[Congressional Record Volume 145, Number 133 (Tuesday, October 5, 1999)]
[House]
[Pages H9391-H9399]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




   TEXAS' EXPERIENCE WITH MANAGED CARE REFORM: A MODEL FOR THE NATION

  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 6, 1999, the gentleman from Texas (Mr. Green) is recognized for 
60 minutes as the designee of the minority leader.
  Mr. Speaker, I want to thank you and also thank our minority leader 
for allowing me to have this second hour tonight and follow the 
gentleman from Missouri. Obviously, I agree with the gentleman from 
Missouri (Mr. Talent) because Missouri has been the ``Show Me State'' 
all of my life, and for the next hour from Texas we are going to show 
him why he is wrong in his statements.
  Mr. Speaker, I would like to first talk about that in the last 2 
years in Texas we have had basically the same law that we are trying to 
pass here tomorrow and Thursday, and the examples offered by the 
gentleman from Missouri just do not hold water, at least they have not 
in the State of Texas.
  First a little background. Before I was elected to Congress, I 
actually helped manage a small business in Houston, a printing 
business. One of my jobs in that business was to shop for our insurance 
and to make sure our 13 or so employees had adequate coverage, because 
our company was under a union contract and we could buy it from the 
union benefit plan or buy on our own if it was either equivalent or 
better, and so we did that.
  And having experience of shopping for a number of years for insurance 
as both a manager and one who had to make sure we also paid the bills 
at the end of the week so we could afford it, I bring that kind of 
experience of a small business, even though I do not serve on the 
committee.
  The other thing I would like to mention, the gentleman talked a great 
deal of time about threats of suits for employers, and it is not in the 
intention of myself or the sponsors of the Norwood-Dingell bill that 
employers will be responsible unless they make those medical decisions. 
I have offered in my own district and even here in Washington to the 
National Association of Manufacturers, give me the language and we will 
sponsor it as an amendment to make sure that employers are not held 
liable unless they are putting themselves in the place of a health care 
provider or health care decision-maker. That is saying to their 
employees, No you cannot do this or you cannot do that.
  Again, having been a manager, I know that sometimes employers and 
businesses can afford a Cadillac plan that pays for a lot. Sometimes 
they can only afford a Chevy plan that does not pay as much. But just 
so they are getting what they are paying for, for their employees; and 
that is what I think the managed care reform and HMO reform issue is 
about and it has been about for the last 2 years.
  Let me follow up too, the gentleman had mentioned that this bill does 
not cover Federal employees. Well, right now as a Federal employee or 
as a State government employee, we have the right to sue our insurance 
company. We have the right under our plan. All we are trying to do with 
this bill is to provide to all the other Americans some of the same 
rights as Members of Congress have. And also it covers the Federal 
insurance plans, whether it be BlueCross or whatever other plans, 
because there are so many of them that the consumer would have the 
right to go to the courthouse ultimately.
  So there was a lot of things the gentleman said during his time; and 
hopefully during the next hour we will hear a lot of folks who have 
real-life experiences from the State of Texas, because we have had a 
Patients' Bill of Rights under State law for over 2 years, and it only 
covers insurance policies that are licensed by the State of Texas.
  That is why we have to pass something on the Federal level, because 
60 percent of the insurance policies in the district I represent come 
under ERISA, come under Federal law. Even though the State of Texas 2 
years ago passed these very same protections, we have to do it on the 
Federal level to cover the citizens of Texas who do not come under the 
State insurance policy.
  In fact, this next hour hopefully we will have a lot of folks, and 
people who like to hear Texas accents will hear them for the next hour, 
because we will talk about the Texas experience with a little bit of 
help from some of our Texas colleagues and some from other parts of the 
country.
  Mr. Speaker, let me address some of the issues. The insurance 
industry and managed care organizations and HMOs have been repeatedly 
trying to scare the American people saying the bill that we are going 
to vote on, the Norwood-Dingell bill, would dramatically raise premiums 
and force employers to drop health insurance. I even heard one of the 
special interest groups say that this number would be as high as 40 
percent.
  Mr. Speaker, once they have spread all of this inaccurate 
information, let me give the experience that not only we have in Texas 
but also from the Congressional Budget Office. The Congressional Budget 
Office is a nonpartisan agency. They analyzed the Patients' Bill of 
Rights and said that the best they could determine, that the cost to 
the beneficiaries under the Patients' Bill of Rights may cost $2 a 
month. That is less than the cost of a Happy Meal to provide fairness 
and protection and accountability.
  But in the State of Texas, even if one does not agree with the 
Congressional Budget Office, and sometimes I disagree with their 
estimates, we need to look at real-life experience for the last

[[Page H9392]]

