[Congressional Record (Bound Edition), Volume 145 (1999), Part 11]
[House]
[Pages 15767-15770]
[From the U.S. Government Publishing Office, www.gpo.gov]




 URGING HOUSE LEADERSHIP TO BRING MANAGED CARE REFORM TO THE FLOOR FOR 
                                 DEBATE

  The SPEAKER pro tempore (Mr. Gary Miller of California). Under the 
Speaker's announced policy of January 6, 1999, the gentleman from Iowa 
(Mr. Ganske) is recognized for 60 minutes.


Commonsense Recommendations on the Budget, the Balanced Budget Act, and 
                                Medicare

  Mr. GANSKE. Mr. Speaker, I find myself agreeing with the gentleman 
from Texas (Mr. Stenholm) on many of the issues that he has talked 
about regarding the budget. We are dealing primarily with what looks 
like a projected $1 trillion surplus. That is assuming that we do not 
have a recession over the next 10 years, that the economy continues to 
be as strong, and that we stay within budget caps related to the 1997 
Balanced Budget Act.
  But as my friend and colleague, the gentleman from Texas, rightly 
points out, I think we will need to go back and do some adjustments on 
the Balanced Budget Act, particularly as it relates to health care.
  I have a lot of rural hospitals in my district, and there is a large 
teaching hospital in my State, just like there is in Texas, just like 
there is in every State in the country. Those rural hospitals and 
teaching hospitals over the next 4 or 5 years are going to lose 
millions and millions of dollars, and they will be in the red. We need 
to do something to adjust the payments, and we are not just talking 
about reductions in the rate of growth for their reimbursement, we are 
talking about a decrease, a real decrease and cuts from today.
  For instance, the average rural hospital in the State of Iowa, my 
home State, currently gets paid by Medicare about $1,200 for their 
costs for a patient who has a cataract operation. That is projected to 
decrease to about $950 under the Balanced Budget Act. That is a real 
cut, that is not a reduction in the rate of growth. I could go through 
one procedure after another.
  So when we look at the total budget, we have to also look at some 
adjustments that we are going to have to make in terms of Medicare. We 
are going to have to look at some real adjustments we are going to have 
to make in order to get our appropriations bills passed.
  We cannot bring to the floor and expect it to pass a bill that would 
cut spending for the FBI by 20 percent. We cannot bring to the floor 
and expect the bill to pass if we would reduce funding for the 
immigration service, the INS, by 15 to 20 percent. That is a cut, not 
just reduce the rate of growth in their cost of living allowance. These 
are some real facts we are going to have to deal with.
  Just like my friend, the gentleman from Texas, I think we ought to 
have a tax cut as well. But I cannot support an $870 billion tax cut 
that we are talking about here in the House, not $870 billion out of $1 
trillion in terms of the surplus.
  I think it would be much more reasonable for us to sit down, reach 
across the aisle, reach down Pennsylvania Avenue, and come to an 
agreement. Let us do some adjustments on that Balanced Budget Act, 
maybe one-third of that surplus. Let us maybe do one-third of that 
surplus for a tax cut. That is still a hefty tax cut.
  And let us do something that all of my constituents say we ought to 
do. For once, and it would probably be the first time in 50 or 60 
years, let us actually reduce the Nation's debt. Let us do some real 
deficit reduction. I got elected in 1994 and took office in 1995. The 
debt has increased every year since I have been in Congress. We have an 
opportunity this year to actually reduce the national debt.
  What would be the benefit of that? Well, it would help reduce 
interest rates for everyone in the country. That makes a big difference 
if one is paying for a house or buying a car. By reducing that total 
debt that the country has, which is over $5 trillion, by reducing that 
now, it gives us some cushion for what we will have to spend later on 
when the baby boomers retire.
  Those are just some commonsense recommendations to my colleagues on 
both sides of the aisle.
  Mr. Speaker, I want to talk primarily tonight about managed care 
reform. So I find myself standing on the floor yet again calling for 
comprehensive patient protection to be debated on the floor of the 
House of Representatives as soon as possible.
  By the way, Mr. Speaker, do Members know the difference between a 
PPO, an HMO, and the PLO? At least, Mr. Speaker, with the PLO, you can 
negotiate.
  Mr. Speaker, the clock continues to tick on our legislative calendar. 
So I ask, for the hundredth time, when are we going to debate 
comprehensive managed care legislation on the floor of the House of 
Representatives, and will the debate be fair? And when will the House 
Committee on Commerce mark up a managed care reform bill?
  The decision was made to let the Committee on Education and the 
Workforce take up the comprehensive patient protection legislation 
first, but they are stalled. Nothing has happened in the Committee on 
Commerce, and nothing is happening in the other committees.
  How can any of us say that we are making a strong effort to address 
managed care reforms when the Committee on Commerce, the committee of 
primary jurisdiction, has yet to hold a markup session on a managed 
care bill?
  Before I go any further, I want to commend my colleagues, the 
gentleman from Georgia (Mr. Norwood) and the gentlewoman from New 
Jersey (Mrs. Roukema), for their strong advocacy of strong patient 
protection legislation in the Committee on Education and the Workforce.
  My colleagues have pointed out that the bills of the Committee on 
Education and the Workforce that were touted to be comprehensive 
managed care bills were, in reality, nothing more than an assurance of 
business as usual for the HMOs. Actually, they were not even business 
as usual, as those bills from the Committee on Education and the 
Workforce actually make it harder for patients to fight HMO abuses 
under the Employee Retirement Income Security Act, ERISA.
  Mr. Speaker, I have spoken many times on this floor about how 
important it is for patients to have care that

