Susan Collins

Ms. COLLINS

Ms. COLLINS. I yield 6 minutes to the Senator from Kansas, Mr. Roberts.

Ms. COLLINS. I yield back the remainder of my time if the other side is ready to yield back. I ask for the yeas and nays on the amendment.

Ms. COLLINS. Is there any time remaining?

Ms. COLLINS. Mr. President, one of the myths in this debate is that unless the Federal Government preempts State insurance laws, somehow millions of Americans will be unprotected in their disputes with HMOs. That is simply untrue. Ironically, my friend from Connecticut makes the point on emergency room care. Forty-four States have enacted legislation guaranteeing access to the nearest emergency room. But they have crafted their laws in different ways depending on the needs of those States. Why should the Federal Government second-guess those laws, substitute its judgment for the judgment of State legislators and Governors' offices all over this country? It does not make sense. The proposal of the Senator from Louisiana would be both burdensome to States and ineffective for consumers. Does anyone really believe that a consumer with a problem with his or her insurance policy is better off calling the HCFA office in Baltimore than dealing with their own State bureau of insurance? The States have more than 50 years of experience in regulating insurance. They have acted without any prod or mandate from Washington to enact good, strong patient protection laws. Let's honor their work. Let's build upon the good works of the States rather than preempting, second-guessing, and superseding their laws.

Ms. COLLINS. Mr. President, I yield 2\1/2\ minutes to the Senator from Ohio, Mr. Voinovich.

Ms. COLLINS. How much time is remaining on my side?

Ms. COLLINS. I yield 5 minutes to the Senator from Nebraska.

Ms. COLLINS. Mr. President, how much time is remaining on our side?

Ms. COLLINS. Mr. President, I ask unanimous consent that the Senator from Virginia, Mr. Allen, be added as a cosponsor of the Collins-Nelson amendment.

Ms. COLLINS

Ms. COLLINS. On behalf of myself, Senator Nelson of Nebraska, Senator Enzi, Senator Voinovich, Senator Hutchinson, and Senator Roberts, I send an amendment to the desk.

Ms. COLLINS. I am very pleased to join with my colleague from Nebraska as well as the other Senators whom I mentioned in offering this amendment. Our amendment will give true deference to State laws and the traditional authority of States to regulate insurance while ensuring that each State addresses the specific patient protections provided in this legislation. We should pass a strong, binding Patients' Bill of Rights. We should pass a bill that holds HMOs accountable for promised care and that ensures that patients receive the health care they need when they need it. However, we should do so in a responsible way that does not add excessive costs and complexity to an already strained health care system. Congress should act to provide the important protections that consumers want and need without causing costs to soar and without preempting State insurance laws. We can do so by passing a carefully crafted bill. I strongly believe we should not preempt or supersede but, rather, build upon the good work the States have done in the area of patients' rights and protections. States have had the primary responsibility for regulating insurance since the 1940s. For more than 60 years, States have been responsible for protecting insurance consumers. As someone who has overseen a bureau of insurance in State government for 5 years, I know firsthand that our States' bureaus of insurance do an excellent job of protecting consumers' rights. One of the myths in the debate on this legislation is that unless the Federal Government preempts State insurance laws, millions of Americans will somehow be unprotected in their disputes with HMOs. That simply is not true. For example, as this chart demonstrates, the States have been extremely active in passing patient protections. In fact, they have been way ahead of the Federal Government and they have acted without any prod or mandate from Washington. Look at this activity: 44 States have dealt with the issue of emergency room access; 49 States have passed laws prohibiting gag clauses in insurance contracts that restrict what a physician can tell a patient. Whether it is access to OB/GYNs, continuity of care, or many of the other issues such as internal or external appeals or patient information, the States have been extremely active in this area. Every single State has acted to pass some sort of patient protections. As is so often the case, it has been the States that have led the way. They have been the laboratories for insurance reform. Moreover, we know one size does not fit all. What may well be appropriate for one State simply may be unworkable or unneeded or too costly in another. What may be appropriate for California, which has a high penetration of HMOs, may simply not be necessary in a State such as Alaska or Wyoming where there is virtually no managed care. In such States, a new blanket of heavyhanded Federal mandates and coverage requirements simply drives up costs that impede rather than expand access to health insurance. That is why the National Association of Insurance Commissioners and the National Conference of State Legislators are very concerned about the language in the McCain-Kennedy bill. The language in that bill will force all States to adopt virtually identical Federal standards. I recently received a letter from the president of the National Association of Insurance Commissioners. She writes that States have faced the challenges and produced laws that balance the two-part objectives of protecting consumer rights and preserving the availability and affordability of coverage. For the Federal Government to unilaterally impose its one-size-fits-all standards on the States could be devastating to State insurance markets. I think we should heed that caution. I think we should heed that warning. The Federal Government does have an important role to play in regulating the self-funded plans under ERISA. That is where our effort should be focused. States are precluded from applying patient protections to these federally regulated plans, and that is why we need a Federal law to ensure that consumers, enrolled in insurance plans beyond the reach of State regulators, have strong patient protections. But the Federal Government should not be in the business of second-guessing and overriding and preempting the carefully crafted patient protections that have been negotiated by our State legislators and Governors to meet the needs of their States' citizens. States which seized the initiative and acted on their own should not have to revise their carefully tailored laws simply to comply with a one-size-fits-all Federal mandate. Under the McCain-Kennedy bill, the Federal Government would preempt existing State laws unless the State has enacted protections that are ``substantially equivalent to and as effective as'' the Federal standard. A reasonable person's interpretation of that standard is the States will have to pass new laws wiping out their carefully crafted work, that are virtually identical to the standards in the McCain-Kennedy bill. The approaches taken by the 50 States to the same type of patient protection vary widely, and with good reason in many cases. Why should States that have already acted on their own to provide strong, workable patient protections have to totally change and make extensive changes in their laws? That is why the National Council of State Legislators supports the Collins-Nelson amendment. It is extremely important to State legislators that they do not have to spend valuable time recrafting and rewriting and reenacting laws already on the books that meet the needs of their citizens. In a recent letter to Senator Nelson and myself, the National Council of State Legislators wrote: [We] support this amendment. States are best situated to provide oversight enforcement of the patient and provider protections established in this legislation. The record of the states is strong. We are looking for an approach that supports the traditional role of States in the regulation of insurance and that recognizes the differences in State insurance plans and provides a mechanism for States to protect those markets. Again, let me be clear. There is a role for the Federal Government, and that is to make sure that those plans, regulated under ERISA, beyond the reach of State regulators, include patient protections. That is why we need a Federal law to accomplish that goal. It is all well and good and appropriate if Congress decides it wants to impose a specific requirement or mandate on these federally regulated insurance plans. But the Federal Government needs to be careful in respecting the good work the States have done. Moreover, let's look at the practical consequences of what would happen under the McCain-Kennedy bill. If a State fails to revise its laws to conform to the Federal standard, under the McCain-Kennedy bill the Health Care Finance Administration, HCFA, would displace the State as the enforcer of insurance patient protection. Talk about a right without a remedy. If there is no enforcement, there is no protection, and experience has already shown that HCFA is completely incapable of carrying out this responsibility. The Health, Education, Labor, and Pensions Committee on which I serve has held yearly hearings to examine the problems that HCFA has experienced as it has attempted to implement and enforce the 1996 Health Insurance Portability and Accountability Act. There are many GAO reports. This one is entitled: Progress Slow In Enforcing Federal Standards in Nonconforming States. That is because HCFA is totally ill- equipped to take on this task. Our States' bureaus of insurance know how to do the job. They have been doing it for 60 years, and they have been doing it well. Consumers should be very concerned, since HCFA has already proven that it is not capable of enforcing existing Federal insurance standards in States that don't conform. In fact, HCFA has shown it cannot even assess the degree of compliance with those Federal laws, where HCFA does play a role. We should be very concerned that we are proposing an empty promise. The States have the systems, the infrastructure necessary to receive and process consumer complaints in a timely fashion and to hold insurers accountable to ensure that they comply with State laws. To me, the bottom line is very simple. My constituents would much rather call the bureau of insurance in Gardiner, ME, than have to deal with the HCFA office in Baltimore if they have a problem with their insurance. Another problem of the McCain-Kennedy approach is that it would create a dual enforcement structure that would be extremely confusing for consumers and, frankly, completely unworkable. Under this bill, if some State laws met the new standards but others did not, who would be the regulator? Would it be HCFA or would it be the bureau of insurance? Would it be HCFA for some parts of the insurance contract and the bureau of insurance in the State for other parts of it? This simply does not work. We would be creating a situation where a patient may have to go to a State bureau of insurance for questions or problems associated with certain patient protections and then try to deal with HCFA if the patient has problems or questions with other parts. Therefore, Senator Nelson and I, supported by a number of our colleagues, are offering an amendment that will give true deference to State laws and the traditional authority of States to regulate insurance. At the same time, we will ensure that each State considers and addresses the specific patient protections proposed by this legislation. First, our amendment would grandfather all State patient protection laws that are in place prior to the effective date of this act. That is October 1 of next year. A State would just certify to the Secretary of HHS that it has addressed one or more of the patient protection requirements to be in compliance with the law. This provision would also give States that have not considered these patient protections an incentive to act before the effective date to avoid Federal intrusion and challenges to their laws. Second, if by the effective date a State has been certified as compliant with all the patient protections in the legislation, it will immediately become eligible for funds from a new patient quality enhancement grant program. States that are not in full compliance by the effective date of the legislation would be required to meet a higher standard in order to be eligible for funds under this new program. If a State has not acted by the effective date, it would have to certify to the Secretary, for each of the remaining protections, that either the State has enacted a law that is ``consistent with the purposes of the Federal standard'' or decline to enact a law because the adverse impact of the law on premiums would lead to a decline in coverage or simply because the existence of a managed care market in the State is negligible; it is just not relevant to that State. Our amendment would recognize the States are the experts in this area. They have led the way. Consumers are best protected if we continue to respect the work that the States have done and give deference to the State's traditional authority to regulate insurance. I reserve the remainder of my time but yield to the Senator from Nebraska, my principal cosponsor, who is a true expert in this area. He knows more than any other Senator. I hope my colleagues will listen very carefully. It has been a great pleasure to work with him on this issue about which we both care a great deal.

