Dianne Feinstein

Mrs. FEINSTEIN

Mrs. FEINSTEIN. Reserving the right to object.

Mrs. FEINSTEIN

Mrs. FEINSTEIN. Mr. President, I don't want to be redundant, but I would like to continue the statement I began to make earlier this morning. Let me quickly put it in perspective. The statement further explains an amendment that I have at the desk, which essentially says that a group health plan or an insurance issuer may not arbitrarily interfere with, or alter, the decision of the treating physician with respect to the manner or the setting in which particular services are delivered if those services are medically necessary or appropriate. It then goes on to define ``medically necessary'' as ``that which is consistent with generally accepted principles of professional medical practice.'' The amendment, of course, means that the doctor can determine what is a medically necessary length for a hospital stay, and the doctor can determine the kind of treatment or drug the patient can be best treated with. I know some people wonder why am I so vociferous about physicians making medical decisions. California has the largest number of individuals in managed care. We have around 20 million people in managed care plans in California. I have heard of many different cases. Let me just give you one other case--I just talked about the person with the brain illness. I can also give you the case of the Central Valley man, 27 years old who had a heart transplant and was forced out of the hospital after 4 days because his HMO would not pay for more days. That constituent of mine died. That is the reason I feel so strongly. Additionally, I know--and the Washington Post this morning documents--that doctors are increasingly frustrated, demoralized, and hamstrung by insurance plans' definitions of medical necessity. An American Medical Association survey reported in the March 2, 1999, Washington Post, quoted an AMA spokeswoman who said that some managed care companies have begun to define explicitly what treatments are ``medically necessary,'' and they have chosen to define them in terms of lowest cost. She says: Doctors used to make that decision solely on the basis of what was best for the patient. She stressed that doctors are unhappy that managed care organizations are ``controlling or influencing medical treatment before the treatment is provided.'' She said, ``Denials and delays in providing care directly harm the health and well-being of the patients.'' A fall 1998 report found that ``patients and physicians can expect to see more barriers to prescriptions being filled as written,'' according to the Scott-Levin consultant firm, because HMOs are requiring more ``prior authorizations'' by the plans before doctors can prescribe them. Then, as I spoke of a little earlier, there is the issue of financial incentives, another form of interference in medical necessity decisions. In November, the New England Journal of Medicine pointed out: Many managed care organizations include financial incentives for primary care physicians that are indexed to various measures of performance. Incentives that depend on limiting referrals or on greater productivity applies selective pressure to physicians in ways that are believed to compromise care. That is what we are trying to stop. Incentives that depend on the quality of care and patients' satisfaction are associated with greater job satisfaction among physicians. Let me describe how Charles Krauthammer put it in writing in the January 9, 1998 Washington Post under the headline, ``Driving the Best Doctors Away'': The second cause of [doctors leaving the profession] is the loss of independence. More than money, this is what is driving these senior doctors crazy: some 24-year-old functionary who knows as much about medicine as he does about cartography demanding to know why Mr. Jones, a diabetic in renal failure, has not been discharged from the hospital yet. Dictated to by medically ignorant administrators, questioned about every prescription and procedure, reduced in status from physician to ``provider,'' these doctors want out. Mr. President, that is a sorry commentary, and it is the truth. One of my deepest interests is cancer. I cochair the Senate Cancer Coalition with the distinguished Senator from Florida, Senator Connie Mack. Let me quote from a report of the President's Cancer Panel: Under the evolving managed care system, participating physicians are increasingly being asked to do more with less--to see a greater volume of patients and provide significantly more documentation of care with less assistance or staff. In addition, managed care has dictated a major shift to primary care gatekeepers who are under pressure to limit referrals to specialists and care provided in tertiary care facilities, and may be financially rewarded for their success in doing so. Nancy Ledbetter, an oncology nurse and clinical research nurse coordinator for Kaiser Permanente said, ``. . . necessary care is being withheld in order to contain costs.'' This is from the June 16, 1999 Journal of the National Cancer Institute. A breast cancer surgeon wrote me: Severe limitations are being placed upon surgeons in giving these women [with breast cancer] total care . . . Patients feel that their care is reduced to the mechanics of surgery alone, ignoring the whole patient's medical, emotional, and psychological needs. Surely, one of the oldest axioms of medicine, and the way my father used to practice medicine, is that you can't just treat the wound, you have to treat the whole patient as an individual, as a human being. In my State, again, over 80 percent of people who have insurance are in managed care. Forty percent of California's Medicare beneficiaries are in managed care. Some say Californians have been pioneers for managed care. Some even say Californians have been the Nation's ``guinea pigs.'' The complaints don't abate: delaying diagnoses and treatments as tumors grow; trying the cheapest therapies first, instead of the most effective; refusing needed hospital admissions; refusing to refer patients to specialists who can accurately diagnose conditions and provide effective treatments; we hear complaints about shoving patients out of the hospitals prematurely, against doctor's wishes. We hear complaints about misclassifying medically necessary treatments as ``cosmetic.'' We hear about plans demanding that doctors justify their care and second-guessing doctors' medical judgments. We have had heard about doctors exaggerating the patient's condition to be able to give them a certain drug, or keep them in a hospital beyond a certain length of time, to get plans to pay for care. I hope this amendment can restore some balance to the system by empowering patients and the medical profession to provide the kind of quality medical care that people not only pay for but that they deserve. That is why I feel so strongly about this amendment. Again, I harken back to the day when I had the first example in 1997 of a woman in a major managed care plan undergoing an outpatient radical mastectomy--7:30 in the morning, surgery; 4:30, out on the street with drains hanging from her chest, and unable to know where she was going. That is not good medicine. I can only end my comments on this amendment by saying that the amendment is sincerely presented. The amendment is the heart of a Patients' Bill of Rights. The amendment should not increase premium costs. The amendment is what the American people expect. And the amendment simply says that an insurance company cannot arbitrarily interfere with the doctor's decision with respect to treatment or hospitalization. I don't think that is too much to ask this body to legislate and to state unequivocally, and I think every single person in my State, as well as every State, will be much better off once this is accomplished. Let me end by saying that I believe that Senator Daschle is willing to work out an agreement which allows a number of amendments to come to the floor and be debated, provided that these amendments can be voted up or down. I suspect that what we are going to really end up with is a bipartisan Patients' Bill of Rights. I suspect that if we can get this unanimous consent agreement, we will find that there will be many on the other side of the aisle who will vote for this amendment, and there will be some of us who will vote for some of the amendments on the other side as well. It seems to me that when you have a situation whereby the physicians in America have reached the point where they have decided to unionize and collectively bargain that this should be a very loud call that all is not well with the practice of medicine in the United States of America. It should be a very loud call for a unanimous consent agreement which will allow us, on the floor of the Senate, to work out a series of amendments which can provide the kind of quality care that the people of the United States are entitled to, and that certainly 20 million Californians in managed care are. I thank the Chair. I yield the floor.

