[Congressional Record (Bound Edition), Volume 145 (1999), Part 13]
[House]
[Pages 19288-19290]
[From the U.S. Government Publishing Office, www.gpo.gov]



                          MANAGED CARE REFORM

  The SPEAKER pro tempore (Mr. Vitter). Under the Speaker's announced 
policy of January 6, 1999, the gentleman from New Jersey (Mr. Pallone) 
is recognized for 27 minutes as the designee of the minority leader.
  Mr. PALLONE. Mr. Speaker, in just 3 days, this House will adjourn 
without having brought to the floor the Patients' Bill of Rights, the 
Democrats' legislation for comprehensive HMO reform.
  I bemoan the fact that that is the case. I think that this 
legislation and the need to address the issue of HMO reform is really 
the preeminent issue that needs to be addressed in this House, in this 
Congress, in this session of Congress.
  I have to say that the Republican leadership since the beginning of 
the year has made many promises with regard to the Patients' Bill of 
Rights and the whole issue of HMO reform. First, the Speaker said that 
we would follow the normal committee process and an HMO reform bill 
would have hearings in the relevant committees and have a markup in 
committee and come to the floor in the normal way, but that has not 
happened.
  Then, as Members know, in the other body basically the Democrats 
forced the issue, forced the other body to bring up HMO reform. 
Unfortunately, the bill that was finally passed was not real reform, 
was ineffective, was a sham, but the impetus, if you will, that at 
least some sort of HMO reform would be brought up in the Senate caused 
the Speaker and the Republican leadership just a few weeks ago after 
the Senate took action and had a hearing and had a markup on the floor, 
basically forced the Speaker to say that a bill would come to the 
floor, an HMO reform bill would come to the floor in the House of 
Representatives sometime before the August recess.
  Well, Mr. Speaker, the August recess begins probably this Friday and 
Democrats have basically been pushing to achieve action here on the 
floor for the Patients' Bill of Rights, our Democratic HMO reform. We 
actually had Members come to the floor over here in the well and sign a 
discharge petition that would force the Republican leadership to bring 
up our Patients' Bill of Rights. One hundred eighty-three Members 
signed that discharge petition. But now ultimately to no avail. The 
Speaker, the Republican Speaker, just announced that no action will be 
taken on the bill before the August recess.
  I ask why? The answer, I think, is very simple. That is, because the 
Republican leadership here in the House as well as in the Senate is a 
captive of the insurance industry. The insurance industry does not want 
a true HMO reform, a true comprehensive bill to come to the floor of 
the House because, unlike the other body, they realize that if it does, 
it will pass. Some of my colleagues, a handful of my colleagues on the 
other side who are health care professionals, doctors, dentists, have 
made the point that they will vote for a strong HMO reform bill, 
something akin to the Democrats' Patients' Bill of Rights. When they 
made that statement and basically indicated to the Republican 
leadership that they would join with the Democrats in passing a bill, 
well, all of a sudden this week we find that the Speaker and the 
Republican leadership say, ``No, no, we're not going to bring a bill to 
the floor. We can wait until the fall. We'll have further discussions. 
No action will be taken now.''
  I just want to commend the Republicans on the other side of the 
aisle, those few, all of whom, I think, who have been most outspoken 
are health care professionals, doctors, because they have stood up and 
said that we need a strong HMO reform bill and they refuse to say that 
the action taken by the other body meets that

[[Page 19289]]

need. In fact, it does not meet that need.
  Mr. Speaker, if I could, I hope that during the August break and when 
we come back in September that we will see a bipartisan coalition of 
the Democrats, all of whom support the Patients' Bill of Rights, and 
enough Republicans on the other side that will come together in a 
bipartisan way to demand action on something like the Patients' Bill of 
Rights so we can have true comprehensive HMO reform come to the floor 
when we return in September.