[[Page 15768]]

fits what are called ``prevailing standards of medical care.'' This 
issue is being debated here on Capitol Hill this week by the other 
body. It is a very, very important issue. So I want to spend a little 
bit of time to talk to my colleagues about this issue.
  Mr. Speaker, many health plans devise their own arbitrary guidelines 
and definitions for ``medical necessity.'' For example, one HMO defines 
``medical necessity'' as the cheapest, least expensive care, without 
any qualification ensuring that patients will still receive quality 
health care coverage.
  We might ask, how is it that HMOs are allowed to do that? That is not 
the case for the majority of insurance companies who sell to individual 
people. They have to follow State insurance laws. Under current Federal 
law, if you or a member of your family is insured by your employer in a 
self-insured plan, your employer can define ``medical necessity'' as 
anything that they want to. Furthermore, they are not liable for their 
decisions, except insofar as to give care that could be denied.
  ERISA was originally designed as a consumer pension bill. It was 
designed to make pension plans uniform for employees, to make it easier 
for employers to issue pensions. It got extended to health plans sort 
of by a quirk 25 years ago. It was not even hardly debated here on the 
floor.
  It did not make that much difference for a long time, when most 
health plans were traditional indemnity insurance plans. Then along 
came managed care. What happened? Those companies started making 
medical decisions. Then we started to run into the problems and the 
complications of those medical decisions.
  Listen to some words that a former HMO reviewer gave as she testified 
before Congress. It was May 30, 1996, when this small, nervous woman 
testified before the Committee on Commerce. Her testimony came after a 
long day of testimony on the abuses of managed care.
  This woman's name was Linda Peeno. She was a claims reviewer for 
several health care plans. She told of the choices that plans are 
making every day when they determine the medical necessity of treatment 
options.
  I am going to recount her testimony: ``I wish to begin by making a 
public confession.'' This is this HMO medical reviewer's words. ``In 
the spring of 1987, I caused the death of a man. Although this was 
known to many people, I have not been taken before 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,'' she said. 
``It brought me an improved reputation in my job and contributed to my 
advancement afterwards. Not only did I demonstrate that I could do what 
was expected of me, I exemplified the good company medical reviewer. I 
saved the company half a million dollars.''
  As I was watching this lady testify, I could see that she was 
anguished. Her voice was husky. She was tearful. I looked around the 
room, and the audience shifted uncomfortably. They drew very quiet as 
her story unfolded. The industry representatives, the HMO 
representatives who were in that committee room, they averted their 
eyes.
  She continued: ``Since that day, I have lived with this act and many 
others eating into my heart and soul. For me, a physician is a 
professional charged with the care of healing of his or her fellow 
human beings. The primary ethical norm is do no harm. I did worse. I 
caused death.''
  She continued, ``Instead of using a clumsy, bloody weapon, I used the 
cleanest, simplest of tools: My words. This man died because I denied 
him a necessary operation to save his heart. I felt little pain or 
remorse at the time. The man's faceless distance soothed my conscience. 
Like a skilled soldier, I was trained for the moment. When any moral 
qualms arose, I was to remember, I am not denying care, I am only 
denying payment.''
  She continued: ``At that time, that helped me avoid any sense of 
responsibility for my decisions. Now I am no longer willing to accept 
the escapist reasoning that allowed me to rationalize that action.''