Mrs. FEINSTEIN

Mrs. FEINSTEIN. Mr. President, I ask unanimous consent that the order for the quorum call be rescinded.

Mrs. FEINSTEIN

Mrs. FEINSTEIN. Thank you very much.

Mrs. FEINSTEIN. I ask the Senator, before you do, may I respond to one quick thing you said on ``medical necessity''? You made the comment: Nobody really knows what ``medical necessity'' is. Let me just very briefly read you the definition because it is a standard definition. The term ``medical necessity'' or ``appropriateness'' means, with respect to a service or benefit, ``a service or benefit which is consistent with generally accepted principles of professional medical practice.'' That is the definition of ``medical necessity'' or ``appropriateness'' in this bill.

Mrs. FEINSTEIN. Mr. President, I will take this opportunity to respond to the distinguished--I was going to say the difficult Senator, but I mean the distinguished Senator from Oklahoma. I feel caught on the horns of a dilemma. On one hand, what I am seeing is this is never going to happen on an agriculture appropriations bill. On the other hand, what I am hearing is, you have an offer to offer your amendment; it will be second-degreed; it will be defeated; there won't be a real opportunity to have an up-or-down vote on the amendment. Our leader, I believe, is willing to come to a reasonable agreement whereby the main points of the Patients' Bill of Rights can be debated on the floor with an agreement that amendments be voted up or down within a certain period of time. But he is very astute. I do not think he wants us to find out that someone comes on the floor, takes up all the time, there is no opportunity for an up-or-down vote on the amendments, there is one vote en bloc, and then the majority leader can come on the floor and undo it all after it is over. What we are asking for, and maybe now is as good a time as any--I have learned there are times when you go to the wall and there are times when you do not go to the wall, and it is important to know the difference in the timing. Let me share with the Senator one story that happened at UCLA, which is why I feel so strongly about this Senate passing legislation that prevents arbitrary interference with the physician's treatment and the setting of that treatment, in other words, the hospital length of stay. If the Senator wants, I can give him the doctor's name and he can verify it. This is about a neurosurgeon who performed surgery at the UCLA Medical Center to remove a brain tumor. The patient's managed care plan covered 1 day in the intensive care unit. After that day, the patient had uneven breathing and fluctuating blood pressure and heart rate. The doctor wanted her to stay in the hospital another day for monitoring. The HMO utilization reviewer consulted the guidebook that said only 1 day was allowed in the ICU, so she was denied the extra day. The doctor thought it would be medically unethical to move the patient out of the ICU, so he kept her there. The next day, the HMO called again and said the cost of the second day would be deducted from the surgeon's fee. That is the kind of thing that is happening. We have to put an end to it because the result is going to be terrible for the practice of medicine. There are now doctors voting to unionize, to collectively bargain. I know some people have said with some disdain: Oh well, that's just over their wages. I am here to say it is not. My own doctor at Great Mount Zion Medical Center, now part of the University of California, after 30 years of practice, says he has never been so disillusioned, never been so disappointed. He said the morale of doctors is so low from being countermanded all the time by medical plans and having to hassle to get a drug approved. Using this kind of disincentive of, if you believe a patient belongs in ICU after brain surgery for an additional day, we are going to deduct it from your fee--what kind of a practice of medicine is that? These are big issues, I say to the Senator from Oklahoma, because, in my view, they are life-or-death issues. We have a chance to address it. I do not want to legislate on an agriculture appropriations bill, but, on the other hand, I believe to the depth and breadth and height of me in this amendment. Other colleagues have other amendments. The time has come to have a debate on the issue. Our leader will negotiate a fair agreement. I really think it is in your hands. We want an up-or-down vote on these amendments. This is not an amendment that has been just quickly put together for what someone might say is a political purpose. This amendment has been worked on, it has been vetted, and it is supported by 200 organizations and supported by every single medical organization in this country-- nurses, the American Cancer Society, the American Heart Association, the American Lung Association--across the board. No one should be afraid to keep a patient, following brain surgery, in intensive care for an extra day. The gall of the health insurance plan to say, OK, we are deducting it from the doctor's fee. I hope the Senator will have some reaction to this, because I know that is not the way he wants to see medicine practiced in this country. I can go on and on. Perhaps because my State is such a big managed care State, there are so many examples. They need to be stopped, and there is no better time than right now. All we need is an agreement that will allow some amendments--leave it up to our leaders--up-or-down vote, and prevent the opportunity from sidetracking that up-or-down vote. At the end of this, we will have something. Senator Kennedy was absolutely right. I remember all the wrangling over the Kennedy-Kassebaum bill, and then finally, bingo, it just got done. That is what we are asking for now. That is what the people of America are asking for now as well. I yield the floor.