2 years in Texas. Again, Texas passed this same legislation in 1997, 
and it became effective in September of 1997; and so we have had over 2 
years of experience.
  In Texas the patient protections included a consensus HMO reform bill 
that had external appeals and also the accountability issue, the 
liability. And over the first 2 years there has been no significant 
increase in premiums. In fact, the analysis shows that the first 
quarter of 1999, premiums in Dallas and Houston have increased about 
half the national average.
  And we know there are lots of things that go into increases in 
premiums, particularly with HMOs because of some of the problems they 
have now. They tried to expand so rapidly, and now they are having to 
contract and they are also increasing their premiums; but they are 
doing it around the country.
  So in Texas we have not seen any increase in 2 years in health 
insurance premiums attributable to the Patients' Bill of Rights. In 
some cases it is attributable to the increased cost for prescription 
medication or for other reasons. Health care costs in Texas have 
increased 4 percent in the first quarter compared to 8 percent in the 
rest of the country. These estimates are based on reality provided by 
the Texas Medical Association, and it is more than a theoretical study 
that should be our guide for the HMO debate.
  Moreover, beyond the slim cost of the increase, there has been no 
exodus by employers to drop health insurance coverage, nor has there 
been any exodus by patients to go to a courthouse.
  Mr. Speaker, in an earlier life I was licensed to practice law, and I 
have to admit we do not have any shortage of plaintiff's lawyers in 
Texas who will go to court if they have that opportunity. But, again, 
in the 2 years we have had it, we have not seen more than four suits, 
and I will talk about that later in the hour if we get to it. But four 
lawsuits in Texas. Although we have a fifth one that may be out there, 
but one of them was by one of the insurance companies challenging the 
law.
  So what Texas residents have is health care protections that they 
needed, and they are enjoying them now; and as Members of Congress we 
owe the duty to provide those same protections on a nationwide basis. 
Unfortunately, instead of recognizing the affordability and value of 
the consensus bill tomorrow, the Norwood-Dingell bill, our Republican 
leadership seems poised to repeat last year's actions and come up with 
imitation bills, and we will talk about those over the next hour also.
  But I see my colleague, the gentleman from San Antonio, Texas (Mr. 
Rodriguez). Before he came to Washington, he served in the Texas 
legislature for a number of years. He knows it is not easy to pass 
major legislation there unless it is consensus. In fact, the gentleman 
was in the State legislature in 1997 when Texas passed that law, and I 
yield to my colleague from San Antonio.
  Mr. RODRIGUEZ. Mr. Speaker, as a State representative from Texas I 
know the situation well, and we in Texas are known for the blue 
bonnets, the Texas barbecue and the champion San Antonio Spurs, the 
beautiful Rio Grande; but we are also known for the changes that we 
have made in managed care reform.
  Two years ago, Texas was fortunate to have the foresight to enact and 
implement its own managed care reform. The days and nights prior to 
that passage are very similar to tonight and this week here in the U.S. 
Congress where the discussions are over one side that says that health 
care costs are going to skyrocket and the other side, the good side, 
saying that we cannot compromise the health care even at the expense of 
losing one individual for the almighty dollar.
  I am of the thinking that health care should not be about 
compromising anyone's life, but rather about health care and promotion 
and education.
  Two major issues that have helped address the health care concerns of 
consumers in Texas are the external review process and the ability to 
hold an HMO liable through a lawsuit. Through the external review 
process, hundreds of individuals in Texas have the opportunity to have 
their cases heard by an outside party. The decisions are made by the 
doctors chosen by an independent medical foundation. The doctors review 
the cases and render a decision based on that information.
  The best part of it is that it is done in a timely manner. In Texas 
we take pride in that we mandate the review to occur within 14 days and 
in cases of life or death, for them to move within 3 days in making 
those life-threatening decisions.
  What is even better is that what the doctor says goes. It is not the 
way we have it right now where an accountant or an insurance person is 
the one dictating what should happen versus what the doctor is saying.
  Nearly 600 cases have been handled in this manner through the 
external and internal review in Texas and guess what? Half of them have 
been ruled on behalf of the patients. So it has gone 50-50. So we feel 
it has been a very fair system that has been working.
  For the States that are not fortunate to have this law, I believe 
that we need to pass Federal legislation here on the Federal level that 
will ensure that all Americans, not just Texans, have that opportunity 
to have a due process.
  A testament to the fact that the Texas' system works is evidenced 
through the story that was told in an article by the U.S. News and 
World Report in March. The story is about a young boy, little Travis, 
who had a medical condition that came from the fact that he had 
difficulty breathing. And I was hearing the comments by the previous 
gentleman out here talking about the external review process being 
useless. The gentleman should tell that to little Travis. That was the 
difference between life and death.
  Because of his condition, his doctor asked the HMO to authorize an 
on-duty nurse. Hard to believe, but the HMO later refused to pay for 
that nurse. An internal review of the case by the HMO doctor ended up 
upholding the HMO decision, so the first internal review they sided 
with the HMO. But thank God the next step was the external review. An 
outside doctor reviewed the case and found that little Travis was, 
indeed, entitled to that nursing care. And this is a case with the HMO 
playing with a little boy's life and it is a serious situation.
  Mr. Speaker, thank God he lived in Texas. Each time he stopped 
breathing, he and his parents knew that he was within moments of 
suffocating. Having a nurse on hand part-time provided the necessary 
care for little Travis who needed it when his parents were not around. 
The external review process works for many, but for those that do not 
have that access, it cannot work. We have got to assure that those 
individuals have access to that opportunity.
  For the positive happening for little Travis's case, it is great. But 
there are too many out there who still suffer under those situations.
  I would also like to mention that I believe that the ability to sue 
HMOs in Texas, there was a lot of talk about the fact that there was 
going to be a lot of lawsuits and that everyone was going to be sue 
happy. This is not the case, and we have had it there over 2 years. So 
the reality is, and I will challenge my colleagues, do not be fearful. 
It is not going to happen. In the State of Texas only five lawsuits 
have been filed. Think about it. It is a State of 4 million individuals 
that are in managed care with only five lawsuits that have been filed.
  Members can say what they will about managed care reform, but in 
Texas it has been working. It is alive and well and serving the best 
interests of those individuals under managed care.
  Mr. Speaker, I want to also just congratulate my fellow colleagues 
and I yield to the gentleman from Texas (Mr. Green).
  Mr. GREEN of Texas. Mr. Speaker, before my colleague leaves, and I 
appreciate the gentleman being here, let me give some updated 
information on the appeals process in Texas. As of August of 1999, 
during the month of August there were only 23 requests for the 
independent review. But from November 1 of 1997 to the present, the 
total requests were 626 appeals in those 2 years. 610 of them were 
completed. The number they upheld was 47. The number of overturned was 
46. And partially overturned was 42. So what we are seeing is about 50-
50 for the external appeals process.
  Again, they are not clogging up the process, but what they are doing 
is

[[Page H9393]]

making sure people have a right to go outside and ask for an appeals 
process. They do not really want to go to court in Texas. The 2 years 
we have had that there have been so few lawsuits, but we have had a lot 
of appeals and people are getting the health care that they need and 
these appeals are being done quick. They ask for them, and they can 
complete them almost within that 30 days.

