[Congressional Record Volume 146, Number 11 (Wednesday, February 9, 2000)]
[House]
[Pages H273-H277]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
TAXES, THE NATIONAL DEBT, AND OUR NATION'S PRIORITIES
The SPEAKER pro tempore (Mr. Whitfield). Under the Speaker's
announced policy of January 6, 1999, the gentleman from Iowa (Mr.
Ganske) is recognized for 60 minutes.
Mr. GANSKE. Mr. Speaker, I had not planned on talking that much about
taxes today, but we will have a tax bill come up on the floor tomorrow,
so in light of the last hour's discussion on taxes, I might as well
give my opinion on this issue.
Mr. Speaker, prior to coming to Congress, I was elected in 1994, I
was a reconstructive surgeon in Des Moines, Iowa. I had been in solo
practice for 10 years. I took care of women who had had cancer
operations, farmers who had put their hands into machines, babies who
were born with birth defects.
I enjoyed it very much and I still do. I still go overseas and do
surgical missions. I expect that some day I will probably return to
that.
So people would ask me, why are you thinking about running for
Congress? Are you tired of medicine? I said, no, I am not tired of
medicine at all. I love it. It is a way to solve problems. But I will
say, Mr. Speaker, there are a couple of problems that I was really
concerned about.
I was concerned about a welfare system that I thought was not
working. I took care of 14- and 15-year-old young mothers who would
bring a baby with a cleft lip or palate into my office. They would be
on welfare. There would almost never be a dad there with them,
[[Page H274]]
because the system was set up so that they only get benefits if a dad
is not there. I did not think that was right.
One of the things I am proudest of since coming to Congress is the
fact that this Republican Congress reformed welfare. It is working
well. It is giving a helping hand, it is helping people get education,
it is providing for child care during that training period of time, but
it also says that if you are able-bodied and you receive that helping
hand, then you ought to take the responsibility and get a job.
{time} 1230
The welfare rolls are down by 50 percent all across the country, and
part of that is due to the economy but part of it is due to the Welfare
Reform Act that this Republican Congress passed. We had to place it on
the President's desk three times before he signed it, but I am proud of
that.
The other reason that I ran, that I decided to leave my medical
practice for a period of time, was because I was very concerned about
our national debt. Remember what it was like back in 1993 when I
decided to run. We were looking at annual deficits into the future of
over $200 billion, as far as we could see. We were looking at trillions
of dollars of national debt.
I have three children. I was worried about what kind of legacy we
were going to leave for them. The bigger the national debt, the more
our kids will have to pay for it. Then we look at the baby-boomers, the
age wave coming down the track. I am 50 years old, right there at the
beginning of that age wave. In another 15 years, every 8 seconds a
baby-boomer is going to be retiring and our kids are going to have to
cover that.
So the other main reason that I ran for Congress, that I left my
medical practice, was to do something to get our national finances in
order, to eliminate these annual deficits, to reduce the debt.
Mr. Speaker, with this Republican Congress we have put some fiscal
restraint on Federal spending and part of the reason that we have a
vibrant economy now is because there is not just a perception but a
reality that this Congress has slowed down spending. That is good. In
1994, I ran against a very nice gentleman from Iowa who had been here
36 years. He was the chairman of Labor HHS Appropriations, which
probably accounts for a lot of his votes, but we had a disagreement.
The incumbent that I beat never saw a spending bill that he did not
like.
We have put some fiscal restraint on this Congress. This brings us
then to last year's tax cut, Republican tax cut. I am one of four
Republicans that voted against that tax cut. That is not easy, let me
say. I talked to the Speaker personally. He wanted me to vote for that
bill. The Speaker is a fine man and a good friend. I had to turn him
down.
I spoke to the chairman of the Committee on Ways and Means, the
gentleman from Texas (Mr. Archer), who I love dearly. He is a good
friend. I had to turn him down.