Mrs. FEINSTEIN

Mrs. FEINSTEIN. Mr. President, I thank the Senator from Massachusetts for his remarks. I don't think anyone in the Senate has ever done more to advance the cause of responsible medical reform than Senator Kennedy from the State of Massachusetts. He also has been here day after day, with comment after comment, in speech after speech, trying to urge this body to act. My general style is probably not as forceful as that of the distinguished Senator from Massachusetts. But about this particular issue I am going to be persistent, and I am going to be here for as long as it takes, until there is an opportunity to have a vote on this amendment. Today, this morning, another arrow in the quiver of reform was played out above the fold in the Washington Post--something, as a doctor's daughter and a doctor's wife for many years, I never thought I would see in the United States of America--and that is, the American Medical Association voting to unionize doctors. The subhead under the headline reads: ``Group Acts in Response to Managed Care's Effect on Rights, Duties of Physicians.'' I want to quote two brief things from the article: In setting up what they are calling a ``national negotiating organization,'' AMA officials contended that only through collective bargaining can doctors win back control over which drugs they may prescribe for patients and how much treatment they can provide. Mr. President, it is a disturbing day when physicians have to unionize to be able to prescribe and treat patients as they see fit. I can't believe that this day has come in the United States of America. Let me end on this subject, with one quote from the AMA president, Dr. Nancy Dickey. She said: Traditional unions are there primarily to care for their employee's needs. We are looking for a vehicle that will allow us to carry out the covenant we have with our patients. That is the reason I am proposing this amendment--or hope to propose the amendment. I hope to have an opportunity to offer an amendment that represents the heart of HMO reform. This amendment will prevent managed care plans from arbitrarily interfering with or altering the physician's decision of what is a medically necessary service. The term medically necessary, or appropriate, is defined as ``a service or benefit which is consistent with generally accepted principles of professional medical practice.'' That is something none of us can be opposed to. If this amendment were in fact the law, it would not be necessary for the American Medical Association to vote to unionize physicians. Physicians would have that right guaranteed by this amendment. Let me prove that by reading the actual wording of the amendment: A group health plan, or health insurance issuer, in connection with health insurance coverage, may not arbitrarily interfere with, or alter, the decision of the treating physician regarding the manner or setting in which particular services are delivered if the services are medically necessary or appropriate for treatment or diagnose to the extent that such treatment or diagnosis is otherwise a covered benefit. The amendment is saying that if an individual buys a policy which specifies treatment for certain illnesses, the physician will be free to treat that patient as medically appropriate with respect to both the treatment and the setting. That is what physicians at the AMA meeting yesterday just voted, to unionize to be able to care for their patients. Why do they need to have a union to achieve something which is self-evident, which is a part of medical training, which is the history of medicine in the United States of America, and has been the history of medicine in this country, up to the growth of managed care, which again could change and alter that history rather dramatically? The terms ``manner'' and ``setting'' mean the location of treatment and the duration of treatment. That means, whether the treatment is in the office or the hospital, the physician has the right to determine the type of treatment and the length of, for example, the hospital stay. The physician would have the right to determine these things. Physicians today are going to unionize in order to get that basic right, a right which we, the Congress, the Senate of the United States, could, if we chose, give them legislatively. The term ``medically necessary or appropriate'' is defined in the amendment as a service or benefit which is consistent with generally accepted medical practice--a very standard definition, a very well- accepted definition. This amendment is intended to restore the physician to medical care. Very simply stated, I agree with the American College of Surgeons, which said: Any health care system or plan that removes the surgeon [or doctor] and the patient from the medical decision-making process only undermines the quality of the patient's care and his or her health and well-being. Our system today has done just that. And the action taken by doctors to unionize strongly suggests that. Medical providers today are feeling kicked around, arm twisted, ``incentivized,'' and compromised when they try to provide good care to sick people. I am compelled to offer this amendment because I have no other choice. Yes, I want to pass an agriculture appropriations bill, but I have been trying for almost 3 years now to pass legislation like this to restore medical decisionmaking to medical professionals. As Congress dawdles, the complaints keep rising, people get poor care, and people die. Let me talk a little bit about managed care. Managed care is a growing form of health insurance in America. I support managed care. I believe it can in fact be a cost-effective way of delivering good health care to large numbers of people. But it can't do that if accountants and the ``green eyeshade'' personnel make the decision for the physician. The physician has to make the decision as to what is appropriate medical care. Today over 160 million Americans--or 75 percent of the insured population--have managed care plans. My State of California--this is the reason I have decided to be so persistent--has the highest penetration of managed care of any state. Eighty-five percent of insured Californians are in some form of managed care. As managed care has grown, so have the complaints. There seems to be a steady stream of them into my offices, and into other Congressional offices and in the media. A Kaiser Family Foundation and Harvard University study found the following: First, a majority--actually 59 percent of Americans--say managed care plans have made it harder for people who are sick to seek medical specialists. Second, three out of five--61 percent--say managed care has reduced the amount of time doctors can spend with patients. Third, a majority of people in managed care--55 percent--say they are worried that if they are sick, their health plan would be more concerned about saving money than about what is the best medical treatment. In Sacramento, a survey of managed care enrollees found that of those consumers experiencing problems, the most common problems were: One, delay, or denial of care, or payment, 42 percent; Two, limited access to physicians, 32 percent, such as difficulty getting an appointment, or limited access to specialists; Three, concerns about quality of care, 11 percent, including inappropriate treatment, facilities, or diagnosis. As managed care has grown, the pressures on doctors and other professionals to control costs have come at the expense of people's health. In other words, as the plans grow, the pressures on doctors to cut treatment, to prescribe cheaper drugs, to cut hospital stays also increase. Doctors report to us that they have to spend hours on the phone with insurance accountants and adjusters justifying medical decisions. That should not happen. They tell me they have to provide mountains of paperwork documenting patients' problems. This is a real change. When my father was chief of surgery at the University of California Medical Center, he had one secretary. He saw patients in his office at the University of California. He taught surgery in the medical school. And there was very little paperwork. Today, walk into virtually any surgeon's office, and there is a mound of paper, there are rooms full of staff, there are accountants, and there is a huge stream of paperwork. Medicine has changed dramatically in the United States. Not all of that is bad. I am the first one to say it. Many people have good coverage. The problem is the cost of that coverage and whether that coverage is providing for timely and appropriate diagnoses and treatments, which are the finest, as Senator Kennedy said, that people can expect. I am also told that physicians are spending increasing time having to fight insurance companies that try to impose rules on their medical practices--rules that are not considered to be the best medical practice or may not even fit an individual's illness. They tell me they have to exaggerate illnesses to get coverage. They tell me they have to struggle to balance medical necessity against insurance company bottom lines. One survey of California doctors by the California Medical Association found that fewer than 10 percent of doctors had good experiences with managed care. That is what is leading to this headline, ``AMA Votes to Unionize.'' That is what this amendment can change. Another study reported in the November 1998 New England Journal of Medicine found that 57 percent of primary care doctors in California felt pressure to limit referrals, and 17 percent said that this actually compromised the care of their patients. Doctors are trained to diagnose and treat based on the best professional medical practice. They know that every individual brings to their office a unique history, unique biology, and unique conditions. And they know that people vary tremendously. What works in one person may not work in the next. The point I am trying to make is that people vary tremendously. The drug that works in one and has no side effects may work differently in another person. A 70-year-old with the flu or pneumonia is very different from a 30-year-old with the flu or pneumonia. A person with high blood pressure or anemia may need an extra day or two in the hospital after surgery. This is why the physician should determine the treatment, the length of treatment, the length of hospital stay. That is what my amendment attempts to accomplish. I yield the floor.

Mrs. FEINSTEIN

Mrs. FEINSTEIN. Mr. President, I ask unanimous consent that reading of the amendment be dispensed with.