                              {time}  2045

  So instead of waiting for 2 years to get to the courthouse, they are 
actually able to get that health care that they need. That is what is 
so important.
  Again, in the last 2 years since November, a little less than 2 years 
because the actual appeals process went into effect November 1 of 1997, 
again half the decisions are in favor of the insurance company, and 
about a little over half are in favor of the patient.
  So what that means is that I feel much more comfortable as a patient 
that, instead of the chance of a flip of the coin, that we have a 
better percentage of upholding HMO's decisions or managed care 
decisions if they had it. But they are losing about half of them in 
Texas, actually a little more than half.
  So that is why it is so important that we pass on a national level a 
real strong external review process backed up by the accountability.
  The reason we do not have the lawsuits in Texas and what is estimated 
by the people at home is that we have a good, tough external review 
process where people get their case heard, they get their health care; 
or they lay out their case, and they do not receive their health care 
because they are not entitled to it.
  It is tough to go to court after one has been through that external 
review process and find out that one really does not have enough that 
even an independent review does not do it.
  What worries me is that the Republican leadership this year, with 
what we are going to do tomorrow, there is going to be a number of 
other plans that will be considered, every one of them is found lacking 
in what we need to do.
  It is so important that we adopt the Norwood-Dingell bill, it is a 
consensus bill, a bipartisan bill, and attack or defeat the poison 
pills that are really there just to cloud the issue and not provide the 
health care that we need.
  Let me talk a little bit about the concern about one of the 
amendments to move these suits to Federal court. Again, in Texas, they 
go to State court. Again, having practiced law, I do not have a lot of 
Federal experience in Federal courts, but there was a reason for that. 
I would much rather go before judges that are elected than judges on 
the Federal level.
  My worry is, if we move these cases to Federal court, that they will 
be there for years and years and years. If they have to go to court, 
one needs to go the quickest one can if one has to.
  In Texas, we have not had but three or four cases, maybe five at the 
most, in 2 years. That is why moving to Federal court in one of the 
amendments tomorrow would be wrong. It would actually be against the 
patients ability to have justice.
  Mr. Speaker, I yield to the gentleman from East Texas (Mr. Turner). 
Again, the gentleman from Texas (Mr. Turner) served as a State 
representative in Texas, State Senator, in fact was a State Senator in 
1995 when the first Patients' Bill of Rights was passed by the 
legislature and vetoed by the Governor at that time. But in 1997, he 
let it become law without his signature. I am glad Governor Bush did 
that in 1997 and saw the error of his ways.
  Mr. TURNER. Mr. Speaker, all three of the Texans here tonight served 
in the legislature, and we all have fought for this issue in our State 
legislature, and that is one of the reasons we feel so strongly about 
the fact that the protections that we have provided in law for all 
Texans should be protections that every American enjoys.
  I am glad to see the gentleman from Iowa (Mr. Ganske) here tonight 
who is a medical doctor who has fought hard on the Republican side to 
help pass the Norwood-Dingell bill, also referred to as the Bipartisan 
Consensus Managed Care Improvement Act, which I think aptly describes 
the bill that we are trying to pass because it has been crafted with 
bipartisan support.
  It has been worked on for many, many months. Those who have worked on 
it have been responsive to any concern that has been expressed about 
it. We are convinced that it is the right bill, and this is the right 
time to pass these protections for all Americans.
  As the gentleman from Texas (Mr. Green) mentioned, I was in the Texas 
Senate in 1995 when the Texas legislature passed the first patient 
protection legislation in the country. That bill, unfortunately, was 
vetoed by Governor Bush.
  The legislature came back in Texas in 1997 and passed similar 
legislation once again, broke it down into four separate bills. Three 
of those bills were signed by the Governor. The fourth he allowed to 
become law without his signature.
  Unfortunately, when we passed the bill the first time in 1995, even 
though we passed it with overwhelming support, over 90 percent of the 
members of each house voting in favor, we passed it at the end of the 
session, and the Governor was able to veto it without an opportunity to 
overturn the veto.
  But we are here tonight to try to provide the same kind of 
protections for all Americans that we provided for Texans in 1997.
  When we passed that bill in 1995 and again in 1997, we had no idea 
that it would not apply to all Texans. But an insurance company went to 
court shortly after we passed our legislation and it had become law, 
and the courts ruled that a Federal law preempted our State law, and 
that all insurance plans covered by the ERISA law that the gentleman 
from Texas (Mr. Green) referred to at Federal law meant that those 
protections that we had provided in our State legislature did not apply 
to all of those plans that were multi-State plans covered under the 
Federal ERISA law.
  So we have a very awkward situation all across the country today 
because State after State after State have passed patient protection 
legislation to protect their patients. Yet, we find there is a Federal 
law standing in the way that has basically meant that about 40 percent 
of all the folks that are insured in this country under managed care 
are not covered by the basic patient protections that their State 
legislatures have passed over the last 2 and 3 years.
  So the Norwood-Dingell bill is designed to change that, to be sure 
that all people enrolled in managed care plans have the same 
protections that we believe are just common sense.
  Things like ensuring that a patient can go to the nearest emergency 
room when he has an emergency. Rights like being able to go to the 
doctor in your own town rather than going to a doctor in an adjoining 
community. Rights like having access to go to a specialist when one 
needs one when one's doctor says he wants to refer one to a specialist. 
Basic rights like not being forced to change doctors and hospitals 
right in the middle of one's treatment just because one's employer 
happens to change their managed care company. Basic protections like 
making sure that medical decisions are made by doctors, not by 
insurance company clerks.
  These are the basic protections that we provided in Texas in 1997, 
and these are the basic protections that we want to provide for all 
patients across the United States in the Norwood-Dingell bill.
  One of the things that always amazes me, we faced it in 1995 in 
Texas, we faced it in 1997 in Texas, and now we are facing it here in 
Washington in 1999, with the managed care companies saying that the sky 
is going to fall if we pass this legislation. They are claiming that 
health care costs are going to go up.
  They had even gotten the folks who carry their insurance for the 
employers and the business community all worked up and speaking out 
against this bill because they think the cost of insuring their 
employees is going to go up.
  As the gentleman from Texas (Mr. Green) pointed out, the 
Congressional Budget Office says the cost of this legislation would be 
less than $2 a month per patient. Very small cost in my judgment to 
protect patients.
  When it comes right down to it, business people in this country care 
very much about their employees and their employees health care. I 
think most businessmen and women understand

[[Page H9394]]