Why was I one of only four Republicans that voted against that $780
billion tax cut last year? Well, Mr. Speaker, it is because when I
looked at the numbers, the projections for the surplus, they were based
on two assumptions that are false. The first assumption was that we
would stick to the spending caps from the 1997 Balanced Budget Act, and
that is false because they are already broken.
We have already gone beyond those spending caps. Those spending caps
would require reductions of 30 percent over current spending in the
next several years. That will never happen. The second assumption was
that there would be no emergency funding for 10 years.
Mr. Speaker, we all know that on the average this Congress has spent
$12 billion to $16 billion a year on emergency funding. There is no way
that we would not have any emergency funding. Emergencies happen. There
are hurricanes that come up the coast. There are droughts. There are
natural disasters. Furthermore, even this year we are looking at
emergency funding for military operations in Kosovo. That should not be
an emergency item. We know that we are there. That should be budgeted,
but that will be stuck into an emergency supplemental bill.
So those two premises upon which that $1 trillion surplus, above and
beyond Social Security, was made are false. It will not be that much. I
pray to God that our economy continues to do well, that we continue to
have government revenues come in as they have under this wonderful
economic expansion, but I do not know that we can bank on that.
So I did not think those premises were true. I did not think we were
truly dealing with that big a surplus, and I am a Republican who came
to Congress, as I said, in 1995 to balance the budget, not to vote for
a bill that could put us back into deficits.
Mr. Speaker, I will match my economic score card for fiscal
conservativeness with just about anybody in this House of
Representatives. I am a fiscal conservative.
Mr. Speaker, I happen to believe that it is conservative to be
careful and not to vote for a bill that could put us into deficits, not
to vote for a bill that could increase our national debt. I think it is
conservative to pay down our national debt first.
What should our priorities be this year? I think we ought to pay down
the debt, for a couple of reasons. Number one, we are currently
spending about $240 billion a year on interest payments. When times are
good, my parents taught me, one should reduce debt so that when times
are bad they do not have to service that debt.
I think we ought to know what our expenses are going to be this year,
and I would agree with my Democratic colleagues that the process should
be, first, get your priorities in order; pay down the debt. Second,
know what your expenditures are going to be and, third, then you know
how much you have available for a tax cut.
I am going to vote tomorrow for a marriage tax relief bill. I think
it is a matter of inequity. I do not think that a couple, both of whom
are working that earn $75,000, should pay more in taxes than a couple
where only one is working and they are earning $75,000. That needs to
be fixed.
I am in agreement with fixing the alternative minimum tax. That tax
was designed for millionaires so that they would have to pay something
in taxes; but unfortunately, because of historical trends in income, it
now affects the middle class. I think we ought to do something to fix
that so I am going to vote for this tomorrow.
What are we going to do later in the year when we have a minimum wage
bill come up and we attach tax provisions to that? How much will those
tax provisions be to help small businesses? What are we going to do if
we want to address access to health care with a Patients' Bill of
Rights that is coupled with an access bill? I firmly believe there is
bipartisan support in Congress to extend to 100 percent deductibility
for the self-insured for their health premiums, make it effective
January 1, 2000. That would help a lot of individuals afford health
insurance, but that could be a major coster in terms of decreased
revenues to Congress.
Where does this all fit in together? Where does it fit in with what
we think we will need to spend for government programs? My colleagues
from the other side of the aisle pointed out that there are a number of
Members of Congress from both sides of the aisle that want to increase
spending on defense. We may be looking at some additional agricultural
relief.
My point of this is that we need to have a process ahead of time so
that we understand where we are going on this budget. If it is the
intent of my leadership to simply take last year's $800 billion tax cut
bill, divide it into little pieces and just bring them one after
another to the floor, then I think after the first one or two they will
find out that they no longer have support because people will start to
get concerned about are we going to end up at the end of the year
dipping into that Social Security surplus. Are we at the end of the
year actually going to be able to say we reduced the debt.
When I talk to my constituents back home in Iowa, I can say
something. Almost unanimously they say our priorities should be reduce
the debt. Among the elderly, they want us to reduce the debt because
they intuitively know that if we have a lower debt that in the year
2013, when the baby-boomers move into retirement, that gives us a
bigger cushion to handle those entitlement programs.