Mrs. FEINSTEIN

Mrs. FEINSTEIN. I will do my best with 7 minutes.

Mrs. FEINSTEIN. I have completed it. I could go on.

Mrs. FEINSTEIN. I thank the Chair. I thank the Senator from Nevada. At an appropriate time, I will submit that amendment. Let me tell you some of the things we are increasingly told: That is, that doctors have to spend hours hassling with insurance company accountants and adjusters to justify medical necessity decisions--why a person needs another day in a hospital, why a patient needs an MRI, why a patient needs a blood test, why a patient should get a particular drug, this drug rather than that drug. Doctors increasingly say they have to exaggerate or lie so their patients can get proper medical care. In USA Today, an article was run saying that 70 percent of doctors interviewed said they exaggerate patients' symptoms to make sure HMOs do not discharge patients from hospitals prematurely. Seventy percent of doctors indicate that they do not tell the truth about a patient's condition so they can be assured that that patient gets adequate hospital care. Now, is this what we want? I don't think it is. I think the doctor's decision, based on an individual's condition, should be the overriding decision that determines medical necessity. The amendment I will introduce will ensure that that happens. In the HHS inspector general's report of June 1998, the following finding was made: Most doctors think working in a Medicare HMO restricts their clinical independence and that HMOs' cost concerns influence their treatment decisions. Mr. President, every patient is different and brings to a situation his or her own unique history and biology. Only a physician who is trained to evaluate the unique needs and problems of a patient can properly diagnose and treat an individual. A Los Angeles doctor by the name of Lloyd Krieger said: Many doctors are demoralized. They feel like they have taken a beating in recent years. Physicians train years to learn how to practice medicine. They work long hours practicing their field. Under this health care system, that training and hard work often seems irrelevant. A bureaucrat decides how doctors are allowed to treat patients. Dr. Krieger says: When I tell someone he is fit to leave the hospital after an operation, I am often given an accusing stare. Sometimes my patient asks: Is that what you really think or are you caving in to HMO pressure to cut corners on care? Here's another example: A California pediatrician treated a baby with infant botulism, a toxin that spread from the intestine to the nervous system so the child really couldn't breathe well. The doctor prescribed a 10- to 14-day hospital stay. That doctor thought that length of stay was medically necessary for that particular baby. The insurance plan cut it short, saying the maximum that baby could remain in the hospital was 1 week. That shouldn't happen. The amendment I will introduce at the appropriate time, and that I so hope this body will agree to, will ensure that medically appropriate and necessary treatment is prescribed by the physician and not contradicted by a green eyeshade. I very much hope this body will accept it. I have introduced this kind of amendment now with Senator D'Amato as a cosponsor and with Senator Olympia Snowe as a cosponsor. Perhaps the time has come to have the opportunity to pass this amendment and to get it done once and for all. I thank the Chair, I thank the Senator from Nevada, and I thank the Senator from Massachusetts as well. I yield the floor. Mr. COCHRAN addressed the Chair.

Mrs. FEINSTEIN. If I could have another 7 to 10 minutes at this time, I would appreciate it very much.

