[Congressional Record Volume 145, Number 112 (Tuesday, August 3, 1999)]
[House]
[Pages H6954-H6956]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
MANAGED CARE REFORM
The SPEAKER pro tempore (Mr. Vitter). Under the Speaker's announced
policy of January 6, 1999, the gentleman from New Jersey (Mr. Pallone)
is recognized for 27 minutes as the designee of the minority leader.
Mr. PALLONE. Mr. Speaker, in just 3 days, this House will adjourn
without having brought to the floor the Patients' Bill of Rights, the
Democrats' legislation for comprehensive HMO reform.
I bemoan the fact that that is the case. I think that this
legislation and the need to address the issue of HMO reform is really
the preeminent issue that needs to be addressed in this House, in this
Congress, in this session of Congress.
I have to say that the Republican leadership since the beginning of
the year has made many promises with regard to the Patients' Bill of
Rights and the whole issue of HMO reform. First, the Speaker said that
we would follow the normal committee process and an HMO reform bill
would have hearings in the relevant committees and have a markup in
committee and come to the floor in the normal way, but that has not
happened.
Then, as Members know, in the other body basically the Democrats
forced the issue, forced the other body to bring up HMO reform.
Unfortunately, the bill that was finally passed was not real reform,
was ineffective, was a sham, but the impetus, if you will, that at
least some sort of HMO reform would be brought up in the Senate caused
the Speaker and the Republican leadership just a few weeks ago after
the Senate took action and had a hearing and had a markup on the floor,
basically forced the Speaker to say that a bill would come to the
floor, an HMO reform bill would come to the floor in the House of
Representatives sometime before the August recess.
Well, Mr. Speaker, the August recess begins probably this Friday and
Democrats have basically been pushing to achieve action here on the
floor for the Patients' Bill of Rights, our Democratic HMO reform. We
actually had Members come to the floor over here in the well and sign a
discharge petition that would force the Republican leadership to bring
up our Patients' Bill of Rights. One hundred eighty-three Members
signed that discharge petition. But now ultimately to no avail. The
Speaker, the Republican Speaker, just announced that no action will be
taken on the bill before the August recess.
I ask why? The answer, I think, is very simple. That is, because the
Republican leadership here in the House as well as in the Senate is a
captive of the insurance industry. The insurance industry does not want
a true HMO reform, a true comprehensive bill to come to the floor of
the House because, unlike the other body, they realize that if it does,
it will pass. Some of my colleagues, a handful of my colleagues on the
other side who are health care professionals, doctors, dentists, have
made the point that they will vote for a strong HMO reform bill,
something akin to the Democrats' Patients' Bill of Rights. When they
made that statement and basically indicated to the Republican
leadership that they would join with the Democrats in passing a bill,
well, all of a sudden this week we find that the Speaker and the
Republican leadership say, ``No, no, we're not going to bring a bill to
the floor. We can wait until the fall. We'll have further discussions.
No action will be taken now.''
I just want to commend the Republicans on the other side of the
aisle, those few, all of whom, I think, who have been most outspoken
are health care professionals, doctors, because they have stood up and
said that we need a strong HMO reform bill and they refuse to say that
the action taken by the other body meets that need. In fact, it does
not meet that need.
Mr. Speaker, if I could, I hope that during the August break and when
we come back in September that we will see a bipartisan coalition of
the Democrats, all of whom support the Patients' Bill of Rights, and
enough Republicans on the other side that will come together in a
bipartisan way to demand action on something like the Patients' Bill of
Rights so we can have true comprehensive HMO reform come to the floor
when we return in September.
{time} 2310
Mr. Speaker, if the House leadership is not willing to bring it up, I
think we will simply have to get every Democrat to sign the discharge
petition and join with some of the Republicans who are willing to sign
it to force the issue to make sure that the Patients' Bill of Rights or
some strong comprehensive reform like it comes to the floor.
As my colleagues know, Mr. Speaker, I just wanted to point out that
increasingly we are seeing every comprehensive report, every study that
is being done around the country about what the American people want,
what the health professionals want, what people see basically as common
sense reform with regard to HMOs, that we need some kind of action
taken.
There were two reports that came out just in the last week that I
wanted to mention tonight. One of them was basically a report, if you
will, where various doctors and health care professionals were
interviewed. It was a survey that found nearly nine in 10 doctors and
more than one in four consumers are having trouble receiving the
medical care and services they need within the context of HMOs managed
care, and as a result between one-third and two-thirds of the doctors
said the service denial resulted in adverse health consequences for the
patient.
The types of problems that we are seeing that myself and others have
documented on the floor about people who have had abusive situations
with managed care and with HMOs, this is becoming commonplace, and both
consumers, patients as well as doctors, are decrying the situation, and
I say to my colleagues and, I guess, to the American people as well,
why is it that the Republican leadership will not allow us to take
action when the majority of us in a bipartisan way would like to see
comprehensive HMO reform? And it always comes back to the same thing,
and that is the money spent by the insurance industry against this type
of comprehensive HMO reform.
