[Congressional Record Volume 147, Number 58 (Wednesday, May 2, 2001)]
[House]
[Pages H1833-H1835]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




     PATIENT PROTECTION AND PRESCRIPTION DRUG COVERAGE LEGISLATION

  The SPEAKER pro tempore (Mr. Graves). Under the Speaker's announced 
policy of January 3, 2001, the gentleman from Iowa (Mr. Ganske) is 
recognized for 60 minutes as the designee of the majority leader.
  Mr. GANSKE. Mr. Speaker, just a heads up, I will probably only take 
about half of this time, so that if any Members on the other side are 
going to give a Special Order, they should realize that I will not take 
the full hour.
  Mr. Speaker, I want to talk a little bit about two health care issues 
that are very important: patient protection legislation and 
prescription drug coverage. Just last night, Mr. Speaker, I was at an 
event here in Washington, and a gentleman who is a CEO of one of the 
world's largest corporations received an award. This gentleman had had, 
when he was a child, a bilateral cleft lip repaired, and he spoke 
beautifully. He has risen to the pinnacle of the business world. He had 
the advantage of having the appropriate care when he was a baby. And 
yet if we look at what has happened, my colleagues, around the country, 
with the advent of managed care, we will see cases like this.
  Before coming to Congress, I was a plastic and reconstructive 
surgeon. I took care of lots of babies that were born with birth 
defects like this, a cleft lip and a cleft palate. And in the last 
several years, at least 50 percent of the surgeons who take care of 
children with birth defects like this have had operations on their 
patients denied because they were not ``medically necessary.'' Not 
medically necessary.
  Let me give a few other examples. In 1996, Musette Batas was 6 months 
pregnant when she had an inflammatory bowel disease flare-up. Her 
insurance company authored a 1-day hospitalization. Her primary care 
physician asked for a longer stay, but her HMO concurrent review nurse 
looked at Mrs. Batas' chart and said it was not ``medically 
necessary.''
  Now, the nurse never consulted with the physician; she never saw the 
patient. Musette Batas went to the emergency department 10 days later 
with fever and pain. A physician sought approval for exploratory 
surgery. Three days later, the doctor still had not heard from the HMO 
and her intestine burst. Four days after emergency surgery, in which 
part of her colon was removed, the HMO nurse told her physician she had 
to be discharged. The physician refused. The nurse reviewed her chart, 
she consulted Millimen and Robertson's care guidelines, and based on 
that, the nurse said the HMO would not pay for any more time in the 
hospital because it was not ``medically necessary.'' So she left the 
hospital because she could not afford to pay for it herself.
  How about down in Texas in the last few years? There is a gentleman 
named Plocica. Mr. Plocica. He was suicidal. He was in the hospital. 
His psychiatrist said he needed to stay in the hospital. His HMO said 
no, we do not think he does. It is not medically necessary. So we are 
not going to pay for any more hospitalization. And when an HMO does not 
pay for a hospitalization, most people cannot stay in the hospital 
because they cannot afford the care.
  They could not afford to pay for it out of pocket, so Mr. Plocica 
went home. His family reluctantly took him home, and that night he 
drank half a gallon of antifreeze and he committed suicide.
  How about Nancy T. Vogel? She had a total abdominal hysterectomy to 
remove two tumors that weighed more than 3\1/2\ pounds. Her doctor said 
she needed at least 96 hours in the hospital to recover. As a 
physician, I would say that is the minimum. An HMO nurse looked at 
Millimen and Robertson's guidelines, guidelines that are used by HMOs, 
and determined that only 48 hours was medically necessary. So she left 
after 48 hours.

[[Page H1834]]

  I would argue that those definitions of ``medical necessity'' are a 
medical judgment under those HMO contracts. I think a licensed 
physician should be the one making those medical judgments, not the 
HMO. And certainly not based on guidelines like Millimen and 
Robertson's. In fact, Millimen and Robertson's itself admits that its 
guidelines are not based on prevailing medical opinion but are 
``goals'' that predict what should happen in the best cases with 
patients free of any complications.
  How about this case? Another medical judgment case by an HMO. A 
little baby, James, who was about 6 months old when this picture was 
taken. One night he has a temperature of about 104, 105. He is really 
sick. It is 2 or 3 in the morning. His mother phones the 1-800-HMO 
number, explains that her baby is really sick and needs to go to the 
emergency room, and from some disembodied voice thousands of miles away 
she gets instructions: I want you to go to this particular hospital, 
and that is the only hospital I will authorize you to go to, because 
that is the only one we have a contract with. And the mother says, 
well, where is it? And the reviewer says, well, I do not know, find a 
map.