The younger people want us to reduce the debt because they know if we
[[Page H275]]
do it we will reduce interest rates so that they have to pay less on
their home payments. Reduce the debt, figure out what an accurate
budget should be and fit your tax cuts into that. That should be the
process by which we go through here.
I am in agreement with my colleagues on the other side of the aisle
on this. I think we are going to be looking at some legislation down
the road this year that is important, and we need to know where we are
going to be on this issue.
As I said, Mr. Speaker, I am as fiscally conservative as just about
anybody in the Republican caucus. I do not enjoy being at odds with my
leadership on this issue. I happen to think that our leadership, in
talking now about debt reduction, is getting the message. I happen to
think that we can go out and we can be honest with people and we can
say, look, the conservative position on this is, number one, do not
vote for a bill that has the potential to increase deficits and
increase debt. Pay down the debt first.
Patient Protection Legislation
Mr. GANSKE. Mr. Speaker, in my remaining time I want to speak a
little bit about patient protection legislation. We have been working
on this issue for 5 years now. Back in 1995 when I first came to
Congress, reports came out about how HMOs were writing contracts that
had gag clauses in them, in which they basically said that before a
physician could say to the patient what their treatment options were
they first had to get an okay from the company.
Now think about that for a minute. Let us say that a woman with a
lump in her breast goes in to see her doctor. The doctor takes her
history, examines her, and knows that there are three treatment options
for this lady; but one of them may be more expensive than the other and
because he has this gag rule written into his HMO contract he has to
say, excuse me, ma'am; leaves the room goes to a telephone; gets on the
phone, dials a 1-800 number and says, Mrs. So and So has a lump in her
breast. She has three treatment options. Can I tell her about them?
I firmly believe that patient has the right to know all her treatment
options and that an HMO should not censor her physician. That is a blow
right to the patient/doctor relationship. That should be outlawed. So I
wrote a bill in 1995 called the Patient Right to Know Act. I went out
and I obtained 285 bipartisan cosponsors and, Mr. Speaker, I could not
get that bipartisan bill to the floor, which would have passed with
over 400 votes.
My leadership, the Republican leadership of this Congress, would not
even allow a simple bill like that to come to the floor, despite
promises that they would.
So the next year came along, and we wrote a more comprehensive bill
because we also knew that in the meantime HMOs were refusing to pay for
emergency care.
Let us say a patient has crushing chest pain. We have just seen on TV
that crushing chest pain can be a sign of a heart attack. Pass go, go
immediately to that emergency room because if one delays they could
have a heart attack and die on the way. The American Heart Association
says that.
So people would have crushing chest pain, break out in a sweat, know
that that could be a heart attack. They go to their emergency room.
They would have a test, and some of the time it would not show a heart
attack. Some of the time it would show severe inflammation of the
esophagus or the stomach instead.
{time} 1245
The EKG would be normal. So ex-post facto, the HMO would refuse to
pay for that emergency room visit, because, you see, the patient was
not having a heart attack after all.
Well, when word of that type of treatment gets around, people start
to think twice about really whether they are going to go to the
emergency room when they need to, because, after all, they could be
stuck with a bill. Is that fair? Is that just? No. But it is one of
those ways that HMOs have tried to cut down on care to increase their
bottom-line profits.
Well, we had hearings on patient protection legislation. We had a
hearing back in May, 1996, 4 years ago. Buried in the fourth panel at
the end of a long day was testimony from a small, nervous woman. This
was before the House Committee on Commerce. By that time, the reporters
are gone, the cameras are gone, most of the original crowd had
dispersed. She should have been the first witness that day, not the
last.
She told about the choices that managed care companies and self-
insured plans are making every day when they determine what is known as
``medical necessity.'' Linda Peeno had been a claims reviewer for
several HMOs. I want to relate her testimony to my colleagues.