The second survey that came out in the last week or so basically said
that last year 1.4 to $2 billion was paid to lobbyists to influence
politicians and policy, a 13 percent increase from 1997; and for the
second year in a row the insurance industry topped the list in lobbying
costs, nearly $203 million last year alone.
The Republicans basically on the leadership or amongst the Republican
leadership are bowing to the insurance industry which is spending
millions of dollars once again trying to defeat true HMO reform.
Mr. Speaker, I just wanted to, if I could, make reference to a New
York Times editorial that was in the New York Times on July 16 of this
year, and it just kind of sums up what is happening out there and why
we cannot see action on the House floor, and I quote. It says:
``There is no mystery here. Campaign money is dictating medical
policy in the Senate. The political system and especially the
Republican party is awash in money from the health care industry. As
President Clinton said yesterday, and this was back on July 16, GOP
senators could not support the Patients' Bill of Rights because the
health insurers will not let them do so. That is the bottom line, Mr.
Speaker.''
Mr. Speaker, if I could just use a couple minutes of my time to talk
about some of the comparisons between the
[[Page H6955]]
Patients' Bill of Rights, the bill that the Democrats and some of the
Republicans want to bring to the floor, versus the bill that passed the
Senate and the one that would have been considered, I believe, on the
floor pursuant to the Republican leadership if they thought that they
could get the votes to pass it. There is a real contrast, if you will,
between that Republican Senate bill and the Democratic Patients' Bill
of Rights, and let me just go through a few highlights of it, if I
could this evening.
The Republican bill, and I refer to the Senate bill, leaves more than
100 million Americans uncovered because most substantive protections in
the bill apply only to individuals enrolled in private, employer-based,
self-funded insurance plans, and self-funded coverage is typically
offered only by large companies. Only 48 million people are enrolled in
such plans, and of those 48 million only a small number, at most 10
percent, are in HMOs.
So the Senate Republican bill really does not help effectively
anyone, does not provide patient protections really to almost anyone.
What the Democrats insist on in the Patients' Bill of Rights and the
Republicans that support us have said is that all, all 161 million
privately insured Americans have to be covered by the bill, by the
patient protections.
Let me just give my colleagues some of the other examples that I
think are important. In the Democratic bill we have talked about the
prudent lay-person standard in the situation where you go to an
emergency room. This is so important. So many people come up to me and
say, if I have under my HMO, if I want to go to the local emergency
room, I cannot. I have to go to one maybe 20 miles away, 30 miles away,
50 miles away, and when a person is in extremis or has a problem and
has to go to an emergency room, they do not want to have to travel 20
or 30 miles away when the emergency room for the local hospital is
maybe only within a mile distance from where they are.
Well, under the Democratic bill, what we say is that an individual
who has symptoms that meet a prudent lay person, what the average
person would think is the need to go to the emergency room under given
certain circumstances, that that standard should allow them to go to
the local emergency room, the closest one, without pre-authorization,
and the insurance plan must cover the visit. The plan may not impose
additional charges for use of non-network facilities.
It is unclear in the Republican Senate bill whether that kind of
standard would apply. There really is not any prudent lay person
standard, if you will, in the Republican bill.
Most important in the Democratic bill is that we provide for adequate
specialty care. It provides the right in our Patients' Bill of Rights
to specialty care if specialty care is medically indicated. It ensures
no extra charge for use of non-network specialists if the HMO has no
specialist in the network that is appropriate to treat the condition.
I just wanted to mention a couple other things that I think that are
really crucial in terms of the differences between the Democratic bill
and what the Republicans passed in the Senate, and one of those most
important distinctions is on the issue of medical necessity. The issue
of medical necessity is basically whether or not a particular type of
care, operation, equipment, length of stay in the hospital will be
provided in a given circumstance if you get sick, and basically the
Republican Senate bill allows HMOs to define what is medically
necessary. No matter how narrow or unfair to patients, the HMO's
definition is their definition controls in any coverage situation
including decisions by an independent third-party reviewer.
The Democratic bill by contrast codifies a traditional definition of
medically necessary or appropriate means of service or benefit
consistent with generally accepted principles of professional medical
practice. In other words, what we are saying in the Patients' Bill of
Rights is that the doctor and the patient have to decide based on
standards that are used for most physicians in a given circumstance. It
is an independent standard, if you will, not defined by the HMO.
Most important also, the distinction on the issue of external
appeals. The Republican Senate bill allows the HMO to choose and pay
the appeal entity that decides the case. It also allows the HMO or
insured to define medical necessity, tying the hands of the independent
review entity and forcing them to defer to the HMO's definition. It
does not provide, the Republican bill, an appeal when most rights under
the bill are denied. For example, when emergency care is denied or
access to a specialist is denied, no appeal is allowed.
The Democratic Patients' Bill of Rights by contrast ensures the State
or Federal agency controls the process for choosing the independent
appeal entity, not the insurer.