Mrs. FEINSTEIN

Mrs. FEINSTEIN. Mr. President, I am on the floor because I anticipated that at 2 o'clock we would be returning to the agriculture appropriations bill. I indicated this morning that I would be proposing an amendment to that bill that has to do with giving the physician the right to provide medically necessary services in a setting which that physician believes is best for the patient. I now see that this has been postponed an hour, so I would like to speak to the amendment now and then introduce it at 3 o'clock. I hope there will be no objection to that. Let me begin by saying, once again, what this amendment does. Essentially, the amendment says that a group health plan or a health insurance issuer, in connection with health insurance coverage, may not arbitrarily interfere with or alter the decision of the treating physician regarding the manner or the setting in which particular services are delivered if the services are medically necessary or appropriate for treatment or diagnosis, to the extent that such treatment or diagnosis is otherwise a covered benefit. I read that specific language because it is important to understand that because most people buying a health insurance plan believe that their doctor is, in fact, going to be prescribing the treatment that is best for them, not the treatment that is the least cost effective, not the treatment that might run a risk to the patient but be good for somebody else, but the treatment or the procedure, in an appropriate setting, that is right for that patient. What is right for a patient who is 18 years old may not be right for a patient who is 75 years old, and so on. I will read from the legislation the definition of ``medical necessity'' or ``appropriateness'': The term ``medical necessity'' or ``appropriate'' means, ``with respect to a service or a benefit, a service or benefit which is consistent with generally accepted principles of professional medical practice.'' That is something that everyone expects, that everyone is accustomed to in this Nation, and I believe that is the way medicine should, in fact, be practiced. I am very pleased to say the language of this amendment, from the larger Patients' Bill of Rights (S. 6) is supported by some 200 organizations all across the United States, including the American Academy of Emergency Medicine; the American Academy of Neurology; American Academy of Pediatrics; American Association of University Women; American Cancer Society; American College of Physicians; American Heart Association; American Lung Association, and the American Medical Association, which is the largest association of practicing physicians in the country. Then there is the American Psychological Association; the American Public Health Association; the American Society of Clinical Oncology; virtually every breast cancer organization; the Consumer Federation of America; the Epilepsy Foundation; the Leukemia Society; the National Alliance of Breast Cancer Organizations; the National Association of Children's Hospitals; the National Association of People with AIDS; the National Council of Senior Citizens; the National Black Women's Health Project; the National Breast Cancer Coalition; the Older Women's League; the Paralyzed Veterans of America--on and on and on. This is a widely accepted amendment that virtually has the support of every professional and patient organization that deals with health care anywhere in the United States. Let me read a statement from the American College of Surgeons, certainly the most prestigious body for surgeons, and one to which my husband, Bert Feinstein, belonged: We believe very strongly that any health care system or plan that removes the surgeon and patient from the medical decisionmaking process only undermines the quality of that patient's care and his or her health and well-being. Similarly, the American Medical Association has said, ``Medical decisions should be made by patients and their physicians, rather than by insurers or legislators.'' I have worked on this now for 3 years. In the last Congress, I introduced legislation to allow doctors to decide when to discharge a woman from the hospital after a mastectomy. I did this with Senator D'Amato in the last Congress and with Senator Snowe in this Congress. And I introduced a bill that would allow doctors to decide when to discharge a person from the hospital after any procedure or treatment, with Senators D'Amato and Snowe. Why do we need these bills? Senator Mikulski from Maryland this morning made a very impassioned case about mastectomies. And we learned in 1997 that women were being pushed out of the hospital on the same day after a mastectomy. I was amazed to hear from a woman named Nancy Couchot of Newark, CA, who wrote me in 1997 that she had a modified radical mastectomy at 11:30 in the morning and was released from the hospital by 4:30 that afternoon. She could not walk to the bathroom without help. She said in her letter: Any woman, under these circumstances, should be able to opt for overnight stay to receive professional help and strong pain relief. Victoria Berck of Los Angeles wrote that she went in at 7:30 a.m. and was released at 2:30 p.m. with drains attached to her body. She said, ``No civilized country in the world has a mastectomy as an outpatient procedure.'' It was a very large health care network in California that was doing these ``drive-through'' mastectomies on the same day. I believe ``drive-through'' mastectomies have been largely stopped, but patients had to rise up, and patients had to say you can't do this to me. You can't push me out a few hours after an anesthetic with drains in my body, having had a radical mastectomy and not being able to take care of myself. What if the woman is 75 instead of 25? It makes no sense. We also learned that insurance plans were insisting one-night hospital stays if you had a child. We learned that babies--infants--were going home with jaundice, and they had to come back to the hospital for treatment once, twice, or three times. There was a lot of ``tsk-tsking.'' What a terrible procedure. How could they do this? Now it has changed because Congress acted, requiring a minimum of two days for childbirth, for a normal delivery. What if you need 5 days for care, or 6 days for care? The point is that it should be a decision made by the physician. It should not be countermanded by someone unqualified to make that decision. A California neurologist told us about a 7-year-old girl with an ear infection who went to the doctor with a high fever which developed into pneumonia, and she was hospitalized. The HMO insisted that she be sent home after 2 days. She ended up returning to the hospital three times, sicker each time to the point where she developed meningitis. The doctor said that if she had stayed in the hospital for 5 to 7 days the first time that she could have been given antibiotics, been monitored, and would not have gotten meningitis. What is the problem? Let me read the definition of medical necessity in an insurance contract provided to me by the American Medical Association. This is from the Aetna/U.S. Healthcare standard Texas contract. I quote: ``Health care services that are appropriate and consistent with the diagnosis in accordance with accepted medical standards and which are likely to result in demonstrable medical benefit,'' and here is the point, ``and which are the least costly of alternative supplies or levels of service.'' It is not ``and/or.'' It is ``and which are the least costly.'' So if you belong to that plan and there is a drug that is the least costly, perhaps not as effective or perhaps not good for you with your present condition, or because of your age, that is the drug you are forced to take because the insurance plan says so, despite what the doctor says. If there is a diagnostic process that may be less effective than an MRI, that MRI is very often prohibited for you. What is happening out there? What is the problem? The problem is that doctors are finding insurance plans overriding their decisions, dictating their decisions, second-guessing their decisions about what is medically necessary. We aim in this amendment to give that basic right of medical practice back to the physician. In fact, today doctors all across this Nation will tell you that they spend hours hassling with insurance company accountants and adjusters to justify medical necessity decisions --why a person needs another day in a hospital, why a person needs an MRI, why a patient needs a blood test, why a patient should get this drug instead of that drug. Seventy percent of doctors across this great Nation say they are forced to exaggerate a patient's symptoms to make sure HMOs don't discharge patients from hospitals prematurely. Is this the kind of medical care that we want to see HMOs press us toward where a doctor has to lie, fabricate, or exaggerate the condition of the patient to be sure that patient gets what is medically appropriate for that particular patient? I truly think not. Every patient is different. Every patient brings to a situation his or her own unique history and biology. Doctors should be able to use their best professional judgment in each individual case based upon the needs or condition of the patient. Pneumonia in a 30-year-old patient is different from pneumonia in a 70-year-old patient. Doctors know the difference, and most of us do, too. A Maryland nurse said: I spend my days watching the care in my unit be directed by faceless people from insurance companies on the other end of the phone. My hospital employs a full-time nurse whose entire job is to talk to insurance reviewers. I myself in 1989 had to have a hysterectomy. I was extraordinarily anemic. As I was in the hospital for a blood transfusion, the phone rang. I picked up the phone. It was my insurance company. What they said to me is: Why are you still in the hospital? You are supposed to be out of there by now. My only response was: I am here because I am currently having a blood transfusion. A patient shouldn't have to go through this. It happened to me. You can be sure it is happening all across this country. Doctor Robert Weinman told the San Jose Mercury News that a doctor prescribed a brain wave test for a convulsing epileptic child. The HMO board--consisting of one accountant, the chief financial officer, and one doctor--refused coverage, depriving the doctor of the necessary diagnostic information. On June 14, just a couple of weeks ago, a California nurse practitioner told my staff that insurance plans will allow people with ulcers to take Prilosec for only 4 to 6 weeks, even though the gastroenterologists say that it is needed for a longer period. Plans say patients can take Tagamet, which is cheaper but not as effective for this particular condition. This is what this amendment seeks to avoid. The doctor should be able to prescribe based on medical necessity what is appropriate to each patient--a hallmark of good medical care. A California doctor told us about a patient who needed a total hip replacement because her hip had failed. The doctor said that patient should remain in the hospital for 7 days. The plan would only authorize 5 days. Let me quote once again from a Los Angeles physician. Many doctors are demoralized. They feel like they have taken a beating in recent years. . .physicians train years to learn how to practice medicine. They work long hours practicing their field. Under this health care system, that training and hard work often seem irrelevant. A bureaucrat dictates how doctors are allowed to treat parties. . . When I tell someone he is fit to leave the hospital after an operation, I am often given an accusing stare. Sometimes my patients even say: ``Is that what you really think or are you caving in to HMO pressure to cut corners on care?'' Medicine shouldn't have to be practiced this way in the United States of America. Over 80 percent of the people of my State are in some form of managed care. California has been a laboratory for managed care. Californians are speaking out on the issue. Over one half of Californians say that major changes are needed in our health care system. Californians say they have to wait for care longer, they are rushed through appointments, they have to navigate impersonal systems when they are trying to get care. A survey of 900 doctors in California found that 7 out of 10 were dissatisfied with managed care organizations. Insurance companies have invaded the examining room, the emergency room, and the hospital room. The ``care'' is rapidly going out of health care. Getting good health care should not be a battle. I think everyone in this body understands HMOs can be effective good, they can reduce costs in a medically acceptable way. And that is the key--in a medically acceptable way, without adversely impacting the patient. The way to do this is not to countermand the physician, not to tell the physician what drug he or she can or cannot give a patient based on the cost, not to tell a physician he has to conduct a radical mastectomy at 7:30 in the morning, removing sometimes both of a woman's breasts and lymph nodes, and push her out on the street with drains in her chest and pain coursing through her body. That isn't good health care for anyone. This is a simple amendment. It is supported by virtually over 200 health organizations. Some might say why not wait until we work out an agreement so a Patients' Bill of Rights--whether it be Democrat or Republican--can come to the floor. I have waited for 3 years for an opportunity to move this kind of legislation. We cannot wait any longer. Senator D'Amato and I, 3 years ago, held a press conference urging this kind of legislation. Senator Snowe and I, in this Congress, have introduced similar legislation. The beauty of this amendment, that I want to bring before the Senate for a vote, is that it states very simply that health insurance coverage may not arbitrarily interfere or alter the decision of the treating physician regarding the manner or setting--hospital, emergency room, outpatient clinic, whatever it is--in which particular services are delivered, if the services are medically necessary or appropriate for treatment or diagnosis. Every single patient in managed care anywhere in the United States of America will be better off the sooner this amendment becomes law. I believe to wait is wrong. I believe to wait will cost lives. I believe to wait will increase morbidity. I believe to wait is unfair to the physicians who are trained, able, and ready to carry out their profession. I am hopeful I will have an opportunity, in 25 minutes when the agricultural appropriations bill is on the floor, to offer this amendment which is broadly and widely supported all across the United States. Once and for all, the physician and the patient will together make the medical decisions--not a green eyeshade somewhere in a remote HMO office. I yield the floor.