                              {time}  2215

  I accept my responsibility now for that man's death as well as for 
the immeasurable pain and suffering many other decisions of mine 
caused.
  Well, at that point Ms. Peeno described many ways managed care plans 
deny care, but she emphasized one in particular: The right to decide 
what care is medically necessary. She said, quote, ``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 necessity 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 are rarely 
available for prior review by the physicians or the members of the 
plan. And we have enough experience from history to demonstrate the 
consequences of secretive unregulated systems that go awry.''
  Well, Mr. Speaker, the room was stone quiet. The chairman of the 
committee mumbled ``thank you.'' This medical reviewer could have 
rationalized her decisions as so many have done. She could have said, 
``I was just working within guidelines'' or ``I was just following 
orders.'' We have heard that one before. Or, ``We have to save 
resources.'' Or, ``Well, this is not about treatment, it is really 
about benefits.''
  But this HMO reviewer refused to continue this type of psychological 
denial and she will do penance for her sins the rest of her life. And 
to atone for that she is exposing the dirty little secret of HMOs 
determining medical necessity.
  Mr. Speaker, if there is only one thing my colleagues learn before 
voting on patient protection legislation, I beg them to listen to the 
following: before voting on any patient protection legislation, keep in 
mind the fact that no amount of procedural protection or schemes of 
external review can help patients if insurers are legislatively given 
broad powers to determine what standards will be used to make decisions 
about coverage. As Ms. Peeno so poignantly observed, insurers now 
routinely make treatment decisions by determining what goods or 
services they will pay for.
  Let me give an example of how they can arbitrarily determine medical 
necessity. There is a health plan out there that determines medical 
necessity by defining it as: The cheapest, least expensive care as 
determined by us. So well, what could be wrong with that? What is wrong 
with the cheapest, least expensive care?
  Well, before I came to Congress and in some surgical trips that I 
make abroad I still do this, I took care of a lot of children with 
cleft lips and palates. Let me show the birth defect of one of these 
children. This is a little baby born with a complete cleft lip and 
palate. This occurs about one in 500 births, so it is pretty frequent. 
A huge hole right in the middle of the face. Imagine being a mom or dad 
and giving birth to a little baby with this birth defect, and then 
think of that HMO that defines medical necessity as the cheapest, least 
expensive care.
  Mr. Speaker, the prevailing standard of care, a standard that we have 
used in this country for over 200 years, would say the prevailing 
standard of care to fix this defect in the roof of this child's mouth 
is a surgical operation to fix that. I have done hundreds of those 
operations. That is the standard care everywhere in the world. However, 
that HMO, by its contractual language, can say but the cheapest, least 
expensive care would be to use what is called a plastic obturator. It 
would be like an upper denture plate. That way the food will not go up 
into the roof of the mouth, up into the nasal passages so much.
  Of course, with that little plastic device which would be the 
cheapest, least expensive care, the child will probably never speak as 
good as if the child had a surgical correction of this birth defect. 
But so what does the HMO care? They are increasing their bottom line, 
their profits. And furthermore, under Federal law they can define it 
any way they want to by their contractual language if one happens to 
get their insurance from an employer.
  Mr. Speaker, I think that is a tragedy. I think that is a travesty. 
Congress created that law 25 years ago