Ms. COLLINS. I ask unanimous consent reading of the amendment be dispensed with.

Ms. COLLINS. I ask unanimous consent that the pending amendment be set aside.

Ms. COLLINS. Mr. President, I first want to say I very much enjoyed working with my colleague from New England. He is a passionate advocate for children on health care and education issues. He did, however, make a misstatement about the implications of my amendment and has invited me to correct the record if it was wrong. I want to take the opportunity to do so. In fact, my approach does provide new consumer protections. Let me expand on that because I must not have been clear in explaining it earlier. Under current law, there are federally regulated insurance plans and there are State-regulated insurance plans. The Federal plans, under ERISA, are beyond the reach of Federal regulators. So all those laws we have talked about, those 1,100 or more State laws and regulations, do not apply to consumers who are enrolled and covered by ERISA plans, the federally regulated plans, because State governments are prohibited from applying regulations to ERISA plans. They are preempted in that way. All of these great consumer protections that the States have enacted over the last decade do not apply to patients who are covered by ERISA plans. This legislation--and it is one of the reasons I strongly support patient protection legislation at the Federal level--would close that gap. It would ensure that consumers who are part of ERISA plans receive the kinds of consumer protections that are available to patients whose health care coverage is provided by plans that are regulated by State governments. So it is not accurate to say my approach will not result in any new consumer protections. Rather, the approach my colleague from Nebraska, Senator Nelson, and I have proposed is intended to make sure we can provide the same kinds of protections for consumers in Federal plans that the States have done for consumers who are covered by State- regulated plans. In addition, there is a requirement under the Collins-Nelson amendment for States that have not enacted consumer protection laws-- there are many that have in many areas, but there are some holes here and there. There is a requirement that those States either enact a law that is consistent with the purposes of those patient protections in the McCain-Kennedy bill by the date of enactment--we are not even giving them very long. They have to do it by October 1 of next year. That is going to be difficult for some States that have biennial legislatures. But we require them to either enact a law that is consistent with the purposes of the consumer protections in the McCain-Kennedy law or, if they decline to do so, they have to certify their reasons for not doing so to the Secretary. It is just not true to say our approach, the Collins-Nelson approach, does not result in any new consumer protections. In fact, what it does is preserve the good work that the States have done, rather than requiring the States to adopt a one-size-fits-all, made-in-Washington approach that may not work in their particular States. We preserve the State laws, but then we close the gap by requiring federally regulated insurance plans to have similar consumer protections. That is very important. That does result in new patient protections for millions of Americans whose insurance is under federally regulated plans. In addition, States cannot ignore this issue. They haven't ignored it; they have been very active, but, as I said, there are some holes. What they would have to do as a State is consider this issue and No. 1, enact a law consistent with the purposes of McCain-Kennedy or, No. 2, certify to the Secretary that they did not enact a law because either there is no managed care in their State--such as Alaska or Wyoming, where it is irrelevant--or they believed the costs were such that they would drive people out of the insurance market and cause people to lose access to health insurance altogether. Let us remember the best consumer protection is having health insurance coverage. That is the best patient protection we can apply and provide. So our amendment, the amendment I have crafted with my colleague, Senator Nelson, which is supported by so many of our colleagues who have spoken eloquently tonight, is an important one. It will advance consumer protections. But it will respect the good work that has been done by the States, the States that have been far ahead of the Federal Government. Finally, let's remember the important point. States have been regulating insurance for more than 50 years. They have done a good job. They have acted without any prod or mandate from Washington to provide patient protections. They are way ahead of us in this area. Why do we want to second guess their work? Why do we want to supersede their laws? Why do we want to wipe out the good work done by the States? I submit we should grandfather in those good State laws and concentrate on the gaps. Mr. President, I yield the floor.