  So they start looking for this hospital. It is 70 miles away, clear 
on the other side of Atlanta, Georgia. But mom and dad, they are not 
medical professionals, they do not know exactly how sick little James 
is. They do know that if they go to an unauthorized hospital they will 
be stuck with the bill, and they are not rich people.
  So they bundle Jimmy up, they start on their trip, and halfway 
through the trip they pass three emergency rooms that they could have 
stopped at but for which they did not have an authorization. They were 
not told by the reviewer that their baby was really sick, take him to 
the nearest emergency room. Oh no, we will only authorize care at this 
very distant hospital. And before they get to the hospital, little 
James has a cardiac arrest.
  So imagine this. You are dad, driving like crazy, and mom trying to 
keep this little baby alive, after the HMO makes a medical judgment 
over a telephone never having seen the baby. Well, they come screeching 
into the emergency room. Mom leaps out of the car screaming, ``Save my 
baby. Save my baby.'' Nurses come running out, and they manage to get 
an IV started. They manage to get the baby's heart going, and they save 
his life. The wonders of modern medicine. But they were not able to 
save all of Jimmy, because Jimmy ended up with gangrene in both hands 
and both feet. Because of that HMO's medical judgment, both of his 
hands and both of his feet had to be amputated.
  My colleagues will be happy to know that under a Federal law that was 
passed by Congress 25 years ago, that HMO is liable for nothing for 
that negligent medical decision other than the cost of care needed, 
i.e., his amputations. Is that justice?
  We had testimony 4 years ago in front of my committee from an HMO 
medical reviewer who testified that she had made decisions that had 
cost people their lives. She had denied them proper care, and she could 
hide behind what she called the smart bomb of HMO cost containment: 
denials on medical necessity.
  In fact, under contracts that HMOs can write, they can define medical 
necessity in any way they want to under the Federal law ERISA. They can 
write a contract with an employer that says we define medical necessity 
as the cheapest, least expensive care. A person who does not have 
enough blood supply going to his legs, where a physician could save the 
legs by vascular reconstruction, that HMO could justify an amputation. 
Because, after all, under their own definition, that is the cheapest, 
least expensive care.
  We have to do something to fix this. This is a travesty. We have been 
having this debate on patient protection for 5 years now, and yet the 
forces of the HMO industry have spent hundreds of millions of dollars 
to try to defeat us. Eighty-five percent of the people in this country 
want to have Congress fix that Federal law. They think Congress should 
do something to prevent a travesty like this from happening.