that, when they sign up with an insurance company to provide health 
insurance for their employees, they want a plan that is going to take 
care of those employees.
  Right now, we have a situation where these basic protections are not 
guaranteed, and some managed care companies, I understand, today, are 
already providing these, but many are not.
  I really think it would be a lot easier for the average businessman 
or woman in selecting health insurance for their employees to know that 
every plan, no matter what proposal is laid on their desk, and no 
matter what price is offered to them for coverage of their employees, 
that they know these very basic common sense protections are in every 
plan.
  Right now, I think health care is in turmoil in this country. Doctors 
are not happy, having to make ten and twenty phone calls to a managed 
care company just to get something approved that they know their 
patient needs.
  I have talked to these doctors. They are really frustrated with the 
system as we know it today. I have talked to patients who wonder why 
they cannot get simple care from a specialist simply because their plan 
denies them access to a specialist. They do not understand that kind of 
treatment. They do not understand why they cannot go to an emergency 
room and have a doctor in the emergency room make a decision as to 
whether or not there is an emergency rather than having to get on the 
phone and call the insurance company clerk in some far-off city and 
find out whether or not they can receive emergency treatment. Those 
kind of basic protections patients deserve. Employers who want to take 
care of their employees want this kind of protection for their 
employees as well.
  The truth of the matter is, if we are going to have a health care 
system in this country that works for everybody, the employers, those 
who are insured, the doctors, and other health care providers, we need 
to pass this legislation, because the further we go down the road and 
find patients being abused and managed care companies doing a shoddy 
job of rendering care, the more we are going to undermine what has 
become known for many years as the finest system of health care in the 
entire world.
  So what we are really fighting for here tonight is, not only the 
protection of patients, individual patients and their families, but we 
are fighting to preserve the finest quality system of health care the 
world has ever known. We need the stability in health care that this 
legislation will provide.
  Now, the big debate is over this issue of accountability. Should a 
managed care company be accountable for their decisions? Well, frankly, 
I think that the answer is pretty obvious. Certainly they should be 
accountable. All of us are accountable for our decisions. All of us can 
end up in court if we are negligent or make a mistake.
  Frankly, the rule really is pretty simple, I think, that should be 
applied in this debate; and that is, when health insurance companies 
make medical decisions, they should be accountable in the same way that 
one's doctor is accountable when he makes a health care decision. We 
all know in this country that, if a doctor happens to make a mistake in 
the operating room, happens to do something that causes injury to one 
or one's children, that one can go to the courthouse and seek redress, 
seek recovery of injuries. A child who is paralyzed for life because of 
a mistake of a medical provider, that family can go to court, be 
compensated in damages. That is what our American system of legal 
justice guaranties all of us.
  If a managed care company makes a decision that denies one health 
care when it is covered under the plan, now if it is not covered, it is 
just not covered and it is not going to be paid for, but if it is 
covered and, in their review of medical necessity they say one does not 
need that care, one's doctor is standing there all the while saying, 
yes, my patient needs that care, and the managed care company says, no, 
and one goes under the Norwood-Dingell bill and appeals that 
internally, and one appeals that externally, and one has got a 
decision, and one finds out that still the decision of the managed care 
company was wrong, every American ought to have the right to go to the 
courthouse and seek their damages. That is what the American system of 
justice is all about.
  So if a doctor makes a mistake, he knows he has to go to the 
courthouse or could go to the courthouse. That is why he buys 
malpractice insurance. What is wrong with asking managed care companies 
to also carry malpractice insurance? Every profession in the United 
States, every individual who is a doctor, a lawyer, an engineer carries 
malpractice insurance. It is a wonderful thing, insurance. We spread 
the risk of loss among all of us to protect each of us individually.
  Why should we in this hallowed hall of the House of Representatives 
declare this week that the only group in America that can never be held 
accountable in a court of law is a managed care insurance company? That 
is wrong, and we cannot let that happen.
  I think we have a good bill. It ensures accountability, and it is 
drafted in a fair way. The only way one can go to court and sue a 
managed care company under this legislation is after one has gone 
through the internal and the external review procedure.
  In Texas, the sky has not fallen. In Texas, we have the right to go 
to the courthouse. As the gentleman from Texas (Mr. Green) pointed out, 
there has only been a handful of lawsuits. In fact, there has only been 
five filed in Texas.
  The author of the legislation that did pass in 1997, Senator David 
Sibley, a Republican, good friend of mine, carried that bill. He says, 
and I quote, ``The sky did not fall. Those horror stories raised by the 
industry just did not transpire.'' Dave Sibley, the sponsor of the bill 
is a lawyer, former doctor, an ally of Governor Bush.
  Even Governor Bush acknowledged in the Washington Post September of 
this year that he believes the law in Texas has worked well.
  I believe every American deserves the protection that we fought to 
give Texans in 1997. This legislation is long overdue.
  I appreciate so very much the gentleman from Texas (Mr. Green) 
reserving this hour to give us the opportunity to talk about this 
important bill.
  I believe the American people want this legislation. I believe the 
employers of this country who believe in protecting their employees 
want this legislation. I believe we need to ensure the long-term 
stability of the best health care system the world has ever known, and 
this bill moves us along the road in ensuring that.

                              {time}  2100

  Mr. GREEN of Texas. I thank my colleague. Again, having served with 
the gentleman both in the State legislature, the Senate and the House, 
and now in the Congress, we have gotten to that point. Because as 
Texans we brag all the time about how great our State is, and sometimes 
we puff it up a little bit; but we are not puffing on this legislation. 
This has worked in Texas, it has provided the benefits, all the 
accountability, the outside appeals process, the anti-gag orders so 
doctors can actually talk to their patients; and it has allowed 
patients to go to the closest emergency room without having to drive by 
closer emergency rooms.
  So there are so many things I am proud of. Always proud to be a 
Texan, but particularly because of this legislation.
  Mr. Speaker, I now want to yield to another good friend who I serve 
with on the Committee on Education and the Workforce. And I might just 
mention that her State, California, just recently passed a series of 
bills just similar to this, and I know Governor Davis signed them into 
law about a week ago.
  I yield to the gentlewoman from California (Ms. Woolsey).
  Ms. WOOLSEY. Mr. Speaker, I thank the gentleman from Texas and would 
like to compliment him for sharing with us tonight the experience of 
Texas in health maintenance organization reform. It is particularly 
appropriate that we are here tonight, because tomorrow, after fighting 
for more than 2 years, the House actually has a real shot at passing a 
managed care reform bill. The American people want this. In fact, they 
are demanding that we pass managed care reform, and I am particularly 
glad that this House is finally rising to the occasion.
  I am also pleased that the Democrats and Republicans have worked 
together

[[Page H9395]]