Ms. COLLINS. Mr. President, I will be brief because I see the Senator from Massachusetts also desires to speak. First, I thank my colleague and friend from Wyoming for his extraordinarily generous comments and also for his excellent statement. As a former State senator, he has a great deal of experience in this area. As a businessman, he knows what it is to provide health insurance and to try to provide good benefits for his employees. I am grateful for his support. Very briefly, I want to respond to a couple of comments that have been made tonight. The former chairman of the Finance Committee, Senator Grassley, talked about the burden on HCFA. I think this is very important because the McCain-Kennedy bill--and, unfortunately, the amendment offered by my friend from Louisiana continues this problem-- is expecting that HCFA is somehow going to be able to step into the role of insurance regulator, which is something the States have performed well for more than 50 years. Look at what would be required under the Breaux-Jeffords amendment. Let me read you one part of the burden on the Secretary under the provisions called ``Petition Process'': Effective on the date on which the provisions of this Act become effective, as provided for in section 401, a group health plan, health insurance issuer, participant, beneficiary, or enrollee may submit a petition to the Secretary for an advisory opinion as to whether or not a standard or requirement under a State law applicable to the plan, issuer, participant, beneficiary, or enrollee that is not the subject of a certification under this subsection, is superseded under subsection (a)(1) because such standard or requirement prevents the application of a requirement of this title. In other words, this sets up a process by which the Secretary of HHS is going to be inundated with requests for advisory opinions from anyone who is covered under a State-regulated insurance plan who wants to know whether or not a certain provision of that particular State's laws is superseded by the Federal law. This is just not workable. There is just no way that HCFA is going to be able to take over these responsibilities. My friend from Louisiana drew the analogy with the State Children's Insurance Plans. I am very proud of that program. I was one of the original cosponsors of the legislation that the Senator from Massachusetts and the Senator from Utah proposed to create this important program to expand access to insurance to low-income children. But these are not analogous situations. We are not talking about a federally funded health program. We are not talking about that. We are talking about the regulation of health insurance. The Federal Government is not providing funds for this. The Federal Government is not involved in this traditionally. This is entirely different from pointing to a Federal program that happens to be administered by the States but which is federally funded where, of course, it makes sense for the Federal Government to set standards. So it is two entirely different matters. Finally, I make the point that one should look--and I encourage the Senator from Louisiana to look--at the provisions of his State's laws on consumer and patient protections. They are not identical to the standards in the McCain-Kennedy bill. For example, when you look at the Louisiana law dealing with emergency room access, we find that Louisiana has a law, but that it is crafted in a different way than the McCain-Kennedy bill. So now we have to decide, is it substantially compliant with the provisions of the bill, which would be the standard the Senator from Louisiana would have? It differs in some respects--on reimbursements, on how much is covered, on poststabilization care. If the State of Louisiana crafted a law dealing with emergency room access, as they have, why should we second-guess that law? Why should we substitute our judgment for the judgment of the good people of the State of Louisiana? I remind my colleagues that the States have not fallen down on the job. There are more than 1,100 patient protections out there far beyond the confines of this bill. Unfortunately, while the Breaux-Jeffords amendment is an improvement over the underlying bill, it is still fatally flawed. I urge my colleagues to vote no on the Breaux-Jeffords amendment and yes on the Collins-Nelson amendment. I thank the Chair, and I yield the floor.

Ms. COLLINS. Madam President, I know we are about to vote shortly on another amendment. Let me just summarize this part of the debate--we will be resuming the debate after the vote--by quoting a letter from the National Association of Insurance Commissioners to Senator Nelson and myself. They raise exactly the point that Senator Nelson and I have raised: Members of the NAIC are also concerned about enforcement. As you know as a former state regulator, if there is no enforcement then there is no protection. States have developed the infrastructure necessary to receive and process consumer complaints in a timely fashion and ensure that insurers comply with the laws. The federal government does not have this capability, and [these] proposals [before the Senate] do not provide any resources to federal agencies to develop such capability. It has taken the Health Care Financing Administration (HCFA) years to develop the infrastructure required to enforce the Health Insurance Portability and Accountability Act (HIPAA) which included only six basic provisions that most states had already enacted. The proposed patient protection bills are far more complicated than HIPAA and will require considerable oversight. If we pass the McCain-Kennedy bill without this amendment, we are holding forth a hollow promise to consumers. Amendment No. 820