{time} 2320
It ensures a de novo review, a fresh look at the facts. It ensures
the reviewer's decision is based on a statutory definition of medical
necessity, not the insurer's plan's definition, and the review of best
available medical evidence, and all denials of care are appealable.
Finally, the most important distinction between the Democratic
Patients' Bill of Rights and the Republican Senate bill is the ability
to hold HMOs accountable. Under the Republican bill, it maintains
existing Federal law that basically preempts state remedies, and the
only remedy under ERISA, which is the federally covered plans, is
recovery of the cost of the denied benefit.
For example, if a patient is denied a mammogram and dies of breast
cancer as a result, the only remedy under the Republican bill available
to the family is the recovery of the costs of the mammogram, not the
damages that result, including the death of the patient.
Under the Democratic bill, by contrast, the ERISA presumption of
State remedies, the ability to go to State court, only exists when the
actions of an HMO have killed--well, essentially what we are saying is
that that ERISA preemption is repealed, and you can go to State court
and you can seek damages and you can recover for the damage that the
HMO has inflicted, just like you would in any normal tort action.
Mr. Speaker, I think that there are crucial differences here, and I
think that ultimately what it comes down to is money. It is a very sad
day, but what we are seeing is the insurers increasingly spending a lot
of money on TV trying to get the word out that somehow what we are
trying to do with the Patients' Bill of Rights is not going to work,
that it is going to cost more money, that it is not going to achieve
the desired result.
The fact of the matter is that the American people are crying out for
comprehensive HMO reform. They want to see something like the Patients'
Bill of Rights passed. Again, I want to commend some of my Republican
colleagues, particularly the physicians on the other side of the aisle
who are saying, you know, we are practicing doctors. We see what
happens. We know there are abuses, and we want strong HMO reform
passed, something like the Democratic bill, and we will work together
with the Democrats to achieve a bipartisan proposal.
If I could just conclude tonight, I always like to talk when I come
to the floor about local people in my part of New Jersey who have had
problems with HMOs, because that is really what it is all about. We are
talking a little bit in the abstract here about what needs to be done,
but the bottom line is it is our own constituents coming to us and
saying we need HMO reform, we need something done because of what is
happening to them.
If I could just conclude tonight with a letter that was in the Asbury
Park press, which is the largest circulation daily in my district in
Monmouth County, New Jersey, and this was in the Asbury Park Press, a
letter to the editor on Thursday, July 15, from Jack Moriarty of Dover
Township. I am going to read part of it because I think it is so
telling.
He says,
Each time I must deal with my health maintenance
organization on any matter other than the routine and the
basic, problems continue. This is a system designed and
managed to restrict our access to medical care and to place
roadblock after roadblock in our way as we attempt to
circumvent that design feature.
On July 6th I sustained an eye injury while swimming when a
thumb with sharpened fingernail found its way into my eye. I
stopped
[[Page H6956]]
the bleeding, applied ice and went to bed. This morning there
was blood on the pillowcase, the pain had intensified, and my
vision was blurred. I reasoned this required an objective
medical evaluation to ensure there was no permanent damage.
Thus began my hassle for the day.
What followed was more than a dozen telephone calls to
various medical professionals and administrators to get
permission to go to the doctor and secure the required
referral for them to be paid. I knew what had to be done, but
what is the justification for wasting my time and causing me
anxiety and aggravation? As a professional, if I am not
working, I am not being paid. Consequently, the very real
financial loss I endure by sitting in a waiting room makes me
choose the medical visit option only as a last resort.
That day I wasted additional time and resources playing
phone tag all around the State trying to get some paperwork-
pushing clerk to give me permission to do what I knew to be
right. And, by the way, we pay for this, which is what truly
amazes me.
What should we do? I suggest we all write to our State and
Federal elected officials demanding that they return the
right of self-determination in health matters to us by
passing the Patients' Bill of Rights and similar state
statutes. It is no wonder the doctors are unionizing. Perhaps
the patients should too.
He was talking about an eye injury, but we just know that with the
case of eye injury or so many other serious problems that people face
the same reality.
All I am really saying tonight, Mr. Speaker, because this may be the
last opportunity we get to talk about this before the August break, is
let us bring up the Patients' Bill of Rights. Let us bring up HMO
reform. Let those Democrats and those Republicans, and I see my
colleague is going to come after me, the gentleman from Iowa (Mr.
Ganske), let us put together a bill I think that is very close to the
Patients' Bill of Rights that really provides comprehensive HMO reform.
This is what the public wants, this is what we keep hearing every day
from our constituents, and I know that I am going to use the time
during this August break to go out and explain to the public why we
need to bring this up on the floor of the House when we come back in
September.
I am confident when I see people like my colleague, the gentleman
from Iowa (Mr. Ganske) and others on the Republican side that are
demanding that we take action, that when we come back in September,
either through the means of a discharge petition or because the
Republican leadership finally sees they have to do something, that we
will see comprehensive HMO reform. But I am not going to rest, and I
know the gentleman from Iowa (Mr. Ganske) and a lot of us are not going
to rest until that happens.
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