to support a common sense patient protection bill. It is bipartisan. It 
is called, in fact, the bipartisan Dingell-Norwood bill. And any of my 
colleagues who are saying the Dingell-Norwood bill will not work are 
very, very wrong; and they have to review what has gone on in Texas. If 
they will pay attention to the Texas experience, they will know that 
the sky will not fall if we take care of patients when they are covered 
by a health maintenance organization.
  I would like to share also some of the recent accomplishments from my 
State, the State of California, where just last week Governor Gray 
Davis signed landmark legislation that put health decisions back in the 
hands of 20 million patients and their doctors. This comprehensive 
package is made up of 19 bills, and it will absolutely overhaul the way 
HMOs do business in California.
  A key piece in the package includes managed care accountability. The 
State now has a new Department of Managed Care, which will act as a 
watchdog for patients with HMO providers. This State agency is devoted 
exclusively to the licensing and regulation of health plans. The 
legislation will also include a new Office of Patient Advocate, which 
will assist in enrollees with complaints, provide education guidelines, 
issue annual reports, and make recommendations on consumer issues.
  With this legislation, Californians now have the right to an external 
review of their health care coverage decisions by an independent group 
of medical experts. By January 1, 2001, this external review program 
will dispute claims when a patient's treatment has been delayed, 
denied, or modified.
  I am proud to tell my colleagues that the package also includes HMO 
liability, giving Californians the right to sue their HMO for harm 
caused by failure to provide appropriate and/or necessary care. This is 
a much-needed remedy for any family harmed by a decision made by the 
HMO or by a clerk working for the HMO. Any decision that would delay, 
deny, or modify medically necessary treatment will be under scrutiny.
  In addition, Californians can look forward, under this legislation, 
to new consumer protections. These protections will include a second 
medical opinion, upon request for patients; expanded patient privacy 
rights will prohibit the release of mental health information, unless 
patient notice is provided; and a prohibition on the selling, sharing 
or use of medical information for any purpose not necessary to provide 
health care services.
  This legislation in California sets procedures for HMOs to review a 
treatment request by a doctor to ensure that timely information and 
decisions regarding a patient's treatment needs come forward at the 
right time. Patients will be informed of the process used by a doctor 
when that doctor determines whether to deny, modify, or approve health 
care services.
  In fact, Californians are also guaranteed the right to hold an HMO 
accountable by seeking punitive damages in court if and when harm comes 
to a patient. Congress should take note that if California can do it, 
and if California can pass similar reforms as those in the Dingell-
Norwood bill, then, for Heaven's sake, we can pass the same type of 
legislation for our country. Because California has the population and 
the economy of a country in and of itself. California has 33 million 
people, and the challenge has been met.
  Tomorrow, the Dingell-Norwood bill is a good starting point for the 
managed care reform we need in this Nation. The Norwood-Dingell bill 
provides Americans the ability to choose their own doctor, to get 
emergency room care, to see a specialist, and unleash their doctor from 
HMO gag rules on treatment options. And especially important for 
Americans is that the Dingell-Norwood bill holds HMOs accountable.
  This bill has bipartisan support as well as support from more than 
300 health care and consumer groups. I am convinced that this 
bipartisan bill deserves a clean up or down vote. It does not need to 
have any amendments.
  The American people are counting on us to take heed of the Texas and 
the California accomplishments in HMO reform, so let us focus tomorrow 
on the consensus we have built. Let us accept no substitutes to the 
vital patient protections in the Dingell-Norwood bill, and let us again 
pay attention to what other States have been able to accomplish, such 
as Texas.
  We are going to hear from Wisconsin and North Carolina, and we will 
see that the people in this country are telling us that they want and 
they demand health care reform and managed care reform, and we must 
heed this and go forward tomorrow.
  Again, Mr. Speaker, I thank the gentleman from Texas for having this 
special order tonight.
  Mr. GREEN of Texas. I thank my colleague from California. It is great 
to serve with the gentlewoman on the Committee on Education and the 
Workforce.
  And the gentlewoman is right. In the California experience, it is 
both rural and urban. Just like Texas is rural and urban. So it will be 
a great example of making it work in this country from one coast to the 
other coast. We need to make sure that we have real patient care and 
managed care reform.
  I would like to now yield to my colleague, the gentlewoman from North 
Carolina (Mrs. Clayton), who came in the same class as I did, in 1993.
  Mrs. CLAYTON. Mr. Speaker, I thank the gentleman for yielding to me 
and arranging for this special order for us to talk about the provision 
in the bipartisan manage care reform bill known as the Dingell-Norwood 
bill. I am pleased to have this opportunity to discuss it before we 
debate it on the floor tomorrow.
  I am proud to be one of the original cosponsors of the bill and to be 
an advocate for it. I also serve as the co-chair of a health task 
force. And as an individual coming from a rural area, where a lot of 
our patients are still uninsured, I can also be a very strong advocate 
for this bill, which gives protection for managed care.
  We have just heard recently that, indeed, the uninsured have 
increased. And I am concerned about that because many of the people in 
my district are indeed part of that uninsured. So my support for the 
Norwood-Dingell bill does not diminish my advocacy for making sure that 
we find ways of insuring more of the uninsured. Indeed, it was almost 
predictable, because we did not do what we could have done earlier when 
we had the opportunity to look at health care reform that, indeed, this 
rise would occur. I think we have an opportunity to speak to that, but 
I do not think one negates the other. So as one who is an advocate for 
making sure the uninsured are also protected, I strongly advocate the 
provisions of the bipartisan bill.
  This bipartisan bill gives increased access to patients in a variety 
of areas. It says first that those who have emergencies should not have 
to have prior approval. They have immediate access for emergency 
treatment, even at the emergency hospitals of their choice. They should 
not have to be shifted around to various hospitals in that area.
  It also increases the protections for women who want to be protected 
under this bill. It increases that access. It also increases access for 
those patients who have special needs and need to have specialty 
providers in treating their conditions. So the access is enhanced for 
those who have a managed care program.
  Let me just say parenthetically that there are, indeed, good managed 
care programs. This is not to negate where there are positive managed 
care programs. This is to improve and to give some minimal standards 
that the managed care programs that people have should be dependable, 
they should be held accountable for their care, and they should be 
aware of defining medical necessity. All of these are to ensure that 
whatever plans we have, they should be the kind of plans that patients 
can have confidence in.
  I cannot understand why it is that people are afraid of being held 
accountable. If they say they are going to provide certain services, 
they should be honored to say that they will be held accountable for 
those services. Indeed, being held accountable allows a review process. 
And if in the review process arbitration does not work out, the patient 
has the right to go to court. They have that opportunity.
  Also, the bill protects the provider. And this is very, very 
important, because many doctors have said they

[[Page H9396]]

 have been under a gag rule. They cannot tell their patient all of the 
options that they know would be good for their health care. So they are 
prevented from telling them options that would perhaps provide the 
right medical treatment because it is not the most economical treatment 
in that area. The anti-gag provision in this bill prevents that. It 
means that we protect the providers and we assure the confidentiality 
and the professional care between a doctor and their patient. And the 
patient also has a right in the selection of the provider that is 
adequately trained in those areas.
  All of these provisions go to making the managed care program 
stronger for patients who have to have these insurance provisions. So I 
want to say to our colleagues that as we debate this bill tomorrow, 
that any options or amendments or substitutes that are being offered, 
and offered in glorious terms as being a cure-all for health care, are, 
indeed, poison pills. And if we are ensuring that patients have good 
health care, we have to vote down each and every one of those 
substitutes as well as those amendments.
  So I urge my colleagues to give Americans a choice and, indeed, to 
give them a clean bipartisan Patients' Bill of Rights. And I thank the 
gentleman once again.
  Mr. GREEN of Texas. Mr. Speaker, I thank the gentlewoman, and I want 
her to know that I am aware of the devastation in the gentlewoman's 
district, we talked about it today, from the hurricane. In Texas, we 
are familiar with hurricanes damaging our coast.
  I would like to now yield, Mr. Speaker, to a new Member, a very 
active new Member from Wisconsin. And like I said earlier, we have 
people from not only the West Coast in California but North Carolina, 
on the East Coast, and of course in Texas, and also now the gentlewoman 
from Wisconsin (Ms. Baldwin), and I yield to her.
  Ms. BALDWIN. Mr. Speaker, I thank the gentleman for organizing this 
special order.
  Time and time again we hear how the United States has the best health 
care in the world, but that does not matter if a health plan denies 
meaningful access to the health care system when individuals are sick. 
Managed care was designed to provide the best health care available at 
a lower cost. But what does it matter if in addition to our health 
insurance premium we still have to pay sizable, sometimes enormous out-
of-pocket costs for needed tests or treatments that our health plan 
will not cover.

