, you should not have to resort to a 
costly and lengthy court battle to get the care you need. You should 
not have to hire a lawyer and file an expensive lawsuit to get 
treatment.
  Our approach contrasts with the approach taken in the measure offered 
by Senator Kennedy. Their approach, which I do not support, would 
encourage patients to sue health care plans. You just can't sue your 
way to quality health care. We want to solve the problems upfront, when 
the care is needed, not months or even years later, after the harm has 
occurred.
  According to the GAO, it takes an average of 33 months to resolve 
medical malpractice cases. This does nothing to ensure a patient's 
right to timely and appropriate care. Moreover, patients only receive 
43 cents out of every dollar awarded in malpractice cases. The rest 
winds up in the pockets of trial lawyers and the administrators of 
court and insurance systems.
  Suing is not the answer. The answer is having a fair, free, and 
prompt appeals process that gets patients the care they need, the care 
they were promised before harm can be done.
  I recently met with a group of Maine employers who expressed their 
very serious concerns about the Kennedy proposal to expand liability 
for health plans and employers. One of these employers was Bowdoin 
College in Brunswick, ME. I want to talk briefly about Bowdoin's 
experience.
  They moved to a self-funded plan in order to improve the coverage 
provided to their employees. They now provide an annual physical, low-
cost prescription coverage, and well-baby care. But they told me that 
if the Democrats' proposal to expand liability goes through, it would 
seriously jeopardize their ability to offer affordable coverage for 
their employees. They would return to the insurance market and to a 
plan less favorable to their employees.
  I thank the assistant majority leader for yielding the additional 
minute. I yield back my time to the assistant majority leader.
  Mr. NICKLES. Mr. President, how much time remains?
  The PRESIDING OFFICER. The Senator has 1 minute 12 seconds.
  Mr. NICKLES. I will reserve 12 seconds.
  In a moment there will be a motion to table the Republican 
substitute. I hope our colleagues will vote against that motion to 
table and then, hopefully, after that is not tabled, I will move to 
table the Kennedy amendment.
  Mr. President, I will do so for a couple of reasons. One, it doesn't 
belong on the agriculture bill. I told my colleagues we are willing to 
come up with a reasonable time agreement and a limited number of 
amendments to debate this issue. It doesn't belong on the agriculture 
appropriations bill.
  There are other reasons to table the underlying Kennedy amendment. If 
you want to increase health care costs, that is what this bill does. It 
will increase health care costs 5 percent, in addition to the 6, 7, 8, 
9 percent of health care inflation. You are going to have a 13 or 14-
percent increase in health care costs, which is going to increase the 
number of uninsured probably by 1.5 million, maybe more. We should not 
be passing legislation to put 1.5 million people into the uninsured 
category. That would be a serious mistake.
  The PRESIDING OFFICER. The time of the Senator has expired.
  Mr. KENNEDY addressed the Chair.
  The PRESIDING OFFICER. The Senator from Massachusetts.
  Mr. KENNEDY. Mr. President, the issue that is before us with the 
proposal that Senator Daschle has advanced is a very basic and 
fundamental one: Who ought to be making the decisions on your health 
care?
  The whole concept behind the Daschle proposal is that we should let 
the medical professional guide that judgment--the doctor, nurse and 
patient together. That ought to be the basis of the judgment--not an 
accountant, not an insurance company official. That is really at the 
heart of this whole legislation. Our legislation protects that and 
preserves it.
  The other legislation that is reported out of our committee fails to 
do it. That is why we have the support of the health care professionals 
and they do not. I hope we will have the opportunity to at least debate 
these various issues in an orderly way. That is what this battle is 
about. I hope that we will be able to continue with a reasonable 
procedure to permit the Senate to make a judgment.
  Mr. NICKLES addressed the Chair.
  The PRESIDING OFFICER. The Senator from Oklahoma.
  Mr. NICKLES. Mr. President, I am afraid my colleague from 
Massachusetts didn't hear my colleague from Tennessee state that we do 
have internal appeals that are decided by physicians. We also have 
external appeals that are decided by experts in the medical community. 
So if his statement is correct, he should vote for our proposal. I 
encourage him to do so.
  Mr. LOTT addressed the Chair.
  The PRESIDING OFFICER. The majority leader is recognized.
  Mr. LOTT. Mr. President, has all time expired?

[[Page S7446]]

  The PRESIDING OFFICER. Yes.
  Mr. LOTT. Mr. President, I move to table amendment No. 703 and ask 
for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The yeas and nays were ordered.
  The PRESIDING OFFICER. The question is on agreeing to the motion to 
table amendment No. 703. The yeas and nays have been ordered. The clerk 
will call the roll.
  The legislative assistant called the roll.
  The PRESIDING OFFICER (Mr. Brownback). Are there any other Senators 
in the Chamber desiring to vote?
  The result was announced--yeas 45, nays 55, as follows:

                      [Rollcall Vote No. 181 Leg.]