Mrs. FEINSTEIN

Mrs. FEINSTEIN. I thank the Senator.

Mrs. FEINSTEIN. We would have minority rights to amend that bill?

Mrs. FEINSTEIN. In exchange for a definitive date of bringing up the Patients' Bill of Rights?

Mrs. FEINSTEIN. Mr. President, I say to the distinguished whip, I have been here for a long time hoping to offer an amendment to the agriculture appropriations bill. Can you give me any time when that bill might be coming to the floor?

Mrs. FEINSTEIN. Mr. President, reserving the right to object.

Mrs. FEINSTEIN

Mrs. FEINSTEIN. I thank the Chair, and I thank the Senator from Nevada. Mr. President, when we return to the bill, it will be my intention to offer an amendment to the agriculture appropriations bill. I think that my amendment will deal with one of the most fundamental concerns in health care today; that is, the restoration to the physician of the basic right of patient care, patient treatment, and to be the determinator of patient care and the length of hospital stay. I think one of the things we have seen emerge in health care throughout the United States in the past 2 to 3 years is the development of the so-called green eyeshade of an HMO determining what is appropriate patient care, regardless of the physical condition of an individual patient. The amendment I will offer essentially says that a group health plan or a health insurance issuer, in connection with health insurance coverage, may not arbitrarily interfere with or alter the decision of the treating physician regarding the manner or setting in which particular services are delivered, if the services are medically necessary or appropriate for treatment or diagnosis to the extent that such treatment or diagnosis is otherwise a covered benefit. In other words, if you have coverage for a treatment in your plan, the physician determines that treatment based on you, based on your needs, based on your illness--not based on the calculation of a green eyeshade in a health insurance plan. My father was a surgeon. He was chief of surgery at the University of California. My husband, Bert Feinstein, was a neurosurgeon. I grew up and lived a good deal of my life in a medical family. In all of that time, the doctors determined the appropriateness of care, the doctors determined the length of hospitalization, the doctors determined whether a particular treatment was suitable for an individual--not an arbitrary HMO, not physicians out of context of an individual physician and patient. Every person sitting in this gallery today is different, one from the other. They are different in how they react to drugs. They are different in how they react to radiation--

Mrs. FEINSTEIN. If I may finish my sentence.

Mrs. FEINSTEIN

Mrs. FEINSTEIN. Mr. President, my amendment calls upon the Department of State to provide Congress with a report on the global proliferation of small arms and light weapons, and State Department activities to address this issue. For fifty years we have been used to thinking about arms control in terms of nuclear weapons and ballistic missiles. But, to my mind, the widespread proliferation of small arms and light weapons has now emerged as an equally pressing issue on the international arms control agenda. Let me try to sketch out the scope and dimension of this problem, and why I think it is critical that this issue be included in the first- rank of U.S. arms control and security policy: An estimated 500 million illicit small arms and light weapons are in circulation around the globe. In the past decade, an estimated 4 million people have been killed in civil war and bloody fighting. Nine out of ten of these deaths are attributed to small arms and light weapons, and, according to the International Committee of the Red Cross, more than 50% of those killed are believed to be civilians. The sheer volume of available weaponry has been a major factor in the devastation witnessed in recent conflicts in Angola, Cambodia, Liberia, Mozambique, Rwanda, Sierra Leone, Somalia, Sri Lanka, and Afghanistan, among others, as well as the sort of violence endemic to narco- trafficking in Colombia and Mexico. According to a report last year by ABC News, at least seven million illicit small arms and light weapons are in circulation in West Africa. According to Human Rights Watch, a variety of small arms and light weapons were readily available on the black market in Rwanda prior to the civil war and genocide in that country: In 1994 an AK-47 could be purchased in Rwanda for $250; a grenade for $20; and, a 60mm Mortar Bomb for $85. More than 50 million AK-47s have been manufactured in the last 40 years, far more than are accounted for in government stockpiles or registries. During the past decade it is estimated that more than 1 million Uzis and 10 million Uzi copies have gone into circulation. According to the South African Institute for Security Studies, an estimated 30,000 stolen firearms enter the illegal marketplace annually in South Africa. Mozambique, a country whose total population is 15 million, has more than 10 million small arms in circulation. Although there are no reliable statistics available, numerous analysts and press reports have noted that in recent years various actors in the Russian military, government, and mafia have been active in selling large quantities of Russian military equipment on the black market. The United Nations and the Red Cross estimate that there are that more than 10 million small arms are in circulation in Afghanistan, where the terrorist organization of Osama Bin Laden is based. Over 1 million small arms--ranging from pistols to AK-47s to hand grenades--are readily available in arms bazaars on the Pakistani side of the Afghan border. Many of these weapons are believed to flow to the Kashmir, where they contribute to the instability and tension between India and Pakistan, who both now posses nuclear weapons. The United Nations estimated that over 650,000 weapons disappeared from government depots in Albania in the three years leading up to the outbreak of violence in the Balkans, including 20,000 tons of explosives. The NATO peacekeepers who are now moving into Kosovo may be under threat and danger from these weapons. In fact, the increased access by terrorists, guerilla groups, criminals, and others to small arms and light weapons poses a real threat to U.S. participants in peacekeeping operations and U.S. forces based overseas. Although it is my belief that the United States is not the biggest contributor to the problem of the global proliferation of small arms and light weapons--the United Nations has found that almost 300 companies in 50 countries now manufacture small arms and related equipment, a 25% increase in production since 1984--in 1996 the U.S. licensed for export more than $527 million in light military weapons. With the average price of $100-300 per weapon, this represents a huge volume of weapons. Most troubling, there is increased incidence of U.S. manufactured weapons flowing in the international black market. In 1998, at the request of foreign governments, the U.S. Bureau of Alcohol, Tobacco, and Firearms conducted 15,199 traces of weapons used in crimes. In 1994, Mexico reported 3,376 illegally acquired U.S.-origin firearms. Many of these weapons were originally sold legally to legitimate buyers but then transferred illegally, many to the Mexican drug cartels, once they left the United States: Between 1989 and 1993, the State Department approved 108 licenses for the export of $34 million in small arms to Mexico, but it performed only three follow-up inspections to ensure that the weapons were delivered to and stayed in the hands of the intended users. Other countries have equally porous arms sales and licensing regulations: In the United Kingdom, only 24 of 2,181 arms export licenses to 35 countries were refused last year. Clearly this is a huge problem, with profound implications for U.S. security interests. As Secretary Albright noted in her speech to the International Rescue Committee last year: ``The world is awash in small arms and light weapons.'' The purpose of this amendment is very simple. It calls for a Report by the Department of State to provide Congress with an assessment of the dimension of the problem, the threats posed by these weapons to U.S. interests, and the activities of the Department regarding the proliferation of small arms and light weapons. It is my hope that this information will provide policymakers with a better understanding of this issue, whether sufficient resources are being devoted to addressing the threats posed to U.S. interests, and if additional resources will need to be directed towards this issue in the future. I understand that the Managers have cleared and will accept this Amendment for inclusion in the State Department Authorization bill. As a former member of the Foreign Relations Committee it was a pleasure to be able to work again with my former Chairman and Ranking Member, and I would like to thank them for working with me on this Amendment. I look forward to the opportunity to continue to work with them on this important issue.

