[Congressional Record Volume 145, Number 90 (Wednesday, June 23, 1999)]
[Senate]
[Pages S7517-S7521]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                     EXTENSION OF MORNING BUSINESS

  Mr. FRIST. Mr. President, I ask unanimous consent that morning 
business be extended to 5:30, as under the previous agreement.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. FRIST. Mr. President, I rise in part to respond to much of the 
discussion that has gone on this afternoon. But really, I think more 
important, to put in perspective where we are today with this issue of 
the Patients' Bill of Rights and what we can do as a legislative body 
to address some very real problems, very real challenges that face the 
health care system, that face individuals, that face patients, and face 
potential patients as they travel through a health care structure that 
in some ways is very confusing, in some ways is conflicting but 
underneath provides the very best care of anyplace in the world.
  Many of the challenges we face today are a product of an evolving 
health care system where we have Medicare, which treats about 39 
million seniors and individuals with disabilities. We have real 
challenges in Medicare because it is a government-run program that is 
going bankrupt. It is a program that has a wonderful, over 30-year 
history of treating seniors, people over the age of 65, and individuals 
with disabilities. These are people who probably could not get care 
anywhere near the degree of quality they can get today. Yet we have 
huge problems and we have tried to address them through a Medicare 
Commission. Unfortunately, even though we had a majority of votes 
supporting a proposal there called Premium Support, the President of 
the United States felt he could not support that proposal and thus, 
right before the final vote, pulled back and said I will provide a 
solution to Medicare in the next several weeks.
  To date we have not heard from the President of the United States. 
Yet we have a program with 39 million people in it going bankrupt. It 
is going bankrupt in--now the year is 2014. That is about 39 million 
people. About 30 million people are in Medicaid. That is another 
government-run program, the joint Federal-State program, funded 
principally, almost half and half, by Federal and State but run by the 
States. That is directed at the indigent population, principally. There 
are just over 30 million people in it. It is a program that I think 
also has been very effective.
  As a physician in Tennessee, I had the opportunity, the blessed 
opportunity of taking care of hundreds and hundreds and hundreds of 
Medicaid patients. But also, as you talk about States in the Medicaid 
program, there is a lot of discussion of how we can improve it, how we 
can improve quality. That discussion needs to continue. It is going on 
in every courthouse in every State, every legislative body, every 
Governor's office, every community townhall right now.
  Then we have the third area, the nongovernmental area, where this 
whole Patients' Bill of Rights issue is one we must address.
  I should say, because we have heard so much to the contrary, we have 
a bill, the Republican bill. It is called the Patients' Bill of Rights 
Plus. That was introduced in the last Congress. That was talked about 
along with the Kennedy-Daschle bill from last year. Both of those bills 
were brought into Congress. It was the Republican bill which was what 
we call ``marked up.'' That means it was taken to the Committee on 
Health, Education, Labor and Pensions, the Health Committee, the 
appropriate committee. In that committee, it was debated; it was talked 
about. We probably had, I don't know--we started with about 40 
amendments in that committee about 3 or 4 months ago on the Patients' 
Bill of Rights Plus. They were debated. We had some good debate. Some 
things we did not debate and they need to be taken forward and further 
discussed.

[[Page S7518]]