She began, ``I wish to begin by making a public confession. In the
spring,'' now this is a former claims reviewer, medical reviewer for an
HMO. She said, ``In the spring of 1987, I caused the death of a man.
Although this was known to many people, I have not been taken to any
court of law or called to account for this in any professional or
public forum. In fact, just the opposite occurred. I was rewarded for
this. It brought me an improved reputation in my job. It contributed to
my advancement afterwards. Not only did I demonstrate that I could do
what was expected of me, I exemplified the good company employee. I
saved half a million dollars.''
As she spoke, a hush came over that room. Mr. Speaker, I think you
may have been in the room when this lady testified. The representatives
of the trade associations who were there averted their eyes. The
audience shifted uncomfortably in their seats, alarmed by her story.
Her voice became husky, and I could see tears in her eyes. Her anguish
over harming patients as a managed care reviewer had caused that woman
to come forth and to bear her soul.
She continued, ``Since that day, I have lived with this act and many
others eating into my heart and soul. I was a professional charged with
the care or healing of his or her fellow human beings. The primary
ethical norm is `do no harm.' I did worse,'' she said. ``I caused the
death. Instead of using a clumsy, bloody weapon, I used the simplest,
cleanest of tools: my words. This man died because I denied him a
necessary operation to save his heart.''
This medical reviewer continued, ``I felt little pain or remorse at
the time. The man's faceless distance soothed my conscious. Like a
skilled soldier, I was trained for this moment. When any qualms arose,
I was to remember, I am not denying care. I am only denying payment.''
Well, by this time, the trade association representatives were
staring at the floor. The Congressmen who had spoken on behalf of the
HMOs were distinctly uncomfortable. The staff, several of whom became
representatives of HMO trade associations, were thanking God that this
witness was at the end of the day.
Her testimony continued, ``At that time, this helped me avoid any
sense of responsibility for my decision. Now I am no longer willing to
accept the escapist reasoning that allowed me to rationalize that
action. I accept my responsibility now for this man's death as well as
for the immeasurable pain and suffering many other decisions of mine
caused.''
This is testimony from a medical reviewer for an HMO before Congress
in 1996. Congress has dilly dallied for 4 years and has not done
anything to fix this.
She then listed the many ways that managed care plans deny care to
patients; but she emphasized one particular issue, the right to decide
what care is medically necessary.
She said, ``There is one last activity that I think deserves a
special place on this list, and this is what I call the smart bomb of
cost containment, and that is medical necessities denials. Even when
medical criteria is used, it is rarely developed in any kind of
standard traditional clinical process. It is rarely standardized across
the field. The criteria is rarely available for prior review by the
physicians or members of the plan.''
She says, ``We have enough experience from history,'' we have enough
experience from history, I think she was referring to World War II,
``to demonstrate the consequences of secretive, unregulated systems
that go awry.''
After exposing her own transgressions, she closed urging everyone in
the room to examine their own conscience. She closed by saying, ``One
can
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only wonder how much pain, suffering, and death will we have before we
have the courage to change our course. Personally, I have decided that
even one death is too much for me.''
At that point in time, the room was stone-cold quiet. The chairman
mumbled, ``Thank you.''
Well, Mr. Speaker, let me tell you about some of the real-life people
that have been affected by HMO abuses. It is important, when we talk
about the details, the technical details of some of these bills, that
we remember that there are actually people involved with the
consequences of HMO decisions.
It has now been about 4 years since a woman was hiking about 40 miles
east of Washington here. She fell off a 40-foot cliff. She fractured
her skull, broke her arm, had a fractured pelvis. She was laying on the
rocks at the base of a 40-foot cliff, close to a pond. Fortunately she
did not fall into that. Her boyfriend who was hiking with her managed
to get her life-flighted to a hospital.
This was that young woman, Jackie Lee, being trundled up, put on the
helicopter. She spent about a month in the ICU. She was really sick.
She had severe injuries. She was on intravenous morphine for pain.