                              {time}  2115

  There was a time when we paid our health insurance premiums trusting 
that when we got sick our doctors would make his or her recommendations 
for treatment and that our health insurance would pay for that 
treatment. This just does not seem to be the case any more. We no 
longer trust that the best medical decisions are being made in this 
system, and too many people with health care coverage are being driven 
into debt because necessary treatment is not being covered by their 
managed care company.
  As my colleagues know, families in my community in Wisconsin feel 
very anxious about the state of health care in America. They are 
increasingly concerned that medical decisions are being made by 
accountants, by managers, by other insurance company employees instead 
of the doctors and the patients making the decisions; and too often 
profit is taking a priority over a sick patient in need.
  Patients are losing faith that they can count on their health 
insurance plans to provide the care that they were promised when they 
enrolled and faithfully paid their premiums.
  We have all read the stories, and those of us who have the privilege 
of serving here have often heard painful firsthand accounts from 
families and individuals who sent us here to fight for them, to 
represent them, people who were denied care or services by managed care 
providers.
  I recall reading an article last winter in Wisconsin about a young 
man struggling with known Hodgkin's lymphoma. He was told by his doctor 
that the most promising and potential cure, a bone marrow transplant, 
was not going to be covered by his plan. Chemotherapy in his case would 
only slow down the disease. The prognosis they gave him was up to 10 
years to live, and according to this prognosis 5 of those years his 
cancer with chemotherapy would likely to be in some sort of remission. 
However it would likely come back sometime within the second 5 years 
and get steadily worse. He underwent a round of chemotherapy because 
that is what his insurance company would cover. In his case his earlier 
prognosis was not accurate. It did not even give him 5 years of 
remission. Instead the cancer re-appeared in only 8 months.
  Now this was a highly publicized case in my State, and because of the 
negative publicity and the public outcry, his insurance company 
relented and permitted the bone marrow transplant admitting belatedly. 
According to the medical literature, this was not a treatment that was 
regarded in the medical literature as experimental. Unfortunately, it 
was too late for this 41-year-old young man, and he passed away earlier 
this year.
  But people should not have to wage publicity campaigns to shame their 
health care plans into covering medically necessary procedures. They 
should have appeals processes, not publicity campaigns.
  I was deeply disturbed when I heard of another poignant case in my 
district. This is a story of a man who is in the hospital. He was 
recovering from a procedure, and he received a phone call from the 
representative of his HMO in his room saying that if he stayed in the 
hospital room past midnight, his insurance company was not going to 
cover it.
  Now this gentleman had just gotten out of intensive care, and it was 
all he could do practically to reach over and pick up the phone, and I 
just think how frightening this experience must be for the patient, for 
the family and for those who hear of it and wonder whether their 
insurance, their health care plans, their managed care plans are really 
going to cover them.
  As my colleagues know, having a recourse when something goes wrong is 
so vital, and health plans should not be allowed to escape 
responsibility for their actions when their decisions kill or injure 
patients.
  Six years ago we were promised reform that would guarantee every 
American the health care they needed. That vision was not realized. In 
this time of economic prosperity, in this time of rapidly changing 
medicine, in this time of political opportunity, I think it is time 
that we renew our commitment to the health care security for all; and 
when I think about what that means, I believe that health care security 
for all encompasses both the notion that we must cover the uninsured 
and the effort to fully protect those who already have health care 
coverage but find that is not the security blanket that they thought 
they had purchased.
  Many States have taken steps to establish some of these patient 
protections. We heard about Texas and California earlier this hour. 
Unfortunately, most States have only passed a few of the protections 
contained in this bill before us, and there are many gaps that remain 
to be filled. Even States with strong consumer protection laws cannot 
cover a large number of their residents, the 50 million Americans who 
receive their insurance from a self-insured employer plan under 
ERISA and are not protected under State law.

  We need comprehensive Federal legislation that provides a minimum 
standard of patient protections for all Americans. The Norwood-Dingell 
bill will do just that, and I hope tomorrow that this Congress rises to 
the occasion to pass this vital legislation.
  Mr. GREEN of Texas. Mr. Speaker, I appreciate our colleague from 
Wisconsin in being here this evening and joining in this. We only have 
a few minutes left before our colleague from Iowa (Mr. Ganske) comes to 
the floor. Having watched Dr. Ganske over the last number of weeks and 
sitting in my office, returning phone calls, thank goodness an hour 
earlier in Texas, and I can catch up on that, and his efforts on 
managed care reform and his efforts over the last, in the last session 
of Congress.
  Let me talk before we close about some of the bills or the 
competitive bills tomorrow to the Norwood-Dingell bill. There will be a 
bill called the Comprehensive Access and Responsibility Act introduced 
by the gentleman

[[Page H9397]]

 from Ohio (Mr. Boehner). Which is one of the two alternatives. It 
falls very far short of the Norwood-Dingell bill and the protections 
that are in there. The biggest problem is it does not cover as many 
Americans as the Norwood-Dingell bill. It is very limited. Moreover, 
the bill has no provision to hold HMOs accountable for the decisions 
that harm their customers that are enrollees, and every other business 
in America is subject to liability for poor judgment, and why should 
not the health plans be any different?
  Finally, this bill does not allow chronically ill patients to 
designate their specialist as a primary care provider. As our colleague 
from Wisconsin mentioned, there are times that you might need if it is 
an oncologist, if you have a cancer, if you have some other type of 
illness, you might want to designate that specialist as your primary 
care person, and that is in the Norwood-Dingell bill.
  The other alternative by a couple Members of Congress, the gentleman 
from Oklahoma (Mr. Coburn), the gentleman from Arizona (Mr. Shadegg), 
it is called the Health Care Quality and Choice Act. Now again for most 
folks who watch Congress and they understand that there is no 
requirement that the actual title of the bill reflect what is in the 
body of the bill, and we do not have any truth in titling here in 
Congress, because their bill again falls short. It would force patients 
harmed by their HMOs to go to Federal court so you can get behind all 
the Federal cases, and in Texas most of the Federal cases are drug 
cases, and they have preference; criminal cases have preference. So 
their bill would require you to go to Federal court.
  First, the Federal system is much more difficult and expensive to 
access than State courts, and there are fewer of them, so patients will 
be forced to travel long distances, and particularly in rural areas, 
but even in Houston we have many more State courts in Harris County, 
Texas, than we ever have Federal courts. And worse yet, Federal law 
gives that priority to criminal cases over civil cases. So, in other 
words, maybe a decision will be made on whether you should have that 
bone marrow transplant. By the time you get to Federal court after all 
the other criminal cases are there, it may be 5 or 6 years later, and 
health care delayed is health care denied.
  The Dingell-Norwood consensus bill is the only bipartisan bill that 
we have that recognizes medical necessity, that allows the patient and 
the doctor to define medical necessity based on the medical history and 
the specific need of that patient.
  Appeals process. Again, modeled after the Texas law, allows patients 
to appeal the decision of their HMO to an independent external panel of 
specialists.
  Access to specialists. As I said earlier, the bill requires health 
care plans to include access to specialists and offer access to 
specialists that the patient needs.
  Emergency room coverage. The bill provides guaranteed access to 
emergency services to managed care enrollees and requires a plan to pay 
for those services if a prudent lay person believes that they are in a 
health, in a life-threatening situation, and I use the example: I am a 
lay person. I do not know if I am having chest pains because of the 
pizza I had last night or it is because I am actually having a heart 
attack. I should not have to make that decision. That is why we need to 
go to the closest emergency room.
  But the most important and the final issue is accountability. The 
reason the appeals process in Texas works is because ultimately they 
could go to court, and it is also the most controversial; but again 
this is modeled after the Texas law, and we have over 2 years 
experience. This bill allows Americans harmed by their HMOs to seek 
redress in the State court. However, to prevent frivolous cases, they 
can only sue after they have exhausted their appeals and the patient is 
harmed. The provision is tightly crafted so not only to hold the 
medical decision maker accountable.
  And let me say in brief I had, a couple of years ago I had the 
opportunity to speak to the Harris County Medical Society, and after 
talking about some of the bills I have been working on, the first 
question from a doctor was, and by the way, I joked about my daughter 
having 2 weeks in medical school, and she was not quite ready to do 
brain surgery. The first question from that doctor to me said, you know 
your daughter after 2 weeks in medical school has more training than 
the person I call to treat my patients.
  That is what is wrong with our medical system we have now. We do have 
the greatest health care system in the world. People come from all over 
the world to get to us to have that system, but we are denying it to 
some of our folks who have insurance, and we need to change that. We 
need to make sure that we restore that health care provider and that 
doctor so they can talk to their patient.
  The reason, reasons the consensus bill are so insistent on 
accountability provision, because if you do not have that, you will not 
have, they will not have the incentive to change their practices, and 
while opponents of the strong binding consensus bill claim it 
would dramatically increase health costs, we know in Texas it has not 
increased health costs in 2 years; and what we found in Texas, that 
patients are right and about half their appeals in the health care 
plans honor that decision because they do not want to get sued. All the 
people want is their health care. They do not want to have to go to 
court; they do not want to have to go to State court, much less Federal 
court that is in some of the alternatives.