                              {time}  2310

  Mr. Speaker, if the House leadership is not willing to bring it up, I 
think we will simply have to get every Democrat to sign the discharge 
petition and join with some of the Republicans who are willing to sign 
it to force the issue to make sure that the Patients' Bill of Rights or 
some strong comprehensive reform like it comes to the floor.
  As my colleagues know, Mr. Speaker, I just wanted to point out that 
increasingly we are seeing every comprehensive report, every study that 
is being done around the country about what the American people want, 
what the health professionals want, what people see basically as common 
sense reform with regard to HMOs, that we need some kind of action 
taken.
  There were two reports that came out just in the last week that I 
wanted to mention tonight. One of them was basically a report, if you 
will, where various doctors and health care professionals were 
interviewed. It was a survey that found nearly nine in 10 doctors and 
more than one in four consumers are having trouble receiving the 
medical care and services they need within the context of HMOs managed 
care, and as a result between one-third and two-thirds of the doctors 
said the service denial resulted in adverse health consequences for the 
patient.
  The types of problems that we are seeing that myself and others have 
documented on the floor about people who have had abusive situations 
with managed care and with HMOs, this is becoming commonplace, and both 
consumers, patients as well as doctors, are decrying the situation, and 
I say to my colleagues and, I guess, to the American people as well, 
why is it that the Republican leadership will not allow us to take 
action when the majority of us in a bipartisan way would like to see 
comprehensive HMO reform? And it always comes back to the same thing, 
and that is the money spent by the insurance industry against this type 
of comprehensive HMO reform.
  The second survey that came out in the last week or so basically said 
that last year 1.4 to $2 billion was paid to lobbyists to influence 
politicians and policy, a 13 percent increase from 1997; and for the 
second year in a row the insurance industry topped the list in lobbying 
costs, nearly $203 million last year alone.
  The Republicans basically on the leadership or amongst the Republican 
leadership are bowing to the insurance industry which is spending 
millions of dollars once again trying to defeat true HMO reform.
  Mr. Speaker, I just wanted to, if I could, make reference to a New 
York Times editorial that was in the New York Times on July 16 of this 
year, and it just kind of sums up what is happening out there and why 
we cannot see action on the House floor, and I quote. It says:
  ``There is no mystery here. Campaign money is dictating medical 
policy in the Senate. The political system and especially the 
Republican party is awash in money from the health care industry. As 
President Clinton said yesterday, and this was back on July 16, GOP 
senators could not support the Patients' Bill of Rights because the 
health insurers will not let them do so. That is the bottom line, Mr. 
Speaker.''
  Mr. Speaker, if I could just use a couple minutes of my time to talk 
about some of the comparisons between the Patients' Bill of Rights, the 
bill that the Democrats and some of the Republicans want to bring to 
the floor, versus the bill that passed the Senate and the one that 
would have been considered, I believe, on the floor pursuant to the 
Republican leadership if they thought that they could get the votes to 
pass it. There is a real contrast, if you will, between that Republican 
Senate bill and the Democratic Patients' Bill of Rights, and let me 
just go through a few highlights of it, if I could this evening.
  The Republican bill, and I refer to the Senate bill, leaves more than 
100 million Americans uncovered because most substantive protections in 
the bill apply only to individuals enrolled in private, employer-based, 
self-funded insurance plans, and self-funded coverage is typically 
offered only by large companies. Only 48 million people are enrolled in 
such plans, and of those 48 million only a small number, at most 10 
percent, are in HMOs.
  So the Senate Republican bill really does not help effectively 
anyone, does not provide patient protections really to almost anyone.
  What the Democrats insist on in the Patients' Bill of Rights and the 
Republicans that support us have said is that all, all 161 million 
privately insured Americans have to be covered by the bill, by the 
patient protections.
  Let me just give my colleagues some of the other examples that I 
think are important. In the Democratic bill we have talked about the 
prudent lay-person standard in the situation where you go to an 
emergency room. This is so important. So many people come up to me and 
say, if I have under my HMO, if I want to go to the local emergency 
room, I cannot. I have to go to one maybe 20 miles away, 30 miles away, 
50 miles away, and when a person is in extremis or has a problem and 
has to go to an emergency room, they do not want to have to travel 20 
or 30 miles away when the emergency room for the local hospital is 
maybe only within a mile distance from where they are.
  Well, under the Democratic bill, what we say is that an individual 
who has symptoms that meet a prudent lay person, what the average 
person would think is the need to go to the emergency room under given 
certain circumstances, that that standard should allow them to go to 
the local emergency room, the closest one, without pre-authorization, 
and the insurance plan must cover the visit. The plan may not impose 
additional charges for use of non-network facilities.
  It is unclear in the Republican Senate bill whether that kind of 
standard would apply. There really is not any prudent lay person 
standard, if you will, in the Republican bill.
  Most important in the Democratic bill is that we provide for adequate 
specialty care. It provides the right in our Patients' Bill of Rights 
to specialty care if specialty care is medically indicated. It ensures 
no extra charge for use of non-network specialists if the HMO has no 
specialist in the network that is appropriate to treat the condition.
  I just wanted to mention a couple other things that I think that are 
really crucial in terms of the differences between the Democratic bill 
and what the Republicans passed in the Senate, and one of those most 
important distinctions is on the issue of medical necessity. The issue 
of medical necessity is basically whether or not a particular type of 
care, operation, equipment, length of stay in the hospital will be 
provided in a given circumstance if you get sick, and basically the 
Republican Senate bill allows HMOs to define what is medically 
necessary. No matter how narrow or unfair to patients, the HMO's 
definition is their definition controls in any coverage situation 
including decisions by an independent third-party reviewer.
  The Democratic bill by contrast codifies a traditional definition of 
medically necessary or appropriate means of service or benefit 
consistent with generally accepted principles of professional medical 
practice. In other words, what we are saying in the Patients' Bill of 
Rights is that the doctor and the patient have to decide based on 
standards that are used for most physicians in a given circumstance. It 
is an independent standard, if you will, not defined by the HMO.
  Most important also, the distinction on the issue of external 
appeals. The Republican Senate bill allows the HMO