  Mr. WELLSTONE. Will the Senator yield for a question?
  Mr. FRIST. No, I will not. For the last 2 hours I really had not had 
an opportunity to talk. If I can just finish my remarks?
  Mr. WELLSTONE. I thought the Senator would yield for a question.
  Mr. FRIST. The issue is have we been able to debate or talk about or 
discuss this. Let's remember through the appropriate senatorial 
committee process we have debated this very bill. We have debated such 
things as consumer protection standards. We have debated specialty 
care, access to specialists, continuity of care, emergency care, choice 
of plans, access to medication, access to specialists, grievance and 
appeals. These were introduced and we talked about discrimination by 
insurance companies using genetic information, medical savings 
accounts. These are all issues that have been debated.
  I, for one, as a physician, as a United States Senator, as a chairman 
of the Subcommittee on Public Health, and as a member of the Health, 
Education, Labor, and Pensions Committee, have been involved in those 
debates and in those discussions. So when we have people coming to the 
floor again and again with so much rhetoric and so much fire saying 
those bad Republicans out there really just do not care, do not want to 
talk about it, do not want a debate, do not want to study the issues--
let me just say that is absolutely false. It is absolutely false. The 
American people need to know that. I think the sort of rhetoric we have 
heard this afternoon and over the last several days is clearly 
political points they want made.
  I would like us to come back and continue the debate, the important 
debate on the issue of this nongovernmental sector, to make sure we 
consider that individual patient. Again, I have had the opportunity to 
treat thousands, probably tens of thousands, of these patients. Those 
issues need to be addressed, but I think they need to be addressed in a 
more mature, more sophisticated, more thoughtful way. And we have done 
just that. The Republican leadership bill is a bill that has been 
debated in committee. It has been discussed. It is called the Patients' 
Bill of Rights Plus Act. It basically has six components to address 
this whole issue of health care and Patients' Bill of Rights and a few 
other things.
  One is strong consumer protection standards. No, it does not include 
everybody. Why does it not just include everybody? Because about half, 
a little over half of those people are already protected under State 
law. The States are doing a good job. I guess people can bash the 
States and say the States don't care, the Governors don't care, State 
legislatures don't care, but I think they do care. We do not have any 
great ownership of concern in this body, being the only ones who care. 
Our Governors do care and they have made great strides.
  So when it comes to emergency care, prohibition of gag clauses, 
continuity of care, access to obstetricians and gynecologists and 
pediatricians, access to specialists--such as me, as a heart surgeon--
access to medications, consumer protections, we say let's apply those 
to the unprotected, the people who are not protected now by State law. 
That is about 48 million people.
  We address issue No. 2, of comparative information. It is very 
confusing today. It is confusing because we had this evolution of 
managed care, which is a new concept. Mr. President, 15 or 20 years ago 
there was no such thing as managed care. Yet right now, 80 percent of 
all care delivered is through managed care through networks and through 
coordinated care. But nobody has the answer yet. We are not smart 
enough to know exactly what is the best way to manage that care.
  Some people think all managed care is a staff model health 
maintenance organization, and there is a lot of anger by the American 
people against health maintenance organizations. But let me at least 
introduce the concept that coordinated care, or organized delivery of 
care so there is an appropriate input of resources, has a very good 
outcome today. That is because of the great dynamism of our health care 
system. Because this is America, because we encourage innovative 
thought and creativity, we are still searching for the model, and we 
are probably not going to come up with a one-size-fits-all cookie-
cutter model. We will probably come up with a range of ways in which 
that coordinated care can be delivered.