[[Page 15769]]

never expecting that this type of behavior would be done by HMOs. Yet 
50 percent of the reconstructive surgeons who take care of children 
with this birth defect have had HMOs deny operations to surgically 
correct this condition by calling them, quote, ``cosmetic operations.''
  This is not a cosmetic operation. Cosmetic operations are repairing 
baggy eyelids or a face lift. This is a birth defect. Prevailing 
standards of care would say surgical correction, not a piece of plastic 
shoved up into the roof of a patient's mouth with food and fluid coming 
out of their nose.
  Who would do that, some would ask? Well, it happens. And we need to 
fix the Federal law that keeps that happening. What else about that 
Federal law needs to be fixed? Well, over the last few days I have 
watched the debate up here on the Hill in the other body. There was an 
amendment that dealt with who would be covered by patient protection 
legislation. The GOP bill would only cover about one quarter of the 
people in this country. There was an amendment to make it cover 
everyone in this country, these patient protections. Getting up and 
arguing against it were my GOP colleagues by saying, hey, we should not 
interfere with the States's ability, States's rights, let the States 
decide this. The only problem with this is that it is Federal law that 
has exempted State regulation and State oversight.
  I want to see in a few days if my colleagues will talk the same tune 
when we are talking about liability. It was Federal law that gave a 
liability shield to HMOs so that if they do negligent, malicious 
behavior that results in injury, loss of limb, or death that they are 
not responsible.
  Let me give an example of what I am talking about in terms of what 
HMOs have done. This is the case of a little 6-month-old boy. A little 
6-month-old boy in Atlanta, Georgia, actually lives south of Atlanta, 
Georgia, woke up one night crying about 3:00 in the morning and had a 
temperature of 104 and looked really sick. His mother thought he needed 
to go to the emergency room. This is this little boy tugging on his 
sister's sleeve before his HMO health care. So his mother phoned the 1-
800 number and she is told, ``We will authorize you to go to an 
emergency room, but we will only let you go to this one hospital a long 
ways away. And if you go to a nearer one, we will not cover it.''
  So Dad gets in the car, Mom wraps up little Jimmy and they start on 
their trek. About halfway through the trip, they pass three hospital 
emergency rooms. Mom and Dad are not health professionals. They know 
Jimmy is sick but they do not know how sick, but they do know if they 
stop without an authorization, they could get stuck with thousands of 
dollars of bills because their HMO will not pay for it. So they push on 
to that one authorized hospital.
  What happens? En route, little Jimmy's eyes roll back in his head, he 
stops breathing, he has a cardiac arrest. Picture Mom and Dad, Dad 
driving like crazy, Mom trying to keep her little infant alive to get 
to the emergency room. Somehow or other they manage to get to the 
emergency room. Mom holding little Jimmy leaps out the car screaming, 
``Help my baby, help my baby.'' A nurse comes out and starts to give 
mouth-to-mouth resuscitation. They bring out the crash cart and get him 
intubated and get the lines going and give him medicines and somehow or 
other this little baby lives. But he does not live whole.
  Because he has had that cardiac arrest en route to the hospital, the 
only one authorized by that HMO which has made that medical decision, 
he ends up with gangrene of both hands and both feet and both hands and 
both feet have to be amputated.
  Here is little Jimmy today. I talked to his mom about 6 weeks ago. 
Jimmy is learning to put on his leg prostheses with his arm stumps. He 
still cannot get on his bilateral hook prostheses for his hands by 
himself. Jimmy will never play basketball. He will certainly never 
wrestle. And some day when he gets married, he will never be able to 
caress the face of the woman that he loves with his hand.
  Mr. Speaker, under Federal law if one's little baby had this happen 
to them and their insurance was from their employer who had a self-
insured plan and their plan had made that decision, that negligent 
decision which had resulted in this disaster, under Federal law that 
plan would be liable for nothing other than the cost of the 
amputations.
  Is that fair? Is that the way it is if one buys insurance as an 
individual from a plan that is covered by State regulation? No. So, Mr. 
Speaker, I would say to my colleagues, my colleagues in the other body 
and my colleagues in this body, when we get a chance to vote on whether 
health plans ought to be liable for decisions that they make that 
result in this type of negligence, a judge reviewed this case. A judge 
looked at the case. He said that the margins of safety by this HMO 
were, quote, ``razor thin.'' I would add to that, about as razor thin 
as the scalpels that had to remove little Jimmy's hands and feet.
  Mr. Speaker, I say to my friends on both sides of the aisle and in 
the other body, when we get a chance to vote on whether a health plan 
should be responsible for their actions that result in this type of 
injury, think, especially my fellow Republicans, think about how we 
always say as Republicans, hey, people should be responsible for their 
actions. Do not we say that? If somebody is able-bodied and they can 
work, they ought to be responsible for providing for their family? Do 
not we say that if somebody kills somebody or is a rapist that they 
ought to be responsible for their criminal behavior?
  How can we then say that an HMO which makes this type of decision 
that results in this type of injury should not also be responsible? 
There is no other entity, no other business, no other individual in 
this country that has that type of legal protection. It is wrong. It 
should be fixed.
  The State of Texas fixed this 2 years ago. They made their health 
plans liable. Now, of course this is being challenged because of the 
ERISA law. But since that time there has not been an explosion of 
lawsuits. There has only been one. I will read about it in a few 
minutes. But why has there not been? Because health plans suddenly 
realized that they cannot cut corners like they did with this little 
boy or they are going to be liable. They are going to be responsible.