Ms. COLLINS. Mr. President, I thank the Senator from Nebraska for his comments. He has stated the case extremely well. He has had the experience not only of being a Governor but of actually being a commissioner of insurance. I spent 5 years in State government overseeing a bureau of insurance. We have confidence in our State's abilities to protect the rights of insurance consumers. Indeed, the States have been way ahead of the Federal Government in this area. I have shown my colleagues the charts of the numerous laws that the States have passed during the past decade dealing with patients' rights. Each State has taken action on some of these consumer protections. They have done so without any mandate from Washington. They have done so because they want to make sure that in State regulated insurance plans these kinds of protections have been included. In fact, the States have passed over 1,100 laws and regulations dealing with patient protections. So this is not a case where the States have failed to act and the Federal Government has to come to the rescue. Rather, it is a case where the States have been far ahead of the Federal Government. We have been slow to provide these kinds of State protections to federally regulated plans under ERISA. That should be the primary focus of this legislation. Both the Senator from Nebraska and I support a strong Patients' Bill of Rights. We want to make sure, in writing this legislation, we do not wipe out the good work of State governments. Every single State has at least one law on the books dealing with portions of the McCain-Kennedy bill. But no State law is identical to the provisions in the McCain-Kennedy bill. States have dealt with these issues in different ways, depending on the negotiations between the State legislatures and their Governors, to meet the needs of that particular State. There is no need to impose a one-size-fits-all Federal mandate on the States when they are already doing a good job. When I was Commissioner of Professional and Financial Regulation in the State of Maine, we had a very active bureau of insurance that lead the way in proposing many reforms in insurance and health insurance that were enacted by our State legislature. In fact, I believe that Maine was the first State in the Nation to pass legislation requiring automatic continuity of coverage, renewability of insurance contracts. We did that way back this the 1980s. We were ahead of the Federal Government by many years in this area. Why should the State of Maine, which has been a leader in insurance regulation, have to go back and revisit its laws, recraft them, and rewrite them to meet the dictates of the McCain-Kennedy bill? That just does not make sense. I think we should respect the work that has been done by the States in this area by honoring the laws that already exist and are on the books. We can encourage those few States--and they are just a handful-- that have not acted in some area to do so, and then to bring their plan to the Federal Government or to tell us why they chose not to. Why does it make sense for a State such as Wyoming or Alaska, which has virtually no managed care, to have to adopt a host of new laws that are irrelevant to their insurance market? States have been strong in this area. They have worked hard to protect their health care consumers. I think we should be assisting them, providing incentives for them to act still further in this area, not preempting their good work. I yield the floor but reserve the remainder of the time on the Collins-Nelson amendment.

Ms. COLLINS

Ms. COLLINS. Mr. President, I am pleased to be joining my distinguished colleague, Senator Snowe, today in introducing this legislation, the Naval Security Group Activity at Winter Harbor Conveyance Act. This conveyance legislation will authorize the transfer of land, which has been under the control of the Naval Security Group for some seventy plus years back to the Department of the Interior, and to the State, ultimately to be put to good use by our local communities. Over the past seven decades, the Navy has performed a key national security mission called Classic Wizard at Winter Harbor. The Navy has played a significant role in the economic development of the local communities as Maine residents and Navy personnel have supported this mission. As the requirement for the Classic Wizard mission at Winter Harbor is coming to an end, and as technology advances, this naval activity will be ending its ties to the base in the summer of 2002. While the Navy will be missed, it has worked hand-in-hand with me and the other members of the Maine delegation, the Department of Interior, National Park Service, and our local communities in creating a viable economic development and reuse plan for the naval base and its associated property. As part of its reuse plan for the site, the National Park Service has proposed developing a research and education center at the Schoodic Point. The center would accommodate and promote a variety of research activities including wildlife genetics and serve as a base for permanent and visiting scientists to conduct interdisciplinary research. I worked with the National Park Service in the development of its proposal, and I have offered to help make the concept a reality. Maine Governor Angus King shares my support for the proposed research and learning center and has expressed the State's willingness to work as a partner in the effort to establish a wildlife genetics laboratory at the center. We believe that such a laboratory would generate good jobs and promote the region's economy. The work done at Schoodic Point also would compliment the world class research underway at other area facilities in the area such as The Jackson Laboratory, the Mount Desert Island Biological Laboratory, and the University of Maine's Cooperative Aquaculture Research Center. The National Park Service's proposed reuse of the peninsula also includes an educational component that would promote the public's understanding of the important natural and cultural resources that are a part of our national park system. Moreover, those who have visited Schoodic would agree that the remarkably beautiful 100 acres are worthy of being a part of Acadia National Park, one of our Nation's greatest natural treasures. It is important for the Federal Government to lend a hand to communities that are struggling to cope with the adverse effects of a base closure. Our legislation, which was developed in consultation with the local communities, the State, the Department of the Interior and the Navy, provides the options and opportunities that the region needs to move beyond the loss of the Naval Security Group Activity at Winter Harbor. I will work to secure approval of this bill by the Senate Armed Services committee and the full Senate.

Ms. COLLINS

Ms. COLLINS. Mr. President, I am pleased to be joining my distinguished colleague, Senator Snowe, today in introducing this legislation, the Naval Security Group Activity at Winter Harbor Conveyance Act. This conveyance legislation will authorize the transfer of land, which has been under the control of the Naval Security Group for some seventy plus years back to the Department of the Interior, and to the State, ultimately to be put to good use by our local communities. Over the past seven decades, the Navy has performed a key national security mission called Classic Wizard at Winter Harbor. The Navy has played a significant role in the economic development of the local communities as Maine residents and Navy personnel have supported this mission. As the requirement for the Classic Wizard mission at Winter Harbor is coming to an end, and as technology advances, this naval activity will be ending its ties to the base in the summer of 2002. While the Navy will be missed, it has worked hand-in-hand with me and the other members of the Maine delegation, the Department of Interior, National Park Service, and our local communities in creating a viable economic development and reuse plan for the naval base and its associated property. As part of its reuse plan for the site, the National Park Service has proposed developing a research and education center at the Schoodic Point. The center would accommodate and promote a variety of research activities including wildlife genetics and serve as a base for permanent and visiting scientists to conduct interdisciplinary research. I worked with the National Park Service in the development of its proposal, and I have offered to help make the concept a reality. Maine Governor Angus King shares my support for the proposed research and learning center and has expressed the State's willingness to work as a partner in the effort to establish a wildlife genetics laboratory at the center. We believe that such a laboratory would generate good jobs and promote the region's economy. The work done at Schoodic Point also would compliment the world class research underway at other area facilities in the area such as The Jackson Laboratory, the Mount Desert Island Biological Laboratory, and the University of Maine's Cooperative Aquaculture Research Center. The National Park Service's proposed reuse of the peninsula also includes an educational component that would promote the public's understanding of the important natural and cultural resources that are a part of our national park system. Moreover, those who have visited Schoodic would agree that the remarkably beautiful 100 acres are worthy of being a part of Acadia National Park, one of our Nation's greatest natural treasures. It is important for the Federal Government to lend a hand to communities that are struggling to cope with the adverse effects of a base closure. Our legislation, which was developed in consultation with the local communities, the State, the Department of the Interior and the Navy, provides the options and opportunities that the region needs to move beyond the loss of the Naval Security Group Activity at Winter Harbor. I will work to secure approval of this bill by the Senate Armed Services committee and the full Senate.