  As we go through that process, it is very confusing to the consumer, 
to the patient, to the individual, what is the best plan. Is it a 
particular HMO? Is it a point-of-service plan? Is it a provider-
sponsored organization?
  In the Patients' Bill of Rights Plus Act, we address that. Basically, 
we say comparative information about health insurance coverage, not 
just for 48 million people but for all 124 million Americans covered by 
self-insured plans and fully insured group plans, must be made 
available. That comparative information is important, because that is 
the only way an individual can really know whether plan A or plan B or 
HMO A or managed care C or fee for service is best for them.
  Internal and external appeal rights: This is the third component of 
the Patients' Bill of Rights Plus Act. Again, it is a very important 
aspect, because it says let's fix the system, instead of what some of 
the other proposals have introduced, which is let's put lawyers and 
trial lawyers in there and let's threaten to sue and that is going to 
change the system.
  What we say is, let's fix the system. An example is, if as a member 
of a health care plan I have a question on coverage and I think a 
particular procedure should be covered, yet there is some question 
about it, I can go to a person in that plan and say: Is this covered or 
not? They will say yes or no. If I disagree, I can contest that, and 
there is an internal appeals process where that questioning can be 
taken care of in a timely fashion.
  Our bill says, if that is the case in this internal appeals process 
and you still disagree, you do not have to stop there; there are 
options, and that is the so-called external appeals process.
  The external appeals process is set up in our Patients' Bill of 
Rights Plus Act to be independent, to be outside the plan--that is why 
it is called external appeals--to be a physician or a medical 
specialist reviewing that coverage decision in the exact same field 
where the coverage decision is in question.
  Internal appeals, external appeals. Let's say you have gone through 
the internal appeals process and the external appeals process, and a 
decision is made by that independent medical reviewer that the 
individual patient is right and the health care plan is wrong. That 
decision in our plan is binding, and therefore you have to receive 
coverage under that plan.
  I walked through that because it is an important part of the 
Patients' Bill of Rights Plus Act and because that is the component 
which fixes the system. It fixes the system instead of having this 
threat of lawsuits trying to put a system back into place but with no 
guarantee.
  A fourth component of the Patients' Bill of Rights Plus Act that has 
been talked about, that passed out of the Committee on Health, 
Education, Labor, and Pensions and has been sent to the floor, is a ban 
on the use of predictive genetic information. This particular aspect of 
the bill does apply to 140 million Americans who are covered by self-
insured and fully insured group health plans, as well as the individual 
plans. I say 140 million people. I talked about the 39 million people 
in Medicare and over 30 million people in Medicaid, and for the 
nongovernmental aspect, the ban on the use of predictive genetic 
information applies to all 140 million people.
  Why is that important? That is in the Republican bill. It is not in 
the Kennedy bill. I believe it is an important aspect, because what it 
recognizes is that technology is changing, new tests are being 
introduced almost daily with a genetic basis, in large part because of 
the Human Genome Project which has introduced about 2 billion bits of 
information that we simply did not know 4 or 5 years ago and because of 
the investments the Federal Government had made in medical science.
  The real problem is, with all of this new testing coming on board, 
there is the potential for an insurance company to discriminate against 
a patient, either to raise premiums or to basically say, ``We are not 
going to cover you.'' Therefore, in this Patients' Bill of Rights Plus 
Act, we put a ban on the use of predictive genetic information, which 
is a very important part of this bill.

[[Page S7519]]