                              {time}  1700

  Our bill would do that. The Ganske-Dingell bill in the House, the 
McCain-Edwards bill in the Senate, we set up a system to prevent this 
type of thing from happening, Mr. Plocica from being sent home 
prematurely from the hospital and then committing suicide.
  We set up a review process because if there is a disparity based on 
standard of care, ultimately you can go to an independent review panel. 
Even on an expedited basis, you can get an independent panel to make a 
medical judgment, a panel that does not have a conflict of interest, 
that is not paid for by the HMO, so that you would know that they would 
be independent and be giving you the truthful answer.
  We believe our bill would prevent the types of lawsuits that resulted 
from the care that Nancy Vogel received. But more importantly, we think 
that if our bill were law, we could help prevent a little boy from 
losing both hands and both feet, Mr. Plocica from committing suicide, 
Nancy Vogel from being sent home prematurely after having 3.5 pounds of 
tumor removed from her belly.
  I ask my colleagues to talk to their constituents back home about 
this issue. I guarantee that a very large percentage of them will not 
have been treated fairly by their employer's health plan, or they know 
somebody at work who has not been treated fairly, or they have a family 
member who has not been treated fairly. Let us pray to God that they 
have not had somebody who has lost their life, because that has 
happened also, as has been outlined in cover stories in Time magazine.
  It is time for this Congress to do something on the Patients' Bill of 
Rights, something real, not an HMO protection bill, but something that 
helps people.
  I urge this Congress to move forward expeditiously. I urge the Senate 
to bring this bill up as soon as possible, and I think that we will do 
that on the House side also. I ask my colleagues not to listen to the 
HMOs.
  Whose side are you going to be on? Are you going to be on the side of 
your constituents and your patients, or are you going to be on the side 
of the HMOs? Can you justify a Federal law that gives legal immunity to 
health plans that are making life-and-death decisions millions of times 
a day, when just a year ago we held hearings in this House on 
Bridgestone and Firestone, on tires that blew up. Is there any other 
industry in this country that has legal immunity other than foreign 
diplomats?
  It was a perversion of the law 25 years ago, that was passed to be a 
consumer protection law for pensions, that became an avenue for HMOs to 
avoid their responsibility, a way for them to cut corners regardless of 
whether it hurt people. This Congress has a moral obligation to come 
back and fix that Federal law. We should do it soon.
  Now let me talk a little bit about another health care issue that is 
really important. That is the issue of the high cost of prescription 
drugs.
  Mr. Speaker, this is a photo of Bill Newton. He is 74 years old from 
Altoona, Iowa, my district. His savings vanished when his late wife, 
Juanita, whose picture he is holding, needed prescription drugs which 
cost as much as $600 per month. He said, ``She had to have them. There 
was no choice. It is a very serious situation and it is not getting any 
better because drugs keep going up and up.''
  Mr. Speaker, I have constituents that write me letters, some of them 
go down to Texas for vacation and they go across the border to Mexico 
and they find that their prescription drug costs are half of what they 
are in the United States. Look at the difference in drug costs between 
the United States and Europe.
  Premarin: U.S. price, $14.98; European price, $4.25. Coumadin: 25 
pills, 10 milligrams, $30 in the United States, $2.85 in Europe.
  How about Claritin, for 20 10-milligram pills, it costs $44 in the 
United States and it costs $8.75 in Europe.
  We need to do something about this. We need to do something about the 
high cost of prescription drugs, not just for senior citizens, but for 
everyone. Because, Mr. Speaker, the main reason why health insurance 
premiums have gone up so fast in the last couple of years has been to 
cover the 20-25 percent annual increase in the cost of prescription 
drugs.
  Now, last year, we had a Republican bill and a Democratic bill. Both 
of

[[Page H1835]]