                              {time}  2230

  Did it significantly increase premiums in Texas? No. Premiums in 
Texas have not gone up any higher than they have anywhere else in the 
country. Did it mean that managed care would die out in Texas? No. 
Several years ago, there were 30 HMOs in Texas. Today, there are 51. 
That law is working. It did not result in a huge number of lawsuits, 
and it has not resulted in a big increase in premiums like all the HMOs 
would have us believe.
  Let me read today an editorial from USA Today. The title of this is, 
``Why should law protect HMOs that injure patients?''

       Last July, Joseph Plocica's health plan discharged him from 
     a hospital, against the advice of his psychiatrist, who said 
     the Fort Worth resident had suicidal depression requiring 
     continued help, according to a lawsuit. That night, Plocica 
     proved his doctor right and his health plan wrong. He drank a 
     half-gallon of antifreeze and died 8 days later.
       As terrible as this story is, at least Plocica's bereaved 
     family has more rights than most. A sweeping 1997 Texas law 
     let them sue Plocica's health plan for malpractice.
       That's a right denied to the roughly 120 million other 
     Americans who receive their health care through work. This 
     week, the federal law that protects those health plans from 
     lawsuits is the focus of a contentious Senate debate over 
     patients' rights.
       The central question: Should HMOs, which often make life 
     and death decisions about treatments, be legally accountable 
     when their decisions go tragically wrong?

  Like Mr. Plocica who drank antifreeze or little Jimmy here who lost 
his hands and feet.
  ``Right now'', the USA Today editorial continues,

     the answer is no, although that is a luxury no doctor, and no 
     other business, enjoy.

[[Page 15770]]

       The provision might have made sense when it was passed by 
     Congress in 1974 as part of a law designed to protect 
     workers' pensions. Most employees were covered by old-style 
     fee-for-service insurance plans and payment disputes took 
     place after health care had been delivered. So a law limiting 
     recovery to the cost of care did not hurt anybody. But today, 
     more than 80 percent of workers are in managed care plans 
     that actively direct what treatments parents received.
       Unfortunately, despite efforts in Texas and a few other 
     states to find ways around this law, the gaping liability 
     loophole is not likely to be closed nationwide any time soon

unless Congress acts.

     Insurance and business groups have mounted an aggressive 
     fight against a version of the Patients' Bill of Rights that 
     allows patients to sue. They say opening up HMOs to lawsuits 
     will result in a flood of litigation and kill cost control by 
     doing little too improve quality care.
       But in Texas, where these same groups made all the same 
     arguments, the reality is far from different.
       No flood of lawsuits. Only a handful of cases have been 
     filed against HMO plans in Texas since the challenge to the 
     law was overturned last fall. This is due, in part, to 
     another feature of that 1997 law, which requires swift 
     independent review of disputes.
       Rates have not shot up. In the two years since the law was 
     passed, HMO premiums in the state are almost exactly where 
     they stood in 1995. Cost increases in Dallas and Houston were 
     below the national average last year.
       Quality may be improving. News accounts from Texas suggests 
     that HMOs, now accountable for their decisions, are more 
     careful making

those decisions.

     Doctors report health plans are less likely to drag their 
     feet, for instance, and less likely to deny treatments 
     doctors believe are needed.
       There's no reason to believe a national law would produce 
     any different results,

continues this editorial.

     Studies by the Congressional Budget Office and the nonprofit 
     Kaiser Family Foundation find HMO liability would produce 
     negligible premium hikes. Only industry-sponsored studies 
     find otherwise.
       Lawmakers would do well to look at the facts before leaving 
     this critical patient right on the cutting room floor.