Mrs. FEINSTEIN

Mrs. FEINSTEIN. Mr. President, I rise today in opposition to the cloture motion to proceed to H.R. 975, the Steel Import bill. I do so for three reasons. First, I think that this legislation is protectionist and invites retaliation under the World Trade Organization; second, I believe that it may endanger the health and stability of the international economy; and, third, I believe that it may endanger the health and stability of the U.S. economy, including the steel industry it is intended to protect. I understand the appeal of this legislation for those who support it, and believe that they are well intentioned in wishing to see legislation passed which protects the U.S. steel industry. As supporters of this legislation have pointed out, there was an undeniable surge in steel imports into the United States last year. Over the past three years, economic instability in East Asia, Russia, and Latin America have resulted in a weakening of the world steel market. According to the Congressional Research Service, between August 1997 and August 1998, imports surged almost 80%. But today, it is important to note, steel imports have returned to their pre-crisis levels, down roughly 44% in April 1999 since last August's peak, according to the office of the United States Trade Representative. Where I disagree with supporters of this legislation, then, is that although I too believe that some complaints about unfair competition and unfair trade practices are, of course, warranted, the solution to those complaints found in this bill--the imposition of unyielding import quotas--is an approach which I believe to be counterproductive and even potentially harmful to the health of the U.S. economy. First, the protectionism sought by this bill would put the United States in violation of world trade rules, and would invite retaliation against U.S. producers of a range of goods in overseas markets, jeopardizing jobs at home. The World Trade Organization permits the application of ``safeguard measures'' such as quotas only in very specific circumstances, and never unilaterally. In the absence of a determination that the product in question is being imported in such increased quantities as to cause or threaten to cause serious injury to the domestic industry, unilateral measures such as those included in this bill are not permitted. And if a nation takes such a unilateral measure, the countries affected are allowed to take retaliatory measures. Thus, if this legislation is enacted, the United States would face the real possibility of retaliation by the world's steel exporting countries. Under the WTO rules, other countries will have the right to retaliate against our exports. They could put at risk our most competitive sectors--such as agriculture, high-tech, or pharmaceuticals. In fact, a June 18 letter signed by the American Farm Bureau Federation, the International Dairy Foods Association, and the National Cattlemen's Beef Association, among others, states that: At a time when U.S. farmers are facing severe financial hardships, continued access to global markets Is critical to preserve farm income . . . since growth for the U.S. agricultural sector hinges on access to world markets, passing legislation that violates the WTO threatens economic growth in the farm sector. In addition, there could also be retaliation against U.S. products that use steel, such as automobiles, heavy machinery, or construction. For example, according to a letter I received from Boeing: In 1999 we expect to deliver approximately $18 billion in airplanes to international customers, many of whom are struggling to purchase these planes as a result of the Asian financial crisis. A number of these airplane deliveries could be at risk if new limits on imported steel are imposed. The unilateral protectionism embodied in this bill would undermine the international trading system and the institutions, rules, and regulations to safeguard the international economy that the United States has worked so hard to put into place over the past fifty years. As we have seen in numerous cases, these institutions and rules have helped the U.S. gain market access when other nations sought to prevent it, and have helped the U.S. economy to grow and created numerous jobs here in the United States. As the world's largest trading nation, U.S. interests are best served by supporting--not undermining--the rules-based international economic and trading system. This leads me to my second point, and the second reason I am opposed to this legislation: I believe that this legislation threatens to undermine the health and stability of the international economy, and with it the base for much of America's current economic prosperity. Free trade has been a prime ingredient in the eight year U.S. economic boom. Moreover, in the past year we have begun to turn the corner on a global economic crisis. Maintaining open world markets is vital to global recovery in Asia, Russia, Brazil, and elsewhere. These countries have not closed their markets to U.S. products despite the economic pressures they have faced in the past several years. If the U.S. takes a significant step towards protectionism, it will set off a global chain-reaction. Indeed, according to a May 25 letter I received from Raymond Chretien, the Canadian Ambassador to the United States, passage of this legislation: . . . would set a protectionist precedent that would encourage other industries, in the U.S. and other countries, to seek unilateral relief outside of legitimate, established, trade remedies. The world economy, and workers in affected countries, can ill afford the turmoil that could ensure in international commerce. According to Brookings Analyst Robert Crandall, HR 975 is ``one of the most blatantly projectionist pieces of legislation since the 1930s''. I do not believe that a single member of this body wants the United States, or the international economy, to risk a return to those days of global depression. Finally, although the quotas might have some marginal palliative effect for some of the old-line steel factories, they would have a far larger effect on the overall health and well-being of the U.S. economy, and threaten to harm countless other U.S. workers and consumers. This is the third reason I oppose this bill: I believe that it is bad for the U.S. economy, including the steel industry. To take one example, steel import quotas would increase the price of steel used by the automobile industry, harming the auto industry and auto workers, and would in turn show up in higher auto sticker prices, harming U.S. consumers hoping to be able to purchase reasonably priced cars. In short, steel import quotas will undermine U.S. manufacturing competitiveness in a range of industries and business that rely on steel, from metal fabrication to transport to industrial machinery to construction; industries that in toto employ over 8 million workers. For example, I received a letter from the Aggressive Engineering Corporation, a small California company that serves military and commercial industry in their metal stamping needs. According to this letter: Our company relies on steel from domestic producers. However, U.S. steel producers are able to supply only about 75% of the demand for steel, leaving a yearly shortfall of 30 million tons. In order to maintain our operations in the United States, we depend on foreign steel. . .While we all agree that it is important to maintain U.S. jobs and job growth, steel is no less important than other sectors. Please remember that steel-using industries employ more than 40 American workers for every worker in the steel industry. Quotas do not work. They will harm consumers and steel- consuming industries to a much greater extent than they could ever help steel producers or steelworkers. It is also important to keep in mind that although many of the old- line steel mills face serious difficulties, that is not the same as saying that overall the U.S. steel industry is in trouble. In fact, many of the problems faced by old-line steel mills stem less from import problems than from decades-old mills that are unable to compete with the efficient new mini-mills located right here in the United States. Even as the U.S. faced the ``import surge'' last year, U.S. mills rolled out 102 million tons of steel in 1998, the second highest total in the past two decades. In addition, The Wall Street Journal has reported that 25% of the steel entering the United States last year was bought by American steelmakers, who otherwise could not have met the demands of their customers. In other words, while seeking to protect the steel industry, this legislation could in fact harm the industry by protecting the least efficient producers at the expense of the more efficient, and by preventing American steelmakers from getting access to the steel they need to meet customer demand. In response to this surge in imports last year, earlier this year the Administration put in place an aggressive Steel Action Plan to strictly enforce the trade laws already on the books; enter into new bilateral agreements with Japan, Russia, and Korea regarding their steel imports to the United States; create new sources of early import data and an active monitoring of safeguards; and lend support for the Section 201 safeguard law. In addition, the Department of Commerce determination on the import surge this February, recently supported by a finding of the International Trade Commission, has paved the way for the Administration to slap duties on Japanese and Brazilian steel and forced Russia to restrict its imports. I believe that the Administration's response has been tough but fair. And I believe that the proof of the effectiveness of this response is in the pudding: By all accounts the steel import crisis is over, with imports having receded back to pre-crisis levels. Under these circumstances--passing potentially harmful quota legislation after the crisis has passed--is the wrong way to approach this issue, and I hope my colleagues will join me in opposing the cloture motion to proceed to this bill.