  A fifth area that is in our bill, that has passed through the 
Committee on Health, Education, Labor, and Pensions under Senator 
Jeffords' leadership, is a real quality focus. The impression is, we 
know what good quality of care is and we know what bad quality of care 
is. All of us, after we see a doctor, like to think we have good 
quality of care. For the most part, the quality of care in our country 
is very high. In truth, how we measure quality of care in this country 
as a science is in its infancy. We are just learning about it. When I 
was in medical school, there was no such field as outcomes research, 
what is the outcome after a particular procedure.
  Mr. President, the Patients' Bill of Rights Plus Act, as we have 
heard, has been debated in the Health, Education, Labor, and Pensions 
Committee and passed successfully by a majority of members and sent to 
the Senate. It is a bill that has really six different components.
  It addresses, I believe, the fundamental challenge that we have; that 
is, to improve the quality of health care, real quality of health care 
for individuals; to improve access to health care, something that I 
believe is very important. The Kennedy bill does the opposite. Instead 
of improving access, diminishing the number of uninsured, his bill does 
just the opposite. It drives people to the ranks of the uninsured, 
increasing the number of uninsured people today by as many as a 
million. Nobody has refuted that.
  The third very important part of the Patients' Bill of Rights Plus 
Act that passed through the Health, Education, Labor, and Pensions 
Committee successfully is that of consumer protections. Again, I keep 
hearing that the Patients' Bill of Rights Plus Act does not do this for 
specialists, does not do this for emergency care, does not offer true 
point of service, and does not offer true continuity of care. I have to 
take a few minutes and run through it.
  Emergency care: Under our bill, plans will be required to use the so-
called ``prudent layperson'' standard for providing in-network and out-
of-network emergency screening exams and stabilization. This prudent 
layperson standard simply means, if you are in a restaurant and 
somebody begins choking, that makes sense as an emergency service. If 
you think you are having a heart attack and it may be indigestion, or 
it may be a heart attack and you go to the emergency room and you find 
it is indigestion, the initial screening exams and stabilization would 
be taken care of. That is a very important component of our bill.
  No. 2, we have heard about pediatricians, obstetricians, 
gynecologists. Under our bill, health plans would be required to allow 
direct access to obstetricians, to gynecologists, and to pediatricians 
for routine care without gatekeepers, without referrals.
  Why is that the case? The reasons are obvious. The pediatricians, 
obstetricians, and gynecologists are in the business of doing what we 
call in the medical field ``primary care.'' You don't need a 
gatekeeper. You shouldn't have a gatekeeper. No managed care company, I 
believe, should require a gatekeeper in terms of access for 
obstetricians, gynecologists, and pediatricians for routine care.
  Thirdly, this issue of continuity of care: I have heard it again and 
again. In our bill, the Patients' Bill of Rights Plus Act, plans who 
terminate physicians or do not renew physicians from their networks 
would allow continued use of that physician, of that provider, at the 
exact same payment or cost-sharing arrangement as before in the plan 
for up to 90 days. If the enrollee is receiving any type of 
institutional care or is terminally ill, or if they happened to be 
pregnant and there is termination or nonrenewal of your physician with 
that plan, you would be covered through the pregnancy through that 
postpartum care. That gives security to the patients. That is why it is 
important to have this very important consumer protection standard.
  Access to specialists: I have heard all day long and over the last 
several days that the Republican bill doesn't give you access to 
specialists. Let me tell you what it does. Health plans would be 
required, under our bill, to ensure that patients have access to 
covered specialty care to a heart surgeon, to a pulmonologist, to an 
arthritis specialist within the network or, if necessary, through 
contractual arrangements outside of the network with specialists. It is 
in the bill.
  People say it is not in the bill. It is in the bill. What more can 
one say. That is why it is important to get rid of the rhetoric and go 
to the heart of the matter--how we improve quality of health care and 
access to health care, and put strong consumer protections in so that 
the patients can work with the health care plan to not sue somebody, 
not empower trial lawyers, not to have angry, rhetorical sort of 
comments but to improve health care, the quality of health care.
  This access to specialists, again, the other side seems to ignore 
what is in the bill. I know they probably haven't had a chance yet to 
read the bill, even though it has gone through the Health, Education, 
Labor, and Pensions Committee. It has been debated. Scores of 
amendments were introduced there. Well over a dozen, I know, were 
debated and voted upon.
  In this access to specialists component, if the plan, under our bill, 
requires authorization by a primary care provider, it must provide for 
an adequate number of referrals to that specialist--I think that is an 
important component--not just one referral where you have to go back to 
a gatekeeper, back and forth, but if you are going to have treatment by 
a specialist, that an adequate number of referrals are made.
  Choice of plans: How many times have we heard: Our plan provides real 
choice and that Republican plan doesn't provide choice?
  Let me tell you what our plan does. Plans that offer network-only 
plans would be--I use the word ``required'' again--required to offer 
enrollees the option to purchase real point-of-service coverage. And 
there can be an exemption for the small employer out there. Other 
health plans could potentially be exempt if they offered two or more 
options.
  People may say, why would you exempt somebody from offering a point-
of-service plan if they have two other health care plans? The reality 
is, if you offer health care plan A and plan B, and they are different 
providers, with different physicians and different nurses in plan A 
than there are in plan B, then you do have a choice among plans. 
Therefore, you don't have to require a very specific out-of-network, 
point-of-service option.
  This whole consumer protection field is an important component, and 
this was actually improved in what we call markup in the Health, 
Education, Labor, and Pensions Committee--access to medications, to 
make sure if you are in a health care plan that offers certain 
coverage, you have access to the appropriate medicines.
  What is in our plan is as follows:
  Health plans that do provide prescription drugs through a formulary 
would be required to ensure the participation of people who understand 
clinical care--physicians and pharmacists--in developing and reviewing 
that formulary.
  That is important. As a physician, you don't want bureaucrats putting 
formularies together, but people who understand clinical care. 
Therefore, that bill was improved to say that physicians and 
pharmacists must be involved.
  In addition, in our bill, plans would also be required to provide for 
exceptions from the formulary limitation when a nonformulary 
alternative is medically necessary and appropriate. I think that is an 
important part of the bill because, as you can imagine, in a formulary 
you can't predict and put on every single medicine for every single 
disease. Therefore, there must be enough flexibility to give 
alternatives if what is in that formulary is not--I use these words 
because it is in the bill --medically necessary and appropriate.
  These are just some of the consumer protections that are part of the 
bill. I think it is important to stress those. Others that are in the 
bill include issues surrounding behavioral health, issues surrounding 
gag clauses. Again, it is inexcusable that a managed care company would 
come forward to a physician and say: Physician, for you to be a member 
of our HMO or our managed care, you cannot and should not discuss the 
full range of alternatives of treatment and care with the patient. That 
has to be prohibited.

