Ted Kennedy

Mr. KENNEDY

Mr. KENNEDY. Would it be agreeable to have an hour, so we could get-- --

Mr. KENNEDY. Mr. President, I have great respect for my friend and colleague from Maine, Senator Collins. Senator Collins is a member of our Health, Education, Labor, and Pensions Committee. As always, she has demonstrated tonight that she is well informed, articulate, and persuasive--I hope in this instance not too persuasive--to her point of view. As always, she spends a great deal of time thinking through these issues. I commend her for her presentation, and I respect her for her position, although it is a position that I cannot support, and I will urge my colleagues to support the alternative, which is the Breaux- Jeffords amendment. We have tried over time, although we do not receive great acknowledgment for it, to find ways we can work with the administration. We have had four or five major issues. The administration really did not take a position about the tax incentives in the legislation, although many of us saw that the tax incentives in the legislation, which many of us supported, would have resulted in the end of this legislation for reasons that have been pointed out earlier. The tax-raising power lies with the House of Representatives, and not with the Senate. Second, on the issue of responsibility of employers, the President made very clear in his statement that he wanted employers who were exercising their judgment in ways HMOs normally do--to bear responsibility if there is injury and harm to patients. We have been wrestling with that definition for several days. We will have an additional opportunity to wrestle with it, but the President has been very clear about wanting to hold responsible those employers who make judgments that interfere with the medical judgments which adversely affect patients. He wants to hold them responsible. That is what many of our colleagues have been attempting to do, and they have been doing it in a bipartisan way. We have had amendments to eliminate all responsibility for employers, and amendments for employers with 50 employees or less. These have been defeated. The President was talking in ways many of us understood. We may differ as to the language, and we do have differences with the President on the liability provisions, but on those other issues, we are very much along the same lines. The President, as well, in his support for the Frist-Breaux bill, basically supported the medical necessity provisions we had included in the McCain-Edwards legislation. They are virtually identical to those in the underlying bill, and the President indicated support of the medical necessity provisions. Those are enormously important. We come to the third of the major issues, and that is scope. Who is going to be covered, and for what particular protections? The President again indicated in his principles for a bipartisan bill that it should apply to all Americans--all Americans; that a Federal Patients' Bill of Rights should ensure that every person--not just some people, not just a few people in some States, not just some who are covered for certain protections in a few States--but that all Americans, every person enrolled in a health plan, enjoy strong patient protections. Those are words that he used. The Breaux amendment is consistent with that particular principle. It is not drafted exactly the way I would like to have it drafted. It does not go to the extent I would like to have gone to guarantee the strong protections which Americans deserve. But nonetheless, in a very important way, the Breaux amendment complies with this particular provision. It will ensure that all Americans are going to be covered and that they will have strong protections. The Breaux proposal also ensures that protections for Americans will remain in the States. They will be the primary regulator under the Breaux proposal. That is the way it was drafted, and it is a preferable way to ensure not only what the President has stated, but what I think I have heard stated by my good friend, the Senator from Tennessee, our ranking member on the HELP Committee, and others. As a matter of fact, every proposal that the House of Representatives considered in their debate last year--I believe there were four major proposals offered by Republicans--all of them included all Americans. That was not a debatable point. It is tonight, and tomorrow morning, we will have the opportunity to see where the Senate is going to stand. I will make a few points, and if I am not correct, Senator Collins will correct me--we only received the amendment just prior to the time the Senator offered it, although clearly we were very much aware this amendment was coming and Senator Collins told us about that. I will make a statement and a point, and if I am wrong, the Senator from Maine will correct me. If her amendment is passed tomorrow, or whenever we pass the final legislation, there will no guarantee of one new protection for most Americans. Do my colleagues understand what I am saying? Mr. President, do they understand what I am saying? If the Collins amendment succeeds and is passed, when it goes into law, there will not be one new protection for most people in this country. There will not be any protection for the children who need speciality care; there will not be any new protections guaranteed for women who need clinical trials; there will be no new protections in a wide range of provisions that are included in the underlying legislation. None, unless--unless--the States go about the business of applying and providing them. Let me be very clear about it, with the passage of her amendment, there is not one new protection from an HMO making the medical decisions they have made in the past. It seems to me that is why we are here because we have, for the last 5 years, been battling to make sure families in this country receive protections, whether they are in Massachusetts, Nevada, or Maine. Let's look at what the circumstances are of some of the States. First, there is an authorization for $500 million, a pool--new funds of $500 million. That is in the amendment. Where we are going to get the money for those funds is not in there. We have authorized funds on many other issues and they have not been appropriated. Welcome to the club. This relies on a $500 million appropriation. When this is passed, there will still be 39 States that do not require any access to clinical trials. In the United States, you might work in Massachusetts today, and maybe you will be transferred to Nevada next year, and then transferred to another State after that. Let me make it clear to you and your family you had better make sure they are one of the 11 States that have clinical trials. Most of the states that have clinical trials are for cancer, but don't include other life- threatening diseases. When I came to the Senate, you worked at the shipyard, your father worked there, and your grandfather worked there. You graduated from high school and had a good life. Those in the workforce today may have nine different jobs over the course of their life, moving all over the country. We ought to get a dartboard to find out where the protections are in the various States for you and your family, moving from one company to another. There are 39 States that do not require clinical trials. Zero States affirmatively require timely access to specialists. If we pass the Collins amendment, there will be a signing ceremony at the White House--hopefully and after the bill is in effect, someone will say: I thought when I had a child who had cancer and we went to our HMO, we would get the guarantee of accessing a specialist. And now that is overridden. I thought we would get the protections we needed. I listened to the debate in Washington that said we could get specialty care. No, no, no, that is not so, because they passed the Collins amendment. The Collins amendment says, only if the States provide it do they get access to specialists. We have 20 States that do not ban financial incentives for providers to delay or deny care. What is happening