them were voluntary. Both of them were set up essentially so that a 
person had to have about $1,000 out-of-pocket expense before they would 
get a benefit for the increased premiums that they would pay. And both 
of those bills' premiums were premised on the fact that 85 percent of 
seniors would sign up for the program.
  Mr. Speaker, look at this data from 1999: 14 percent of senior 
citizens had no drug expenditures a couple of years ago; 36 percent had 
less than $500; another 19 percent had less than $1,000. That meant 
that 50 percent of the Medicare population had drug expenses that were 
less than what the cost of their premiums would have been under either 
the Republican or the Democratic plan last year. Under a voluntary 
plan, that becomes very questionable whether people will sign up for a 
benefit if it is going to cost them more than the benefit is worth.
  Last year, when I talked about this on the floor, we had some 
predictions in terms of what those costs would be.
  I remember back in 1988, I was not in Congress then, but I remember 
when Congress passed a catastrophic bill with a prescription drug 
benefit, passed it one year and repealed it the next because the senior 
citizens did not like the premium increases. I remember within 6 months 
the Congressional Budget Office had doubled their estimates for what 
the cost would be.
  I think it is informative to look at what the estimates today are for 
what last year's House Republican and the Democratic bills were. Last 
year, the House Republicans estimated that the bill would cost $150 
billion. The new estimate in about a 6-month period of time is now, and 
if that bill were law, it would cost $320 billion. So in a 6-month 
period, the estimate for the cost of the Republican bill, that passed 
this House, more than doubled.
  How about the Democratic bill from last year, the Daschle bill? It 
was estimated last year that it would cost $300 billion. This year the 
estimate, if that were law, it would cost $550-$600 billion.
  Now, here are some figures that are mind-boggling. The CBO, the 
Congressional Budget Office, estimate for how much prescription drugs 
would cost senior citizens for the years 2002 to 2011 is $1.456 
trillion. Now, last year, we thought that the Federal Government would 
cover about, roughly speaking, 35 percent of that cost. That means that 
the estimate from last year, which was $150 billion, would be today 
$510 billion.
  Last year, we estimated the cost at providing full coverage for low-
income seniors to be something in the range of $80 billion. Well, if we 
look at the new figures, if we are talking about covering prescription 
drugs for people who are below the poverty line, for 100 percent of 
people below the poverty line, we are now looking at an estimate of 
$255 billion. If we move it up to 135 percent, it would be $425 
billion. If we move it up to 175 percent, it would be $600 billion.
  Some of those costs are already being covered by Medicaid, so 
probably $120 billion could be deducted from this, which means that if 
we are talking about covering low-income seniors, let us say from 135 
percent of poverty to 175 percent of poverty, we are probably looking 
at needing at least $300 billion just to do that.
  Now, Mr. Speaker, I want my colleagues to listen to this. Under the 
current budget resolution which will probably come to the House in the 
next few days, we have only budgeted $300 billion for a prescription 
drug benefit. That means that we would essentially cover low-income 
seniors and no one else. But I would bet that 6 months from now those 
estimates will be readjusted higher than they are now. That is just 
typically the way that it has been when we have tried to estimate 
prescription drug costs.
  That is why I have a bill before Congress which I encourage my 
colleagues to sign onto that I think is realistic. It addresses the 
difference in cost between prescription drugs made in the U.S., but 
sold overseas, and helps fix the reimportation loopholes. It does that.
  But for Medicare, it will help the low-income senior citizen who is 
not so poor that he or she is already on Medicaid, getting a drug 
benefit from Medicaid, but allow senior citizens up to 135 percent of 
poverty and then phased out to 175 percent of poverty to utilize the 
State Medicaid drug programs and pay for it from the Federal side. We 
are not requiring a match from the State legislatures or the State 
governors because a lot of them are finding that they are under 
budgetary constraints.
  No cost share; we provide for this on the Federal side, but we 
utilize the State programs that are already in place. We do not have to 
duplicate the wheel. Those State programs have already negotiated 
discounts with the pharmaceuticals, and that benefit, I think, would 
fit within what we are talking about for a budget. And it is an 
important first step on this.
  Mr. Speaker, it would help the senior citizen, the elderly widow who 
today is trying to pay her energy bills, her food, her housing, and her 
prescription drugs off of a Social Security check. She needs that help; 
and we can do that.
  But I want to tell my colleagues what the really scary statistic is. 
That is that these 10-year projections for what the costs are going to 
be for prescription drug coverage, whether we are talking at the 35 
percent level or a 50 percent level, they all go up, and this is really 
important, I hope my colleagues are listening to this, these estimates 
are all from 2002 to 2011.

                              {time}  1715

  I want to ask my colleagues something. What happens in the year 2012? 
I will tell my colleagues what happens. The baby boomers start to 
retire in 2012. That age wave, my demographic group, the baby boomers, 
start to retire. We will double the number of Medicare senior citizens 
in about 20 years, but we start that in the year 2012. If my colleagues 
think that this prescription drug program is expensive now, wait till 
2012 when the baby boomers start to retire and we will not just see 
$1.4 or $1.5 trillion, we will see multiple trillions of dollars. And 
then we are going to have to ask ourselves, how do we find those funds? 
How do we keep the other aspects of Medicare such as hospital care 
going?
  We cannot just think, Mr. Speaker, about a 10-year window. We have to 
take into account that in 2012, 1 year past this 10-year window, the 
baby boomers start to retire; and we are going to see astronomical 
increases in Medicare costs. I beg my colleagues, when we are looking 
at doing a benefit on prescription drugs, and next year when the 
elections start to roll closer and the pressures get heavy to get 
something done on prescription drugs, which I think we ought to, and I 
think we ought to help senior citizens who need it the most, let us 
look at a way to do this program that helps those that need it the most 
and then see where we are going to be past that 10-year window. Maybe 
Medicare reform will help on that. But I think we ought to see the 
proof in the pudding before we start committing ourselves, not just to 
$1.5 trillion but to multiple, multiple trillions of dollars on a 
prescription drug benefit.
  On that cheery news, Mr. Speaker, I remain eternally optimistic that 
we are going to muddle our way through, that we will pass a real 
patients' bill of rights through a lot of hard work and contention, and 
I am sincerely hopeful that we will be able to look at a prescription 
drug benefit and do the right thing for this.

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