  Mr. Speaker, I do not think we should hesitate about having HMOs be 
responsible, despite the fact that the HMO industry has spent more than 
$100,000 per Congressman lobbying against a strong Patients' Bill of 
Rights. Surveys show that, despite all that advertising, that money 
spent on advertising by the insurance and HMO industry for the last 2 
years, there has been no significant change in public opinion about the 
quality of HMO care.
  Despite tens of millions of dollars of advertising, a recent Kaiser 
survey shows no change in public opinion: 77 percent favor access to 
specialists, 83 percent favor independent review, 76 percent favor 
emergency room coverage, 70 percent favor the right to sue one's HMO. 
Other surveys show that 85 percent of the public think Congress should 
fix these HMO abuses.
  If these concerns are not addressed, I think the public will see 
examples like this, and they will ultimately reject the market model as 
it now exists. However, if we can enact true managed care reform such 
as that embodied by my own Managed Care Reform Act of 1999 or the 
Dingell or the Norwood bills, then consumer rejection of a market model 
will be less likely.
  Common sense, responsible proposals to regulate managed care plans 
are not a rejection of the market model of health care. In fact, they 
are just as likely to have the opposite effect. They will preserve the 
market model by saving it from its own most irresponsible and 
destructive tendencies.
  Mr. Speaker, let us pass real HMO reform. Let us learn from States 
like Texas. After all, is it not Republicans who often say that the 
States are the laboratories of democracy? Yes, let us have some 
insurance tax incentives. But let us be very careful about repeating 
some mistakes that have been made with ERISA in the past that led to 
fraud in regards to association health plans.
  Finally, the Speaker of the House told me before the July 4th recess 
that it was his intent to have HMO reform legislation on the floor by 
the middle of July. Well, Mr. Speaker, here we are. According to my 
watch, it is now the middle of July, and we have no date yet even for a 
full committee mark-up in the House of Representatives. Why? Well 
because it is not clear that another HMO protection bill could make it 
through committee. Too many Republicans and Democrats of each committee 
want to see some real reform to prevent this type of tragedy, real 
reform, not a fig-leaf piece of legislation.
  I think there are even majority votes in both the Committee on 
Education and the Workforce and the Committee on Commerce for strong 
medical necessity and enforcement measures. Maybe that is the reason 
why the committee chairmen are not moving ahead. Maybe that is why the 
leadership of this House is not telling them to get their act in order, 
get this to the floor.
  Well, the Senate is debating HMO reform this week. So let us see what 
happens there.
  I think today the Washington Post called it about right when it 
referenced the GOP Senate bill. It said, ``The Republican bill 
professes to provide many of the same protections, but the fine print 
often belies its claims. Among much else, it turns out to apply only to 
some plans and to only about one-fourth as many people as the 
Democratic bill would cover.''
  The Post then talked about the GOP criticisms of the Democratic bill, 
``Critics say that the Democratic bill, by weakening the cost-
containment industry, would drive up costs.'' The Post continues, ``Our 
contrary sense is that, in the long run, it would strengthen cost 
containment by requiring that it be done in a balanced way'', exactly 
the sentiments that I expressed a few minutes ago.
  Today the Washington Post closed that editorial by saying, ``The 
risks of increased costs tend to be exaggerated in debate. The managed 
care industry says that, by and large, it already does most of the 
modest amount this bill would require of it. If so, the added cost can 
hardly be as great as the critics contend.''
  Mr. Speaker, when we are talking about the cost for a strong 
Patients' Bill of Rights, we are talking about something in the range 
of $36 per year for a family of four. Is that not worth it to prevent 
an HMO tragedy like happened to this little boy?
  Mr. Speaker, please keep your promise. By next week, we should have 
debated HMO reform in full committee, and we should be headed to the 
floor. Is that going to be the situation? Or is it the Speaker's 
intention to try to limit debate on this important issue by putting it 
right up against August recess, when Members have planned vacations 
with their families, in order to limit debate.
  Well, Mr. Speaker, if that is so, it will be seen for what it really 
is, a cynical abuse of scheduling because the leadership of this House 
really does not want a full debate on protecting patients. Mr. Speaker, 
I hope that is not the case. The victims of managed care and their 
families are watching.

                          ____________________