in HMOs is, as we heard in the numerous committee hearings we have held, there are financial incentives and disincentives for doctors on the procedures they recommend in terms of treating patients. Do we do anything about that? No, no, we are not going to do anything about that, not in 20 States, not if you live in one of those 20 States. They will have incentives and disincentives for the doctors. Tell me what consumer knows about that. Ask any Member of the Senate, if they didn't have a briefing sheet before them, whether their State does or does not ban financial incentives. They will not have to worry because we have good Federal employee health insurance. We will not have to worry. But I doubt whether any Member knows whether their State prohibits it or not. There is nothing under the Collins amendment that will make sure states ban inappropriate financial incentives. Under the underlying bill, there is a prohibition on their use. No HMO ought to provide incentives or disincentives to doctors in terms of providing or recommending necessary treatment. What do we have to learn from this? We have hearings, we find out, we see the affected families, and then do we say, no, Washington does not know best, in this case, ensuring we do not have inappropriate financial incentives? We ought to be able to agree on that. Is that a vast intrusion on States rights? The list goes on. We have seven States that have not adopted a prudent layperson standard for emergency care. If you live in one of those seven States and you think you are having a heart attack and go to the emergency room, you may end up without that care covered. We have seen a number of States take action. It is important to do that. The Breaux alternative says, when the States have taken action in these various areas, there will be respect for that action being taken in the State to protect their citizens and deference will be given to them. That is the way it ought to be. In areas where there is no protection, we are trying to establish a federal floor. If the States want to go beyond that, they can, but at least establish a floor of protections. I listened with interest to both the Senator from Maine and the Senator from Wyoming about two previous pieces of legislation, CHIP and HIPAA. When we passed the CHIP program we provided incentives and money. That is not the issue. The issue is, we gave the States the certain criteria that had to be met, and if they met those criteria the Federal provisions did not apply. Mr. President, 49 of 50 States have done that. I monitored that program closely in our HELP committee. Even when I was not chairman, we had meetings with the previous administration to find out what was happening with that program. I am familiar with it. We don't have complaints from the States. We are not hearing from the States about the heavy hand of the Federal Government for establishing CHIP. They can say they were getting money for that, fine; they were also ensuring that children would have the range of services that would meet needs--not the complete range of services I would like to see. We still don't provide the comprehensive care--eyeglasses or hearing that we ought to provide for children. Dental work was left out, along with many other services that children need, but we find States conforming to the package that was developed. The other reference was with regard to HIPAA. I have heard that speech from the Senator from Oklahoma now eight times. He gets better at it each time he talks about HIPAA and HCFA. I point out, when the GAO recommended $11 million so HCFA would be able to implement HIPAA, he was the one who led the fight against the $11 million, and he was successful. They put in $2 million. And he led the fight to strike out that $2 million so that HCFA could not implement it because they wanted greater flexibility in the States so the insurance companies--that is my conclusion--would be less interfered with. I have had that argument and I will not spend time on it now. The fact is, tonight there are only five States which are not in complete compliance with HIPAA. It has taken time. Many of the criteria placed upon the States are similar to what is in the Breaux proposal. I personally would like to see a stronger provision. At the time we pass this bill, I would like to see all Americans have protections. We have taken those steps in the past on other issues. We decided as a pattern of national policy we were going to pass Federal laws to outlaw child labor in this country. We didn't say: You can go ahead and have that up in Massachusetts if you want to. We passed laws. Anyone can visit now in Lawrence and Lowell, go through the mill, look at the museums and read the poems and letters of 9- and 10-year-old children trapped in factories for 10 or 12 hours a day who wrote as they looked outside and saw other children play. We went through that as a nation and passed federal laws to prohibit that. We also said, we will pass a minimum wage law. We know there are many here who resented it. We passed laws in order to protect our environment because we recognize that environmental issues go through various States and the environmental issues know no borders. I make the same case with regard to workers today, as well. It was not that way in the old days, but it is that way today. We made the same judgment with regard to civil rights. You can say, well, these patient protections are not of the dimension of the issues on civil rights. I think there is a lot you can say about that. But if you listen to the HMO victims whom many of us have heard, if you see the failure of the recommendations of doctors and nurses and medical professionals--the failure of their recommendations because of an HMO bureaucrat many miles away, and you see how lives have been destroyed and how families have been absolutely destroyed--we can ask ourselves, why shouldn't we give that kind of protection to families in this country? Americans, I think, are under a lot of pressures today. Working families are under a lot of pressure. They are not asking for much. They are asking for good jobs with a good future. They are asking for schools where their children can learn. They are asking for health insurance that is going to cover them. They want clean water, they want clean air, they want safety and security in their communities, they want to own their own home, they want a national security and defense that are going to protect our interests, and they want human rights policies abroad that are going to represent our fundamental values. They are not asking for much. But one of the things we can do is protect them when they do get that health insurance. We will be back. We give the other side the assurance we will be back. All those speeches we have heard over these past days asking why are we doing this when we have so many people uninsured--we will be back with legislation on the uninsured. We hope for support from so many of those who have been speaking recently about how we ought to make sure people are going to be covered. We will be back to try to make sure we deal with those individuals. But when you have an opportunity to relieve families of the anxiety so every time they go to a doctor they are going to get the best the doctor can prescribe and the best the nurse can give --when you give that guarantee to every family in America, you are going to ease their anxiety when they have a sick one. Why are we going to play roulette? Let's say you live in Massachusetts today, or Florida, or New Mexico tomorrow. You shouldn't have to worry, which one is going to give strong patient protections? That is what this is about. I do not know what we need as a record. The reasons for this are so powerful, so compelling, so real. We have had statements from every Member in this body about the damage that has taken place and the disruptions to families. We have the opportunity to do something about it. It seems scope is a key issue, a key question. I hope the Senate will come down on the side of the proposal of the Senator from Louisiana.