  I would hope that my colleagues tomorrow would reject the poison pill 
amendments. Sure we need to do additional access, and I would hope we 
can do that on the floor of the House sometime but without trying to 
dirty up the waters on providing access in modernization of the HMO 
process.
  I have had my colleagues talk about earlier that all we are asking 
for is some guidelines for managed care to deal with their customers 
and our constituents and the doctors' patients. In fact, over the past 
5 years all 50 States have passed laws to protect patients in State-
regulated plans. Some of them are stronger than others, and these 
alternative bills essentially disregard the advances that are made in 
each State and moreover more people into Federal regulation would lose 
protections.
  These laws have been passed by Democratic and Republican legislators. 
They have been signed into law by Democratic and Republican governors. 
But the Republican leadership would jeopardize the health care of 
millions in these protections unless we pass it tomorrow.
  Mr. Speaker, I again thank my colleagues who were here tonight and 
all those who are listening because tomorrow, Wednesday, and Thursday 
this week this House will make some major decisions; and if we make the 
wrong decision like we did last year, then we will continue to have 
people denied adequate health care in our country. Our country is too 
great to do that.
  Ms. EDDIE BERNICE JOHNSON of Texas. Mr. Speaker, Will enactment of 
the Norwood-Dingell Bill lead to skyrocketing health care costs?
  Since Texas began to implement a series of managed care reforms in 
1995, our HMO premium increases have mirrored or trailed those premium 
hikes in other states that don't have managed care reform bills in 
place.
  Nationally, health care costs have increased by 3.7 percent in 1998 
while in Texas, the costs increased by only 1.10 percent for the same 
period.
  Will enactment of the Norwood-Dingell Bill lead to frivolous law 
suits?
  Since Texas enacted its Patient's Bill of Rights in 1997, there have 
been only five lawsuits in a managed care system that serves four 
million patients.
  This number of lawsuits is low because our patients are fully using 
the external review process that is a component of the Norwood-Dingell 
bill. More than 700 patients have used the external review process in 
the past two years to appeal the decisions made by health plans. Of 
those, about half of the decisions have gone in favor of the HMOs.
  Will the Norwood-Dingell Bill result in employers dropping their 
employees from health care coverage and thus drive up the number of 
uninsured families?
  It may be too early to tell using our state's example. But the fact 
remains that as HMOs have increased penetration in recent years, so has 
the nubmer of uninsured. That is the case in Texas and around the 
nation.
  Since the Texas Legislature made managed-care plans liable for 
malpractice, there have been five known lawsuits from among the 4 
million Texans who belong to HMOs.
  ``The sky didn't fall,'' said Sen. David Sibley, the Republican who 
championed the Texas

[[Page H9398]]

version of the Patient's Bill of Rights. ``Those horror stories,'' 
envisioned by the health insurance industry ``just did not transpire.''
  While it is too early to see the full effect on my state it is 
evident that the implementation of this legislation has had a dramatic 
effect on resolving complaints between patients and their health 
plans--before they get to the courthouse.
  Clearly this legislation has acted as a prime motivator for HMOs to 
settle their disputes with their patients. Regrettably, the vast 
majority of Americans do not have this option. That's why it is vital 
that we have national Patient's Bill of Rights that has some teeth in 
it--that permits patients to suit their HMOs when treatment decisions 
result in injury or death as well as granting patients access to 
emergency care and specialty care that is not currently allowed.
  I strongly believe that the Texas experience strongly speaks to the 
benefits of empowering patients and doctors so that they can work with 
the insurance companies in ensuring that our health care system 
provides the best care for all Americans.

  Republican Health Care Bill:
  The Republicans introduced the Quality Care for the Uninsured Act. 
This legislation does move the health care debate forward. But not very 
far. It is not a bipartisan bill and it does not address that entire 
scope of health care delivery or what's wrong with managed care.
  At best the Republican bill nibbles around the corners of health care 
debate. It provides for Medical Savings Plans and 100 percent 
deductibility of individual insurance premiums for the self-insured and 
uninsured.
  This legislation does nothing to increase access to emergency 
services or ob-gyn. It does nothing to address the lopsided nature of 
the managed care equation in which insurance companies make most of the 
patient decisions, while doctors and the patients themselves are left 
in the waiting room.


     bi-partisan consensus managed care improvement act (h.r. 2723)