[[Page S7520]]

  In our bill, in terms of gag rules, plans would be prohibited from 
including any type of gag rules in doctor contracts, physician 
contracts, provider contracts, or restricting providers from 
communicating with patients about treatment options. No more gag rules.
  The Patients' Bill of Rights Plus Act is a piece of legislation that 
we have all worked very hard on over the last year, year and a half. It 
has gone through the process that has been set up in terms of debate 
and in terms of improving the bill in the Health, Education, Labor, and 
Pensions Committee. It is a bill that I look forward to having on the 
floor so we can debate it and improve it over time, and make sure that 
we have a real balance between the rights of a patient versus the 
rights of managed care.
  The PRESIDING OFFICER (Mr. Abraham). The Senator's time has expired.
  The Senator from Minnesota.
  Mr. WELLSTONE. Mr. President, I say to my colleague from Tennessee, 
if my colleague believes this legislation the Republicans introduced in 
committee--and I am on the same committee--is such a great piece of 
legislation protecting patients' rights, then what in the world is the 
delay in bringing it before this body?
  Again, what I am saying is self-evident. If my colleagues on the 
Republican side think this is such good legislation, why the delay? Why 
the delay and the delay?
  The only reason we are fighting it out on an ag appropriations bill 
is that we want to make it crystal clear we are here to represent the 
people in our States. This piece of legislation which my colleague from 
Tennessee has talked about--I was in the markup on that bill, which is 
when we write a bill in committee--has holes like Swiss cheese. No 
wonder they do not want to bring this bill to the floor.
  They have about a third of the people covered. I will start out with 
the question of who is covered and who is not covered. Their bill 
covers 48 million people. The Democratic bill covers 163 million 
people.
  My colleague says it is the States. Why should a child or a family in 
one State, i.e. like Mississippi, not have any protection because he or 
she lives in Mississippi but have protection in Minnesota or Wisconsin? 
Does that make any sense? Why should a small businessperson in 
Mississippi or a farmer in Mississippi not have any coverage whatsoever 
but have some kind of protection in Wisconsin or Minnesota?
  I would love to have that debate. I would love to have my Republican 
colleagues talk about why they only want to cover about a third of the 
people in the country.
  I would love for them to defend the proposition that many families 
will receive no protection whatsoever, vis-a-vis these large insurance 
companies that practice this bottom-line medicine which basically say, 
when people want access to specialists they need, specialists for their 
children, specialists for women, they are not going to have access and 
there is not going to be any protection for them, because they do not 
live in the right State. Let's debate that.

