[Congressional Record (Bound Edition), Volume 146 (2000), Part 1]
[House]
[Pages 898-901]
[From the U.S. Government Publishing Office, www.gpo.gov]


[[Page 898]]

         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, 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

[[Page 899]]

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 
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

[[Page 900]]

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 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

[[Page 901]]

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 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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