Ms. COLLINS

Ms. COLLINS. Mr. President, I rise today to introduce the Military Spouse Physician Choice Act of 2001. This legislation amends the Civilian Health and Medical Program of the Uniformed Services, CHAMPUS, to eliminate the requirement that a military dependent obtain a nonavailability statement, NAS, or a waiver from a commanding officer of a military treatment facility, in order to receive maternity care from a civilian doctor. I am pleased that my colleague Senator Landrieu is joining me in introducing this legislation. This legislation, which is a companion to H.R. 1511, introduced in the House by Representatives Jim Ryun and Susan Davis, will eliminate the requirement for TRICARE Standard maternity patients to obtain military nonavailability statements before seeing other doctors. Under current policy, Standard patients who live within 40 miles of a military medical facility must obtain a NAS from the facility commander before receiving pregnancy care from a civilian physician. Over 53 percent of our Nation's active service personnel today are married. Maintaining a high quality of life for these men and women in uniform must include the best possible health care for their spouses. While the services may recruit men and women to serve in our military forces, the reality is that we retain families to protect our Nation. It is therefore critical that all military spouses receive the health care services they signed up for. Currently, a military dependent has two options under the military's health care system. All military personnel and 84 percent of military dependents enroll in TRICARE Prime, which is the military's version of an HMO. Prime provides quality care, usually at a military treatment facility on the post or base. However, some dependents choose to enroll in the military's fee-for-service plans, called TRICARE Standard and Extra. These dependents voluntarily accept higher copayments and deductibles in return for the promise of freedom to choose their own doctor. Unfortunately, the promises in the enrollment brochure do not apply in all circumstances. Currently, a woman who chooses a civilian doctor through TRICARE Standard or Extra is forced to change doctors and return to the military treatment facility when she becomes pregnant. The only way for her to continue using her own doctor is to receive special permission from the commanding officer of that military treatment facility. The result is a bureaucratic nightmare. This situation is a concern for military dependents across the country. It represents a break in continuity of care that compromises the invaluable relationship between a woman and her doctor. A woman who has a trusted relationship with her civilian ob/gyn is required to change to a doctor at the military treatment facility due to an unnecessary regulation that can, and should, be fixed. Military families deserve better treatment. Many of them consistently pay higher premiums and accept higher out-of-pocket costs in exchange for an active role in controlling their health care decisions. It should not take a military order to allow a woman to stay with her regular doctor for prenatal, delivery and postnatal care. This is why Senator Landrieu and I are introducing legislation to cut through this burdensome red tape. The Military Spouse Physician Choice Act would eliminate the need for women to get special permission to receive the continuity of care they were promised. Over the past few years, Congress has made several positive changes to military health care services. We have given our military personnel the ability to choose the health care option that is right for each of their families. We have enabled our military treatment facilities to maintain a high level of excellence, making them the choice of most military dependents. It only follows that a pregnant spouse should be able to choose to utilize that treatment facility but not be mandated to do so. If we want to continue to recruit and retain quality people for our armed services, we need to show them that they and their families will be treated fairly when making health care decisions. I am very pleased that the Military Coalition, a consortium of nationally prominent uniformed services and veterans organizations representing more than 5.5 million members plus their families, has endorsed this legislation. The Retired Officers Association, TROA, has as well because the current policy denies TRICARE Standard beneficiaries one of the most important principles of quality health care, continuity of care by a provider of their choice. I urge all Members of the Senate to join me and Senator Landrieu in support of the Military Spouse Physician Choice Act. I ask consent that the text of the bill be printed in the Record.

Ms. COLLINS

Ms. COLLINS. Mr. President, I rise today to introduce the Military Spouse Physician Choice Act of 2001. This legislation amends the Civilian Health and Medical Program of the Uniformed Services, CHAMPUS, to eliminate the requirement that a military dependent obtain a nonavailability statement, NAS, or a waiver from a commanding officer of a military treatment facility, in order to receive maternity care from a civilian doctor. I am pleased that my colleague Senator Landrieu is joining me in introducing this legislation. This legislation, which is a companion to H.R. 1511, introduced in the House by Representatives Jim Ryun and Susan Davis, will eliminate the requirement for TRICARE Standard maternity patients to obtain military nonavailability statements before seeing other doctors. Under current policy, Standard patients who live within 40 miles of a military medical facility must obtain a NAS from the facility commander before receiving pregnancy care from a civilian physician. Over 53 percent of our Nation's active service personnel today are married. Maintaining a high quality of life for these men and women in uniform must include the best possible health care for their spouses. While the services may recruit men and women to serve in our military forces, the reality is that we retain families to protect our Nation. It is therefore critical that all military spouses receive the health care services they signed up for. Currently, a military dependent has two options under the military's health care system. All military personnel and 84 percent of military dependents enroll in TRICARE Prime, which is the military's version of an HMO. Prime provides quality care, usually at a military treatment facility on the post or base. However, some dependents choose to enroll in the military's fee-for-service plans, called TRICARE Standard and Extra. These dependents voluntarily accept higher copayments and deductibles in return for the promise of freedom to choose their own doctor. Unfortunately, the promises in the enrollment brochure do not apply in all circumstances. Currently, a woman who chooses a civilian doctor through TRICARE Standard or Extra is forced to change doctors and return to the military treatment facility when she becomes pregnant. The only way for her to continue using her own doctor is to receive special permission from the commanding officer of that military treatment facility. The result is a bureaucratic nightmare. This situation is a concern for military dependents across the country. It represents a break in continuity of care that compromises the invaluable relationship between a woman and her doctor. A woman who has a trusted relationship with her civilian ob/gyn is required to change to a doctor at the military treatment facility due to an unnecessary regulation that can, and should, be fixed. Military families deserve better treatment. Many of them consistently pay higher premiums and accept higher out-of-pocket costs in exchange for an active role in controlling their health care decisions. It should not take a military order to allow a woman to stay with her regular doctor for prenatal, delivery and postnatal care. This is why Senator Landrieu and I are introducing legislation to cut through this burdensome red tape. The Military Spouse Physician Choice Act would eliminate the need for women to get special permission to receive the continuity of care they were promised. Over the past few years, Congress has made several positive changes to military health care services. We have given our military personnel the ability to choose the health care option that is right for each of their families. We have enabled our military treatment facilities to maintain a high level of excellence, making them the choice of most military dependents. It only follows that a pregnant spouse should be able to choose to utilize that treatment facility but not be mandated to do so. If we want to continue to recruit and retain quality people for our armed services, we need to show them that they and their families will be treated fairly when making health care decisions. I am very pleased that the Military Coalition, a consortium of nationally prominent uniformed services and veterans organizations representing more than 5.5 million members plus their families, has endorsed this legislation. The Retired Officers Association, TROA, has as well because the current policy denies TRICARE Standard beneficiaries one of the most important principles of quality health care, continuity of care by a provider of their choice. I urge all Members of the Senate to join me and Senator Landrieu in support of the Military Spouse Physician Choice Act. I ask consent that the text of the bill be printed in the Record.