  There are 200 consumer, patient, and provider organizations that 
support the Democratic Patients' Bill of Rights legislation; not any 
that I can identify, except for the insurance industry, that support 
the Republican plan.
  Surely these consumer organizations and the providers, the 
caregivers, know something about this topic. Surely they have a 
position that is important. But I do not see any support for this 
Republican plan.
  The Democratic plan protects all patients with private insurance; the 
Republican plan, no.
  The Democratic plan holds these health insurance plans accountable; 
the Republican plan, no.
  In the Democratic plan, we make sure that the physicians, the 
doctors, the nurses, define ``medical necessity.'' We do not have the 
insurance industry's managed care plans dominate--unlike the Republican 
plan.
  In the Democratic plan, we do have a real point-of-service option 
where people are given a choice. It drives people crazy when their 
employer shifts plans and all of a sudden--they had been taking their 
child to a family doctor--they can no longer take that child to that 
doctor. Does the Republican plan assure they will be able to do so? No.
  When are we going to make sure that consumers really do have some due 
process? I heard my colleague from Tennessee talk about an internal 
appeals process. That is within the managed care plans, most of which 
are dominated, owned, by these large insurance companies.
  We are talking about a strong external appeals process. I say to my 
colleague from Wisconsin, we are talking about somewhere that a 
consumer can go and make an appeal. We are talking about an ombudsman 
program where you have an office, you have a telephone number, you have 
advocates to call. Do my Republican colleagues want to do this? No.
  Specialists who can coordinate care. Your child needs to see a 
pediatrician who specializes in oncology because your child is 
struggling with cancer. Do we make sure you have access to that 
specialist? Yes. Does the Republican plan make sure that you--a family 
in Minnesota or Michigan--have access to that specialist you so 
desperately need for your child? No.
  My colleagues come out on the floor--again, with the Senator from 
Tennessee that makes four Republicans who have been out here today--16 
Democrats. They can come out, and they can give a speech and say: Well, 
we have a bill, and it's a very good bill. But you know what. If it is 
such a good bill, bring it out to the floor. If you have such a good 
proposal, bring it out to the floor. Let's debate this. We have had 
enough delay. That is all we have had--delay, delay, delay.
  Emergency room access is really important. I heard my colleague talk 
about that. But I say to the American people, Minnesotans, when you get 
a chance to carefully examine the ``Republican Insurance Company 
Protection Act''--that is what I call it--you will find out there is a 
little bit of protection for emergency room access but it is not really 
strong. Our plan does not equivocate at all. We make sure you have that 
access. We make sure it is covered. You get to keep your doctor 
throughout treatment. The Republican plan gives you a little bit of 
protection. We think you should have complete protection.

  I tell you, this has gone on long enough. My challenge to my 
Republican colleagues is, if you think your plan is so good--and I 
certainly believe you operate in good faith; you have to believe it is 
a good plan or why would you write it--then bring it out here. We have 
to have the debate. We have amendments. We are committed to making sure 
there is good patient protection legislation passed by this Senate. We 
are ready for the debate.
  We would love to debate a plan that covers only one-third of the 
Americans in our country. We would love to debate a plan that does not 
assure a family with a child who is gravely ill that that child will 
have access to the best care available, to the best care that is there. 
We would love to debate that plan. We would love to debate a plan that 
does not provide consumers with a real choice to be able to go out and 
get the very best care they need for their loved ones. We would love to 
debate a plan that does not give consumers the right to really 
challenge some of these bean counters, some of these managed care plans 
owned by these large insurance industries. We would love to debate the 
``Republican Insurance Company Protection Plan'' versus our patient 
protection plan.
  But, again, I am on the floor, and now another speech has been given; 
but I have nobody to debate. I asked if anyone wanted to yield for 
questions. They do not want to yield for questions. Let's debate this. 
It will not be a bitter debate. It will not be a debate with hatred. 
But you know what. It is going to be serious. It is a pretty important 
question for families in our country. It is pretty important to people.
  In case anybody has not noticed--I imagine every Senator has; all you 
have to do is spend 1 minute in your State--people are really getting 
fed up with this. They do not much like the way in which the insurance 
industry dominates health care. They do not much like the fact that 
they believe they have just been left out of the loop. You know what 
else. The caregivers--the doctors and nurses--feel the same way.
  It is time that we pass legislation with teeth. The Republican plan, 
the

[[Page S7521]]