Mr. KENNEDY. Mr. President, I thank the Senator for her correction. The figures are, of the 195 million Americans with private health insurance, the 56 million who are the self-insured would have coverage. This would leave out the 139 million who are not in self-insured plans, as I understand it. These include state and local public service employees. These include firemen. These would be the police officers. These would be the self-employed. There are 139 million who would not have a federal floor of protections. I have read through this, so I appreciate what the Senator has said. Listen to this. Under this proposal, there is going to be some $500 million that is going to be out there. A State can make a proposal for a new program, and they can receive grants for the new program. They say the States can pass laws which are consistent with the purposes of the Federal standard. But they can keep the money and decline to enact a law because of the adverse impact of a law on premiums which would lead to a decline in coverage. So they could get the money to pass it. But, if there is a judgment that there might be a decline in coverage, they could, I guess, keep the money. They do not have to do anything further to enact a law if the managed care market in the State is negligible. There is no additional responsibility for them to take action for additional protections. They still get money from their fund. I make the point that during the course of this debate there have been a lot of different ways of trying to cut the protections. We heard in our Health, Education, Labor and Pensions Committee about the kinds of abuses that are taking place across the country. The President of the United States recognized that. He indicated that he wanted every person covered. We want to have every person covered. We don't want to carve out a third and say they will be covered, but we will leave out two-thirds who will not be covered with a great many of these protections. I continue to believe in the power of this issue and its impact on families. Why are we going to draw a distinction between neighbors on the same street? One works for a fire department, their family goes to a doctor, and the kind of medical advice their doctor gives to them for their child is overridden by an HMO, and they don't have protections, but his neighbor is protected because his employer self-insures? What possible fairness is there in that? What is the possible justice in that? We should be interested in protecting all families. The President understands that. Hopefully the Senate will understand that tomorrow. If it were left up to me, I would make sure that all of these protections were guaranteed. But we have the Breaux amendment which says: Wait. We are going to say if States have taken action in these areas, there is going to be deference given to the State. There is going to be enforcement and supervision by the State in protecting these areas. I would have liked to see it stronger. But what is very important is guaranteeing some floor of protections. Finally, we are talking about commonsense protections. We are talking about access to the emergency room, specialty care, OB/GYN, and continuity of care. If a woman is pregnant, and the HMO and her employer end their relationship, at least she can see her obstetrician until after the baby is born. We are talking about prescription drug formularies. If the doctor recommends a certain medically necessary drug and it is not included in the formulary, the patient can still get the needed drug. There is going to be a shared expense by the patient as well as the HMO. That has been worked out. We use the same cost sharing that is used in the various formularies. Point of service: There is a closed panel, and a need for outside expertise. Clinical trials are so important. Every one of the protections that is guaranteed are in existence today either in Medicare and Medicaid, or they have been recommended by the insurance commissioners, or they were unanimously recommended under President Clinton's panel, which was bipartisan and included distinguished representatives of all aspects of the health delivery system. Those are the only ones. Finally, as we are hopefully coming fairly close to the end of this debate. We have the support of almost every health organization, every professional medical organization, every patients' organization, every children's organization, every women's organization, every disability group, and every cancer organization for this kind of protection. The reason is very simple. They are out there on the firing line day in and day out. They understand what is happening to families. These are trained men and women who have given their lives for the protection of good health care for families in this country. They have seen what is happening and how many times they are being overruled. They have stated that is what is necessary. The scope and protections that Senator Breaux has included are what they strongly support. We will have a chance to say another word about this tomorrow.