Ms. COLLINS

Ms. COLLINS. Mr. President, I commend my friend and colleague from Arkansas for offering this important amendment. It will allow self- employed Americans to deduct the full amount of their health insurance premiums. As we proceed with consideration of legislation to protect patients' rights, legislation I believe every Member of this body, in one form or another, wants to see passed, we should also be considering ways to expand access to health insurance coverage for millions more Americans by making health insurance more affordable. We know that at a time of almost unprecedented prosperity in this country, we have 43 million Americans who lack health insurance. Just think of the impact of an economic downturn and escalating increases in health insurance costs. It will only expand the number of uninsured or underinsured Americans. That is why I support the amendment that has been offered by the Senator from Arkansas. As President Clinton's own Advisory Commission on Consumer Protection and Quality noted in its report: ``Costs matter--health coverage is the best consumer protection.'' Simply put, the biggest single obstacle to expanded health care coverage in the United States is costs. While American employers everywhere are facing huge hikes in their health insurance premiums, these rising costs are particularly problematic for small businesses, and they are most problematic for self-employed individuals who have to purchase health insurance on their own without a subsidy from an employer and without the benefit of a group health plan rate. Since most Americans get their health insurance through the workplace, it is a common assumption that people without health insurance are unemployed, but the fact is that most uninsured Americans are members of families with at least one full-time worker. Eighty-five percent of Americans who do not have health insurance live in a family with a full-time worker. Most of these uninsured workers are self- employed or they work for very small businesses that simply cannot afford to provide health insurance as much as they would like. Our amendment will help make health insurance more affordable for these Americans by allowing those who are self-employed to deduct 100 percent of the cost of their health insurance premiums. Since some 35 million Americans are in families headed by self-employed individuals, this will be of enormous help to them. Five million of those 35 million are uninsured. Establishing parity in the tax treatment of health insurance costs between self-employed individuals and those working for large businesses is also a matter of equity. I have never thought it was fair that a corporation can deduct 100 percent of its share of the health insurance premiums that it pays for its employees, but a person who works for himself or herself can only deduct a portion of that cost. This is a matter of equity, but it would also help to reduce the number of uninsured but working Americans. Our amendment will help make health insurance more affordable for the 82,000 people in my home State of Maine who are self-employed. They include our lobstermen, fishermen, farmers, hairdressers, electricians, plumbers, and the owners of many of the small shops that dot communities throughout our State. We are a State of self-reliant people. We are a State where there is a large number of self-employed, and they deserve to deduct the cost of their health insurance premium just as a large corporation can write off that cost. This is a particularly important amendment when we are looking at a bill that by every estimate is going to drive up the cost of health insurance. This is just a modest effort to provide some assistance to help offset the escalation in health insurance rates that this bill, unfortunately, will produce. This is a reasonable amendment. It deserves bipartisan support. Finally, I am a bit puzzled by some of the statements that have been made by those on the other side of the aisle. During consideration of the budget resolution earlier this year, I offered an amendment to make sure we set aside funds in the budget resolution to provide for 100- percent deductibility for health insurance for the self-employed and also to help our small businesses that are struggling with the cost of health insurance by giving them a tax credit. That amendment was opposed by my colleagues on the other side of the aisle. Had it been accepted--it was narrowly defeated by only one vote--we would have had a better chance of holding those important provisions in the tax bill when we went to conference, but it was opposed by my friends from the other side of the aisle. I find it ironic to hear today the argument that we should have done it earlier, we should have done it on a different bill when, in fact, our attempts to do so were defeated during the course of the budget resolution. This is an excellent amendment. I am puzzled why there would be any opposition to it. Surely we ought to be able to agree that self- employed individuals, those hard-working men and women across America, should be able to deduct the full cost of their health insurance. It is the right policy, it is the fair policy, and it would help expand access to needed health insurance for millions of American families. I hope there will be a strong bipartisan vote for this very important amendment. Again, I commend my friend from Arkansas for his leadership in bringing forth this very important amendment on this bill. I thank the Chair.