After she got out of the hospital, her HMO refused to pay for her
hospitalization. Why was it that her HMO would not pay? Well, the
initial answer was, Jackie had not phoned ahead for prior
authorization. She had not phoned ahead to let them know that she was
going to fall off a cliff and be injured. Boy, I would tell you, you
would need a real crystal ball to get care from that HMO. Or maybe when
she was semicomatose, lying at the base of that cliff, she was supposed
to, with her nonbroken arm, pull a cellular phone out of her pocket and
phone a 1-800 number and say, hey, guess what? I fell off a 40-foot
cliff. I need to go to the emergency room.
Well, then after she contested that, then the HMO still refused to
pay for her bill because they said, ``Well, you were in the hospital
for a while. You did not phone us within the first few days that you
were in the hospital.'' Her rejoinder was, ``I was in the ICU on a
morphine drip. I guess it did not enter my mind.'' That is one of the
examples that we are dealing with.
Under the bill that passed the House of Representatives a couple of
months ago, this woman would be taken care of because we have a
provision in that bill that says that, if one needs to go to the
emergency room, and if a layperson would agree that this is an
emergency, would anyone not agree that that is an emergency, if a
layperson would agree that that is an emergency, then that HMO is
obligated to pay the bill. We passed that provision for Medicare
patients. We still have not done anything for all of the people in this
country.
Well, what about HMOs like this medical reviewer talking about making
determinations of medical necessity that are contrary to what one's own
doctor or physician consultant would give.
This woman was featured on the cover of Time Magazine several years
ago. She had cancer. Her doctor and her consultants all recommended a
type of treatment. Her HMO denied it. There was no specific exclusion
of coverage for that type of treatment or contract. But under Federal
law, her HMO can define medical necessity in any way they want to.
If one gets one's insurance from one's employer, does one's State
insurance commissioner have any say in that? No. Congress took that
away from State insurance commissioners 25 years ago. Under current
law, HMOs that make decisions, medical necessity decisions, through
employer plans, can define medical necessity any way they want. Even
though this woman's doctors all recommended that she have this
treatment that could have saved her life, they said, no, and she died.
Let me tell my colleagues about another type of medical decision that
an HMO made 5 or 6 years ago. About 3:00 in the morning, Lamona Adams
was taking care of little Jimmy when he was 6 months old. He had a
temperature of about 104, 105, and he was pretty sick. She looked at
him, and she talked to her husband, and they thought he needed to go to
the emergency room. So they were good HMO clients. They phoned that 1-
800 HMO number. They got somebody 1,000 miles away who knew nothing
about the Atlanta, Georgia area where they lived.
The person said, ``Yes, I will authorize you to go to an emergency,
but you can only go to this one emergency room.'' Little Jimmy's mother
said, ``Well, where is it?'' The voice at the end of that 1-800 line
said, ``Well, I do not know. Find a map.''
So at 3:30 in the morning, Mom and Dad wrapped up little Jimmy, got
into the car. There is a severe storm outside. They start their trek to
this authorized hospital which is about 70 miles away, 70, 70 miles
away. They live clear on the south side of Atlanta, and this authorized
hospital is on the north side. So they have to go through all of
metropolitan traffic.
On their way, about halfway there, they passed three emergency rooms
that they should have been able to stop at. But they were not medical
professionals. They knew he was sick, but they did not know how sick.
They knew if they stopped at one of those unauthorized hospitals that
the HMO would not pay, and this could be really expensive.
Unfortunately, before they got to the authorized hospital, Jimmy's
eyes rolled back in his head, he stopped breathing, and he had a
cardiac arrest. So, imagine, Dad driving like crazy, Mom trying to keep
her little baby alive. They finally pull into the emergency room. Mom
grabs her baby, jumps out of the car, screaming ``save my baby, save my
baby.''
A nurse comes out, gives him mouth-to-mouth resuscitation. They start
the IVs. They give him medicines, and they save his life. But they do
not save all of this little baby. Because of his cardiac arrest, his
decreased circulation, he ends up with loss of circulation in his hands
and his feet, and gangrene sets in. Both his hands and both his feet
have to be amputated.