[[Page 19290]]

to choose and pay the appeal entity that decides the case. It also 
allows the HMO or insured to define medical necessity, tying the hands 
of the independent review entity and forcing them to defer to the HMO's 
definition. It does not provide, the Republican bill, an appeal when 
most rights under the bill are denied. For example, when emergency care 
is denied or access to a specialist is denied, no appeal is allowed.
  The Democratic Patients' Bill of Rights by contrast ensures the State 
or Federal agency controls the process for choosing the independent 
appeal entity, not the insurer.

                              {time}  2320

  It ensures a de novo review, a fresh look at the facts. It ensures 
the reviewer's decision is based on a statutory definition of medical 
necessity, not the insurer's plan's definition, and the review of best 
available medical evidence, and all denials of care are appealable.
  Finally, the most important distinction between the Democratic 
Patients' Bill of Rights and the Republican Senate bill is the ability 
to hold HMOs accountable. Under the Republican bill, it maintains 
existing Federal law that basically preempts state remedies, and the 
only remedy under ERISA, which is the federally covered plans, is 
recovery of the cost of the denied benefit.
  For example, if a patient is denied a mammogram and dies of breast 
cancer as a result, the only remedy under the Republican bill available 
to the family is the recovery of the costs of the mammogram, not the 
damages that result, including the death of the patient.
  Under the Democratic bill, by contrast, the ERISA presumption of 
State remedies, the ability to go to State court, only exists when the 
actions of an HMO have killed--well, essentially what we are saying is 
that that ERISA preemption is repealed, and you can go to State court 
and you can seek damages and you can recover for the damage that the 
HMO has inflicted, just like you would in any normal tort action.
  Mr. Speaker, I think that there are crucial differences here, and I 
think that ultimately what it comes down to is money. It is a very sad 
day, but what we are seeing is the insurers increasingly spending a lot 
of money on TV trying to get the word out that somehow what we are 
trying to do with the Patients' Bill of Rights is not going to work, 
that it is going to cost more money, that it is not going to achieve 
the desired result.
  The fact of the matter is that the American people are crying out for 
comprehensive HMO reform. They want to see something like the Patients' 
Bill of Rights passed. Again, I want to commend some of my Republican 
colleagues, particularly the physicians on the other side of the aisle 
who are saying, you know, we are practicing doctors. We see what 
happens. We know there are abuses, and we want strong HMO reform 
passed, something like the Democratic bill, and we will work together 
with the Democrats to achieve a bipartisan proposal.
  If I could just conclude tonight, I always like to talk when I come 
to the floor about local people in my part of New Jersey who have had 
problems with HMOs, because that is really what it is all about. We are 
talking a little bit in the abstract here about what needs to be done, 
but the bottom line is it is our own constituents coming to us and 
saying we need HMO reform, we need something done because of what is 
happening to them.
  If I could just conclude tonight with a letter that was in the Asbury 
Park press, which is the largest circulation daily in my district in 
Monmouth County, New Jersey, and this was in the Asbury Park Press, a 
letter to the editor on Thursday, July 15, from Jack Moriarty of Dover 
Township. I am going to read part of it because I think it is so 
telling.
  He says,