``Insurance Company Protection Plan,'' pretends that it is a patient 
protection act. It is full of loopholes. It is Swiss cheese 
legislation. It is hard to defend it.
  I can understand why my colleagues do not want to defend it. I can 
understand why they do not want to debate. I can understand why they 
have blocked our efforts, so far, to bring patient protection 
legislation to the floor. But I am telling you something: People in the 
country are demanding that we pass this legislation.
  We are on a mission. The Democrats are on a mission. We are going to 
bring these amendments to the floor. We are going to insist there be a 
good, strong, honest debate; and we are going to do well by the people 
we represent.
  I would be pleased to debate anybody, but in the absence of anyone to 
debate, I yield the floor.
  Mr. BINGAMAN addressed the Chair.
  The PRESIDING OFFICER. The Senator from New Mexico.
  Mr. BINGAMAN. Mr. President, I want to speak for just a few minutes.
  What is the status of business in the Senate?
  The PRESIDING OFFICER. The Senator from New Mexico should be informed 
we are in morning business and there are 4 minutes remaining under the 
control of the Democratic side.


                         Privilege Of The Floor

  Mr. BINGAMAN. Mr. President, I ask unanimous consent that Robert 
Mendoza, a fellow in my office, be granted floor privileges during my 
remarks.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. BINGAMAN. I would like to use those 4 minutes to say a few things 
about the Patients' Bill of Rights and the importance of the issue to a 
great many people in my State and around the country.
  I think it is clear, from surveys I have seen, the American people 
want reform of this system of managed care and health maintenance 
organizations. There are a great many instances that have been called 
to our attention in our home States. I have heard of them in New 
Mexico, where people think the quality of care and the adequacy of care 
they are being provided with is not what it should be.
  Without passage of some type of meaningful managed care reform, 
critical health care services will continue to be denied to many of the 
people we represent. One of the issues I believe is very important is 
what is referred to as provider nondiscrimination. We need a managed 
care health system that does not permit health plans to leave out 
nonphysician providers. I am talking about groups of health care 
providers such as nurse practitioners, psychologists, nurse midwives, 
leaving those people out of the network so that patients of these 
health maintenance organizations, customers of these health maintenance 
organizations are denied the ability to obtain their health care from 
those types of individuals.

  In New Mexico, this is a critical concern. We have a shortage of 
physicians in our State. It is, in many parts of our State, very 
difficult to get health care, if you are required by your HMO to obtain 
that health care through a physician.
  What we would like to do as part of the bill, which we hope to get to 
vote on in the next week or so, is to ensure that health maintenance 
organizations, where these people are qualified and certified, permit 
nonphysician health care providers to participate in these networks.
  This is a critical concern in my State. I am sure it is a critical 
concern in many States.
  Another issue that clearly needs to be addressed here is access to 
specialists. That is an issue I know came up when we had the debate in 
the Health and Education Committee. An amendment was offered to correct 
that. I believe Senator Harkin offered that amendment; it was not 
successful. I believe it is a very important issue that needs to be 
revisited on the Senate floor.
  There are many people who need the care of a specialist. Whether it 
is a pediatrician, whether it is an oncologist, whatever the specialty 
is, those people should not have to go through a family practitioner 
prior to going to that specialist. We would try to correct that in the 
legislation as well.
  There are many other concerns we have with the bill that came out of 
the Health and Education Committee. I hope very much we get a full 
debate in the Senate on the deficiencies of that bill. I hope we get a 
chance to amend that bill.
  The American people have been anxious to see reform in this area now 
for two Congresses that I am aware of. I think for us to continue to 
delay and put off and evade this issue is not the responsible course 
for us to follow. Our constituents, the people we represent in our 
States, expect better of us.
  The people I represent in New Mexico expect me to do something about 
these very real problems they believe exist. In New Mexico, under the 
Republican bill that was reported out of the Health and Education 
Committee, there are almost 700,000 people who will not have 
substantive protections. In my State, there are 350,000 people who will 
not be covered at all if we pass the bill that came out of committee.
  Mr. President, I see my time is up. I appreciate the opportunity to 
make comments, and I yield the floor.
  Mr. SMITH of New Hampshire addressed the Chair.
  The PRESIDING OFFICER. The Senator from New Hampshire.

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