Here is James after his HMO treatment, without his hands and without
his feet. I brought him to the floor of Congress when we had our
debate. He can put on his leg prostheses with his arm stumps, and he
gets around pretty good, and he is a great kid. He will take a pencil,
and he will hold it with his stumps, and he can draw and write like
that. But I would submit to my colleagues that this little boy will
never play basketball or sports.
{time} 1300
This little boy when he grows up will never be able to caress the
cheek of the woman he loves with his hand. Do you know that under
Federal law the HMO which made that medical determination that he had
to go to that hospital that caused this to happen is liable for the
cost of his amputations?
Mr. Speaker, if he died, then they would not have been liable for
anything. Is that justice? Is that fair? Is that the type of system we
ought to have that covers 75 percent of the people in this country who
receive their insurance from their employer? I think not.
Let me give you another example of the problem with HMOs being able
to determine ``medical necessity'' in any way that they want. Here is a
little baby born with a defect, the type of which I fix; this is a
cleft lip and a cleft palate. It is a birth defect. This is not a,
quote, ``cosmetic defect.'' This is a functional defect.
This little boy when he eats has food come out of his nose. This
little boy, because he does not have a roof of his mouth or a palate,
will never be able to learn to speak normally.
So what is the standard treatment for this? Surgical correction. We
can go a long ways towards making these kids whole again and able to go
out in public and able to speak and able to eat normally by a surgical
correction of their palate.
You know what? There are some HMOs that are defining medical
necessity as the ``cheapest least expensive care,'' ``the cheapest
least expensive care.''
Mr. Speaker, you may say in this age of cost containment, what is
wrong with that? I will tell you what is wrong with that: the standard
of care for this little baby born with this birth defect is surgical
correction of his palate using his own tissues so that he is able to
eat and speak normally.
Under that bizarre definition of an HMO, they can give his parents a
little piece of plastic to shove up in the roof of his mouth, what is
called an obturator, a plastic obturator. It would be
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like an upper denture. Yes, that would keep food some of the time from
going up his nose. He might be able to garble out some type of speech.
But you know what? It would not be an optimal result.
Under Federal law as it currently exists today, that HMO can put that
definition into their health plans, something in the fine print that
none of you would ever know about. They could totally justify this, and
you would have no recourse, other than maybe going to your newspaper
and exposing them. That is wrong.
Mr. Speaker, this House passed by a vote of 275 to 151 a strong
patient protection piece of legislation called the Bipartisan Consensus
Managed Care Act. The gentleman from Georgia (Mr. Norwood), a very
conservative Republican, and I, and the gentleman from Michigan (Mr.
Dingell) wrote that bill. We have had two motions to instruct for our
conferees on this managed care patient reform bill to follow the House
bill.
This House voted on the Senate bill, which is a do-nothing fig leaf
bill, where the fine print is worse than the status quo. This House
voted on that. You know what? This House voted by a vote of 145 for the
Senate bill to 284 against the Senate bill.
We have a chairman of this conference who says we are going to stick
to that Senate bill. Mr. Speaker, we can do better. We can do better
for this little baby. We can do better for James Adams. We can do
better for this lady and her family. We can do better for a woman who
falls off a 40-foot cliff and is told by her HMO, sorry, you did not
notify us before your fall.
We have waited on this legislation too long. It is time to fix it.
The President has said put that bipartisan consensus Managed Care
Reform Act, the one that passed this House with 275 votes, put it on my
desk, and I will sign it. We should do that tomorrow, because I can
guarantee you, Mr. Speaker, there are people out there at this very
moment that are being harmed by HMOs that are being denied necessary
medical care, who may lose their hands and feet or their life because
of arbitrary decisions.
I call upon Members of both side of the aisle to work hard to bring a
real patient protection bill out of conference to this floor and put it
on the President's desk. If the conference brings back that
unsatisfactory Senate bill, then I am just afraid we are all going to
say no. Let us fix this problem, and let us fix it now. People need
their care.
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