Mrs. FEINSTEIN

Mrs. FEINSTEIN. Mr. President, as the distinguished subcommittee chairman, Senator Bennett, just outlined for the Senate, the fiscal year 2000 legislative branch appropriation bill was reported out of the full Appropriations Committee on Thursday, June 10, 1999, by a vote of 28-0. As reported by the committee, the bill, which totals $1,679,010,000 in budget authority, exclusive of House items, is $113,962,000, or 6.4 percent, below last year's enacted level and $104,529,000, or 5.9 percent, below the President's request. For Senate items only, the subcommittee recommends a total of $489,406,000--a reduction of $28,187,000, or 5.4 percent, from the President's request. For the Capitol Police, the subcommittee recommends a total of $88.7 million for salaries and general expenses. This is an increase of $5.8 million, or 6.8 percent, over last year's enacted level. I commend the agency for soliciting a management review which was conducted by an outside consulting firm. Since that time, the Capitol Police has been very aggressive in addressing the management deficiencies outlined in that report. First, they provided the subcommittee with a departmental response which addressed the findings of the review, and they are currently in the process of developing a strategic planning process which will provide for a systematic approach to organizational enhancements and professional growth for the future. In this regard, this bill contains the funding required for improvements to information technology and transfers this responsibilities from the Senate Sergeant at Arms to the Capitol Police. This action was recommended in the management review report. The bill also provides for cost-of-living and comparability increases for the men and women of the United States Capitol Police. For the General Accounting Office, the subcommittee recommends a funding level of $382.3 million, which is $4.8 million below the budget request, but is almost $10 million above what the House is proposing. The level proposed by the subcommittee will permit the GAO to maintain the current level of 3,275 FTEs, which is what the Comptroller requested for Fiscal Year 2000 and it will also provide adequate funds for them to meet their mandatory requirements. Mr. President, I also want to take a minute, as I did during our full committee markup, to talk about the Senate Employees Child Care Center. As Members may be aware, the groundbreaking for the child care center began in the fall of 1996, and the center was to be completed in the fall of 1997. Here we are in June of 1999, and the center remains incomplete. I have encouraged the Architect of the Capital to raise the priority of this project and bring this problem-plagued project to completion by the current targeted date of September 1, 1999. This new center will expand the quality of child care services available to the staff who help us. Again, Mr. President, I want to personally thank the chairman of the subcommittee, Senator Bennett, for the courtesies he has extended to me. He is, indeed, a most thoughtful and gracious chairman--a real gentleman--who has made my first year on the subcommittee a most pleasant one. If I may, Mr. President, I extend my very sincere thanks to Mary Dewald and Christine Ciccone of the staff for their excellent work on this bill. It has been very special, and we are blessed with wonderful staff.

Mrs. FEINSTEIN. Mr. President, I thank the chairman of the subcommittee, Senator Bennett, and commend him for the fair and responsible bill that has been put together. This is my first year as the ranking member of the Legislative Branch Subcommittee, and I have found Senator Bennett to be very open and willing to discuss issues. His leadership on our subcommittee is carried out in the best bipartisan spirit.

Mrs. FEINSTEIN. I yield back the remainder of our time.