Ms. COLLINS

Ms. COLLINS. Mr. President, Maine has led the way on insurance reform. Maine is one of only 12 States that cover clinical trials. The Maine legislators gave careful consideration to what the scope of that coverage should be, and a Democratic legislature and an independent Governor decided, for reasons of cost, to limit the clinical trials provisions to those who were approved by the National Institutes of Health. That is appropriate. What I object to is that the Kennedy approach, the Kennedy-McCain bill, would say that if a State didn't cover clinical trials exactly as the Senator from Massachusetts wants them covered, then Maine's law is wiped out. I don't think that is right. I notice that Maine has been far more active than Massachusetts in the area of patients' protection, so perhaps that explains the difference in the approach that the Senator from Massachusetts, my friend, and I take. I yield the floor. Exhibit No. 1 National Association of Insurance Commissioners, Kansas City, MO, June 19, 2001. Hon. Susan Collins, U.S. Senate, Washington, DC. Dear Senator Collins: As the Senate prepares to debate legislation designed to protect the rights of health insurance consumers I would like to reiterate the concerns of the nation's health insurance regulators. The National Association of Insurance Commissioners (NAIC), which represents all fifty-five insurance commissioners in the states and territories, is primarily concerned about federal preemption of state laws and regulations. All states have passed and implemented legislation to protect the rights of beneficiaries. Over 40 states have acted to ensure access to emergency and OB/GYN care, require fair utilization review and internal and external appeals processes, and prohibit discrimination and gag clauses. Over half of the states have laws ensuring access to specialists and non-formulary prescription drugs, a point of service option, and continuity of care. As members of Congress know from experience, passing patient protection legislation this can be a difficult task with a variety of issues to consider. States have faced the challenges and produced laws that balance the two-part objectives of protecting consumer rights and preserving the availability and affordability of coverage. For the federal government to unilaterally impose its one-size-fits-all standards on the states could be devastating to state insurance markets. Members of the NAIC are also concerned about enforcement. As you know as a former state regulator, if there is no enforcement then there is no protection. States have developed the infrastructure necessary to receive and process consumer complaints in a timely fashion and ensure that insurers comply with the laws. The federal government does not have this capability, and the proposals do not provide any resources to federal agencies to develop such capability. It has taken the Health Care Financing Administration (HCFA) years to develop the infrastructure required to enforce the Health Insurance Portability and Accountability Act (HIPAA) which included only six basic provisions that most states had already enacted. The proposed patient protection bills are far more complicated than HIPAA and will require considerable oversight. To resolve these issues, the NAIC urges Congress to include in any patient protection legislation provisions that would preserve state laws and enforcement procedures, such as internal and external review processes. Failure to maintain state authority in this area could lead to the implementation of regulations that are inconsistent with the needs of consumers in a state and that are not enforced effectively. Protecting patient rights is clearly a goal of both the states and the federal government. Attaining this goal will require cooperation and we look forward to working in partnership with the federal government to implement protections that are in the best interest of consumers in each state. Sincerely, Kathleen Sebelius, President, NAIC, Insurance Commissioner, State of Kansas.

Ms. COLLINS. Thank you, Mr. President. Mr. President, I am pleased that the Senate is now considering the issue of how best to ensure that patients receive the health care they need when they need it and that was promised by their insurance plan. The last 10 years have been particularly turbulent ones for health care providers and patients alike. Concerns about rising costs have led to extensive changes in how health care services are provided and paid for in both public and private health plans. As a consequence, there is a growing unease across the country about the changes in the way we receive our health care. Families worry that if they or their loved ones become seriously ill, their HMO will deny them coverage and force them to accept either inadequate care or financial ruin--or perhaps both. They feel that vital decisions affecting their lives will be made not by a supportive family doctor but by an unfeeling bureaucracy. They fear that they will have to fight their insurance company as well as their illness. These are the concerns that have prompted this important debate about how we can ensure that HMOs are held accountable for promised care and that medical decisions are made by individuals wearing stethoscopes, not green eyeshades. People should not have to worry that their HMO will unfairly deny them treatment or force them to accept inadequate care. Virtually every Senator agrees that medically necessary patient care should not be sacrificed to the bottom line and that health care decisions should be in the hands of doctors, not insurance accountants. But we face an extremely delicate balancing act: as we respond to these concerns, we must be careful not to impose overly burdensome Federal controls and mandates that will drive up costs and cause some people to lose their health insurance altogether. That is the whole crux of the managed care debate. We should pass a strong, binding Patients' Bill of Rights, but we should do so in a responsible way so that we don't add excessive cost, litigation, and complexity to an already strained health care system. Congress should use the set of principles that President Bush has given us as a road map to develop a bipartisan Patients' Bill of Rights--one that applies meaningful patient protections where they are needed without unduly increasing health care costs. The biggest obstacle to health care coverage in the United States today is cost. American employers everywhere--from the giant multinational corporation to the small corner store--are facing huge hikes in their health insurance costs. Rising health insurance costs are particularly problematic for people purchasing coverage in the individual market and for small businesses and their employees. Earlier this year, the dominant carrier in Maine's individual market increased its rates by an average of 23.5 percent for indemnity plans and 32.6 percent for HMO plans. As a result of these increases, many people in my state are either dropping coverage or switching to ``catastrophic'' plans with very high annual deductibles. Similarly, many small employers in Maine are facing premium increases of 20 to 30 percent, forcing them either to drop their health benefits or pass the additional costs on to their employees through increased deductibles, higher copays, or premium hikes. This also adds to the ranks of the uninsured as more lower-wage workers, unable to afford the increased costs, drop coverage or turn it down. No wonder the ranks of uninsured Americans have grown to 43 million. If this happens at a time we have been enjoying a strong economy, just imagine what could happen in an economic downturn. Higher health insurance premiums lead to significant losses in coverage. Studies have shown that for every one percent increase in insurance premiums, insurance coverage for as many as 300,000 people is jeopardized. This is one of the primary reasons I am so concerned about the McCain-Kennedy version of the Patients' Bill of Rights. According to the Congressional Budget Office, the McCain-Kennedy approach will increase health insurance premiums by an additional 4.2 percent over and above the double-digit premium increases we have already experienced. Moreover, this bill is even more expensive than previous versions of the legislation. Congress should act to provide the important protections that consumers want without causing costs to soar, and we can do so by passing a carefully crafted bill. I also believe that we should not pre-empt or supercede, but rather build upon the good work that states have done in the area of patients' rights and protections. States have had the primary responsibility for the regulation of health insurance since the 1940s. As someone who has overseen a Bureau of Insurance in state government, I know that state regulators have done a good job of protecting consumers. One of the myths in this debate is that unless the federal government pre-empts state insurance laws, millions of Americans will somehow be ``unprotected'' in their disputes with HMOs. That simply is untrue. For example, as this chart demonstrates, 48 states have passed laws prohibiting ``gag clauses'' that restrict communications between patients and their doctors. Forty-four states have requirements for emergency medical care; forty-seven have prompt payment requirements; thirty-seven require direct access to an OB/GYN; forty-one have requirements for external appeals; and all fifty have requirements for internal appeals and patient information. As is so often the case, states have been the laboratories for insurance reform. They have acted without any mandate or prodding from Washington to protect their consumers. They have been way ahead of us in enacting patients' rights. Moreover, one size does not fit all. What may be appropriate for one State may not work well in another or may simply be unnecessary. For example, what may be appropriate for California, which has a very high penetration of HMOs, may simply not be needed in States such as Alaska and Wyoming where there is virtually no managed care. In these States, imposing a new blanket of heavy-handed Federal mandates and coverage requirements will simply drive up costs that will impede, not expand, access to health care. That is why the National Association of Insurance Commissioners opposes the approach taken in the McCain-Kennedy bill which would force all States to adopt virtually equivalent Federal standards. Recently, I received a letter from Kathleen Sebelius, the president of the NAIC, in which she writes: States have faced the challenges and produced laws that balance the two-part objectives of protecting consumer rights and preserving availability and affordability of coverage. For the federal government to unilaterally impose its one- size-fits-all standards on the states could be devastating to state insurance markets. Mr. President, I ask unanimous consent this letter from the NAIC be printed in the Record at the conclusion of my remarks.