  H.R. 2723 that has already been introduced by Representatives Charles 
Norwood and John Dingell truly addresses the consumer and provider 
issues that have undermined the health care in America. I am a 
cosponsor of this legislation.
  Its independent external appeals process will help patients get care 
quickly and resolve disputes without resorting to a court fight.
  Once the appeals process has been exhausted patients will be able to 
hold health care plans accountable when they make negligent decisions 
that result in patient injury or death. At the same time, this 
legislation includes safeguards to protect employers from lawsuits and 
punitive damages against health plans that comply with the external 
review determination.
  This legislation also provides patients with other essential 
protections including access to specialty care, emergency care, 
clinical trials and direct access to women's health services. Patients 
who need to go out-of-network for care will have access to a point-of-
service option.
  I look forward to a fair debate between our bi-partisan Patient's 
Bill of Rights versus the Republican Leadership's alternative. Once the 
American people fully understand what's in each bill--I am confident 
that the bi-partisan bill will prevail.
  The majority of Americans would rather have a strong say in how they 
receive medical treatment than nibbling at the edges of this important 
problem.
  Support and protect the Norwood-Dingell Bill; it's the only way to 
put doctors, nurses, and patients back into the business of patient 
care.
  Mr. SANDLIN. Mr. Speaker, the Lone Star State has been a leader in 
health insurance reform. The Texas Legislature enacted a law in 1997 
which protects patients' rights when insurance companies stand in the 
way of common sense and good medicine.
  So what has happened in my home state over the past two years? Have 
our courts been overrun with frivolous lawsuits? Are families saddled 
with growing premiums? Are HMOs being run out of business? No. Not by a 
Texas mile.
  Last week the Washington Post noted that only five lawsuits have been 
filed against health plans in Texas. That's five lawsuits in two years. 
Of the roughly six hundred complaints submitted to the independent 
review system established under the Texas law, about half of the cases 
have been resolved in favor of the patients, half in favor of the 
insurance companies. And premiums have not increased in our state. In 
fact, we enjoy some of the lowest premiums in the country. Almost 
everything is big in Texas.
  And now the Lone Star State is not alone. California and Georgia have 
enacted health care legislation that will enable policyholders to sue 
their HMOs. And the majority of members of this body favor similar bi-
partisan legislation.
  Mr. Speaker, the question is no longer whether such provisions are a 
good idea, or even whether they are supported by legislators across the 
land and here in Washington. The question now is whether or not we, the 
House, will even have a chance to consider this measure. It will take, 
from the Republican leadership, the courage to stand up to big 
insurance companies and their scare tactics. And, I think, it will take 
an ounce of good old Texas courage.


                             General Leave

  Mr. GREEN of Texas. Mr. Speaker, I ask unanimous consent that all 
Members be permitted to extend their remarks and include their 
extraneous material on the subject of this special order speech that I 
and my colleagues have given tonight.
  The SPEAKER pro tempore (Mr. Toomey). Is there objection to the 
request of the gentleman from Texas?
  There was no objection.

            While Covering Uninsured, Let's Fix Managed Care

                       (By U.S. Rep. Gene Green)

       As the Congress prepared to debate several HMO reform bills 
     this week, House Speaker Dennis Hastert, R-Ill., has stated 
     his intention to include in the managed-care reform debate, 
     health-care-related tax cuts. These incentives, called the 
     ``access package,'' are intended to allow tax cuts to the 44 
     million uninsured Americans who cannot afford health-care 
     coverage.
       While it is important that everyone has access to 
     affordable health care, the issue that Congress has been 
     debating for several months and that we should resolve, is 
     how to reform our current managed-care system. If we are 
     truly concerned about the uninsured, let's expand health-
     insurance access to them--insurance that will actually 
     provide quality health care. Various managed-care proposals 
     will be debated, but it is important to look beyond the 
     titles to see what each proposal would do to really protect 
     patients.
       The fact is, 48 million Americans belong to self-funded 
     health-insurance plans that offer very little protection for 
     individuals from neglectful and wrongful decisions made by 
     their insurance plans. Although some states--Texas, for 
     instance--have passed laws that protect consumers from 
     health-insurance malpractice, the protections enacted by 
     states only affect insurance policies licensed by the state. 
     We need a national set of guidelines for health-plan conduct.
       The Dingell/Norwood consensus managed-care reform proposal 
     is the only bipartisan bill that provides the necessary 
     protections to revamp the current managed-care system. This 
     bill, developed over weeks of negotiations, would provide 
     every American in an HMO or managed-care plan the fundamental 
     rights they need to ensure they receive quality health care. 
     Its major provisions are:
       Medical necessity: Allows the patient and the doctor to 
     define medical necessity based on the medical history and 
     specific needs of the patient.
       Appeals process: Allows patients to appeal the decision of 
     their HMO to an independent, external panel of specialists.
       Access to specialists: Requires health plans that include 
     access to specialists to offer access to the specialist that 
     the patient needs.
       Emergency room coverage: Provides guaranteed access to 
     emergency services to managed-care enrollees and requires the 
     plan to pay for those services if a ``prudent layperson'' 
     believes they are in a life-threatening situation.
       Accountability: Allows patients harmed by their HMO to hold 
     their health plan accountable in state court.
       While other bills claim to provide these same protections 
     for patients, one look beyond their titles proves otherwise. 
     The Comprehensive Access and Responsibility Act, introduced 
     by Rep. John Boehner, R-Ohio, does not apply to all 
     Americans. It only covers employer-sponsored health plans, 
     and leaves out the most vulnerable insurance consumers--those 
     who do not have an employer to negotiate for them. Moreover, 
     this bill has no provision to hold HMOs accountable when 
     their decision harms a patient.
       The other alternative is sponsored by Rep. Tom Coburn, R-
     Okla., and Rep. John Shadegg, R-Ariz. This bill would force 
     patients harmed by their HMO to seek remedies in federal 
     court. The practical impact of this provision would be 
     devastating to patients. First, the federal court system is 
     much more difficult and expensive to access than state 
     courts. There are fewer of them, so some patients could be 
     forced to travel long distances. Worse yet, because federal 
     law gives priority to criminal cases over civil cases, 
     patients seeking remedies could be forced to wait years while 
     the backlog of criminal cases clears. Finally, this bill does 
     not allow chronically ill patients to designate their 
     specialist as their primary-care provider. This means that 
     every time they need to see their doctor, they have to go to 
     another primary-care doctor first and get a referral.
       Accountability and enforcement for medical decisions is the 
     critical issue in the HMO debate. Without an effective 
     accountability provision, managed-care companies will never 
     have an incentive to change their practices of placing 
     profits before patients. And while opponents of the strong 
     and binding Norwood-Dingell bill claim it would dramatically 
     increase health costs, we in Texas know it won't. The 
     majority of the ``expensive'' provisions in the bill--which 
     include

[[Page H9399]]

     accountability, decisions of medical necessity and external 
     appeals--were modeled after the Texas law. What we have found 
     in Texas is that patients are right in about half of their 
     appeals and health plans honor that decision. Since the law 
     took effect, health-cost increases in Texas have been a 
     reflection of rising prescription drug costs and inflation--
     just as we have seen in every other state.
       It is our responsibility to ensure that patients get the 
     high-quality health care they pay for and deserve. When 
     Americans buy health insurance, they should not have to lose 
     their relationship with their doctor or worry if their 
     insurance plan will pay for the medical bill as they are 
     heading to the emergency room. It is time that we provide 
     patient-protection rights for consumers and for managed-care 
     plans to be made accountable for delivering quality care and 
     respecting basic consumer rights.

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