       Each time I must deal with my health maintenance 
     organization on any matter other than the routine and the 
     basic, problems continue. This is a system designed and 
     managed to restrict our access to medical care and to place 
     roadblock after roadblock in our way as we attempt to 
     circumvent that design feature.
       On July 6th I sustained an eye injury while swimming when a 
     thumb with sharpened fingernail found its way into my eye. I 
     stopped the bleeding, applied ice and went to bed. This 
     morning there was blood on the pillowcase, the pain had 
     intensified, and my vision was blurred. I reasoned this 
     required an objective medical evaluation to ensure there was 
     no permanent damage. Thus began my hassle for the day.
       What followed was more than a dozen telephone calls to 
     various medical professionals and administrators to get 
     permission to go to the doctor and secure the required 
     referral for them to be paid. I knew what had to be done, but 
     what is the justification for wasting my time and causing me 
     anxiety and aggravation? As a professional, if I am not 
     working, I am not being paid. Consequently, the very real 
     financial loss I endure by sitting in a waiting room makes me 
     choose the medical visit option only as a last resort.
       That day I wasted additional time and resources playing 
     phone tag all around the State trying to get some paperwork-
     pushing clerk to give me permission to do what I knew to be 
     right. And, by the way, we pay for this, which is what truly 
     amazes me.
       What should we do? I suggest we all write to our State and 
     Federal elected officials demanding that they return the 
     right of self-determination in health matters to us by 
     passing the Patients' Bill of Rights and similar state 
     statutes. It is no wonder the doctors are unionizing. Perhaps 
     the patients should too.

  He was talking about an eye injury, but we just know that with the 
case of eye injury or so many other serious problems that people face 
the same reality.
  All I am really saying tonight, Mr. Speaker, because this may be the 
last opportunity we get to talk about this before the August break, is 
let us bring up the Patients' Bill of Rights. Let us bring up HMO 
reform. Let those Democrats and those Republicans, and I see my 
colleague is going to come after me, the gentleman from Iowa (Mr. 
Ganske), let us put together a bill I think that is very close to the 
Patients' Bill of Rights that really provides comprehensive HMO reform. 
This is what the public wants, this is what we keep hearing every day 
from our constituents, and I know that I am going to use the time 
during this August break to go out and explain to the public why we 
need to bring this up on the floor of the House when we come back in 
September.
  I am confident when I see people like my colleague, the gentleman 
from Iowa (Mr. Ganske) and others on the Republican side that are 
demanding that we take action, that when we come back in September, 
either through the means of a discharge petition or because the 
Republican leadership finally sees they have to do something, that we 
will see comprehensive HMO reform. But I am not going to rest, and I 
know the gentleman from Iowa (Mr. Ganske) and a lot of us are not going 
to rest until that happens.

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