Ms. COLLINS. Mr. President, under the McCain-Kennedy bill, the Federal Government could preempt existing State patient protection laws unless they had already enacted identical protections--not just similar ones, identical ones. The approaches taken by the 50 States to the same types of patient protections vary widely and with good reason in many cases. Why should a State that has already acted on its own to provide strong, workable patient protections have to make extensive changes in their laws to comply with new Federal standards? Let me give you a recent example from my home State of Maine. Maine is one of just 12 States that require health plans in the fully insured individual and small group market to provide coverage for routine costs for patients participating in clinical trials. During its consideration of this provision last year, the Maine Legislature made the decision to include only those clinical trials that were approved and funded by the National Institutes of Health. I would note, parenthetically, that this decision was one that was made by a legislature controlled by the Democratic Party. What would happen under the McCain-Kennedy bill? Under that approach, Maine would have to go back and rewrite its law to include clinical trials approved or funded by the Department of Defense, the Veterans' Administration, and the Food and Drug Administration. Why should the State of Maine have to revisit its law? The law that the State of Maine came up with to require coverage of certain clinical trials was carefully debated. It was thoroughly considered. And the Maine State legislature decided that this was the best approach for the citizens of Maine. Yet under the legislation we are considering today, Maine would have to change its law or have it completely superseded by the Federal Government taking over control of its health insurance market. Let me be clear. I believe the Federal Government does have an important role to play in regulating the self-funded plans under ERISA. That is because, under current Federal law, States are precluded from applying patient protections to these Federal plans. That is why we need a Federal law to ensure that consumers enrolled in insurance plans beyond the reach of State regulators enjoy the same kinds of strong patient protections that apply to State-regulated plans. As I said, and as you can see from the chart, the States have been extraordinarily active in this area. It is all well and good if Congress decides that it wants to impose a specific requirement or mandate on federally regulated ERISA plans, since States are, by law, precluded from regulating these insurance plans. But the Federal Government should not be in the business of second-guessing and overriding the carefully crafted patient protections that have been negotiated by our State legislatures and Governors to meet the needs of that State's citizens. States that have seized the initiative and acted on their own should not have to revise their carefully tailored laws simply in order to comply with a Washington-knows-best, one-size-fits-all Federal mandate. Moreover, what if the State has made an affirmative decision not to act in one of these areas for very good reasons, such as the reason I previously gave where a particular State may not have much managed care so that this debate is largely not relevant to its citizens? What if the State legislature, after much discussion and debate, has decided that a particular consumer protection simply isn't needed because the marketplace has already taken care of this issue? Let's look at the consequences under the McCain-Kennedy bill of a State failing to enact an identical provision to the consumer protections in S. 1052. The bill proposes, quite simply, a Federal takeover of State health insurance regulation. The Health Care Financing Administration, HCFA, would be charged with enforcing the new Federal standard. Talk about a right without a remedy. In a report issued in May of this year--5 years after new Federal health insurance standards were enacted under the Health Insurance Portability and Accountability Act, the Mental Health Parity Act, and the Newborns' and Mothers' Health Protection Act--5 years after those laws passed, five States are still out of compliance, and Federal fallback enforcement in these States is virtually nonexistent. Moreover, HCFA told the GAO that it has not even been able to fully assess whether or not the States have complied with the Mental Health Parity Act enacted 5 years ago, and that law is scheduled to sunset this year. Given the fact that the Patients' Bill of Rights--the version we are considering right now--is replete with new health mandates, consumers should be very concerned that HCFA has already proven beyond a shadow of a doubt that it is incapable of enforcing existing Federal insurance standards in States that do not conform. In fact, HCFA has shown that it is incapable of even assessing whether or not the States have complied with these limited Federal insurance standards. So what makes us think that HCFA could in any way take over the responsibility of regulating health insurance in States that do not comply to the letter with the standards in the McCain-Kennedy bill? If HCFA has not been able to handle its limited responsibility under the laws that I mentioned, how in the world would it benefit consumers to provide for a Federal takeover of health insurance regulation in this area? I think the answer is clear. It would be a tremendous disservice to consumers to have HCFA take over health insurance regulation. I know that my consumers, my constituents in Maine will have far better service and far better luck dealing with the Bureau of Insurance in the State of Maine in Gardiner, ME, than trying to call the ERISA office in Boston or the HCFA office in Baltimore. It is that simple. As we consider Federal patient protection legislation, I believe that true deference should be given to the expert decisionmakers who know best what is appropriate for each State and who are most immediately accessible and accountable to that State's citizens. Another of the myths--and there are many--in this current debate is that you can't sue your HMO. That, too, is not true. HMOs--even self- insured ERISA plans--can be sued in State court over quality-of-care treatment decisions. They can also be sued, under current law, in Federal court for injunctive relief to force them to provide needed care or to compensate the patient or provider for the value of the benefit, plus any attorney's fees. This is the exact same legal remedy that is currently available to us as Members of Congress under the Federal Employees Health Benefits Plan.