                                YEAS--45

     Akaka
     Baucus
     Bayh
     Biden
     Bingaman
     Boxer
     Breaux
     Bryan
     Byrd
     Cleland
     Conrad
     Daschle
     Dodd
     Dorgan
     Durbin
     Edwards
     Feingold
     Feinstein
     Graham
     Harkin
     Hollings
     Inouye
     Johnson
     Kennedy
     Kerrey
     Kerry
     Kohl
     Landrieu
     Lautenberg
     Leahy
     Levin
     Lieberman
     Lincoln
     Mikulski
     Moynihan
     Murray
     Reed
     Reid
     Robb
     Rockefeller
     Sarbanes
     Schumer
     Torricelli
     Wellstone
     Wyden

                                NAYS--55

     Abraham
     Allard
     Ashcroft
     Bennett
     Bond
     Brownback
     Bunning
     Burns
     Campbell
     Chafee
     Cochran
     Collins
     Coverdell
     Craig
     Crapo
     DeWine
     Domenici
     Enzi
     Fitzgerald
     Frist
     Gorton
     Gramm
     Grams
     Grassley
     Gregg
     Hagel
     Hatch
     Helms
     Hutchinson
     Hutchison
     Inhofe
     Jeffords
     Kyl
     Lott
     Lugar
     Mack
     McCain
     McConnell
     Murkowski
     Nickles
     Roberts
     Roth
     Santorum
     Sessions
     Shelby
     Smith (NH)
     Smith (OR)
     Snowe
     Specter
     Stevens
     Thomas
     Thompson
     Thurmond
     Voinovich
     Warner
  The motion was rejected.
  The PRESIDING OFFICER. The majority leader.
  Mr. LOTT. Mr. President, I notify Senators that this will be the last 
vote tonight. Tomorrow at 9:30, we will resume consideration of the 
agriculture appropriations bill which will be clean of the Patients' 
Bill of Rights. I urge Members to offer amendments to the agriculture 
appropriations bill as soon as possible. I yield the floor.


                           Amendment No. 702

  Mr. LOTT. Mr. President, I move to table amendment No. 702, and I ask 
for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be a sufficient second.
  The yeas and nays were ordered.
  The PRESIDING OFFICER. The question is on agreeing to the motion to 
table amendment No. 702. The yeas and nays have been ordered. The clerk 
will call the roll.
  The legislative clerk called the roll.
  The result was announced--yeas 53, nays 47, as follows:

                      [Rollcall Vote No. 182 Leg.]

                                YEAS--53

     Abraham
     Allard
     Ashcroft
     Bennett
     Bond
     Brownback
     Bunning
     Burns
     Campbell
     Chafee
     Cochran
     Collins
     Coverdell
     Craig
     Crapo
     DeWine
     Domenici
     Enzi
     Frist
     Gorton
     Gramm
     Grams
     Grassley
     Gregg
     Hagel
     Hatch
     Helms
     Hutchinson
     Hutchison
     Inhofe
     Jeffords
     Kyl
     Lott
     Lugar
     Mack
     McCain
     McConnell
     Murkowski
     Nickles
     Roberts
     Roth
     Santorum
     Sessions
     Shelby
     Smith (NH)
     Smith (OR)
     Snowe
     Stevens
     Thomas
     Thompson
     Thurmond
     Voinovich
     Warner

                                NAYS--47

     Akaka
     Baucus
     Bayh
     Biden
     Bingaman
     Boxer
     Breaux
     Bryan
     Byrd
     Cleland
     Conrad
     Daschle
     Dodd
     Dorgan
     Durbin
     Edwards
     Feingold
     Feinstein
     Fitzgerald
     Graham
     Harkin
     Hollings
     Inouye
     Johnson
     Kennedy
     Kerrey
     Kerry
     Kohl
     Landrieu
     Lautenberg
     Leahy
     Levin
     Lieberman
     Lincoln
     Mikulski
     Moynihan
     Murray
     Reed
     Reid
     Robb
     Rockefeller
     Sarbanes
     Schumer
     Specter
     Torricelli
     Wellstone
     Wyden
  The motion was agreed to.
  Mr. LOTT. Mr. President, I move to reconsider the vote, and I move to 
lay that motion on the table.
  The motion to lay on the table was agreed to.
  Mr. LOTT. Mr. President, I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. LOTT. Mr. President, I ask unanimous consent that the order for 
the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.

                          ____________________