Mr. KENNEDY. I thank my friend from Maine. I am glad to yield.

Mr. KENNEDY. As the language is constructed, they will only provide the protections to these self-insured and not to everyone else who has received their health insurance through other means--the self-employed, those who are getting it through state and local employment, those working for employers who purchase health insurance plans. There are 139 million Americans who will not have those protections. As I mentioned earlier, they will have to rely on protections from the States. There are States that do not require access to clinical trials. There are States that do not require timely access to appropriate, accessible specialists. I mentioned earlier the ban on inappropriate financial incentives. Twenty States don't ban plans from giving financial incentives and disincentives to doctors to delay or deny care. They won't have those protections. The point I mentioned earlier was that we are a society in movement. We find so many families are moving from State to State. Members of families are moving with jobs and going back and forth. We have to ask ourselves ultimately and finally--as the Senator pointed out, this is a federal floor of protections--if you are in a State with clinical trials, why should you have to make sure they have a similar protection requiring access to the clinical trials which your wife might need, but you move to another State and find there is no access to clinical trials? That is strictly because of the protections that you might have in a particular State. It makes absolutely no sense. We ought to have that basic federal floor. I know the Senator agrees with me. The way the Breaux amendment has been devised, it gives the maximum deference to the States if they provide protections in these areas. I mentioned just a half dozen different protections. We could go into others this evening. I will not take the time to do so, but they are illustrative of the protections. These are pretty commonsense protections.

Mr. KENNEDY

Mr. KENNEDY. Mr. President, it is a privilege to join my colleagues Senator Stevens, Senator Inouye, Senator Hutchison, and Senator Corzine in introducing the Comprehensive Tuberculosis Elimination Act. This bipartisan legislation will provide enhanced authority and greater resources to State, local and Federal health officials to do all they can to combat this deadly infectious disease in our country. Tuberculosis is the world's leading infectious killer. Its growth has been propelled by the global HIV epidemic, and multi-drug resistant strains have become increasingly prevalent around the world. The World Health Organization estimates that more than one-third of the world's population is infected with tuberculosis. Every year, there are 8 million new cases of active tuberculosis and 2 million deaths from tuberculosis. This disease causes more deaths among women worldwide than all other causes of maternal death combined. These harrowing statistics illustrate the truth behind the saying that diseases know no borders. Senators Inouye, Stevens, and Hutchison and I have already introduced the Stop TB Now Act, which focuses on international tuberculosis control. The bill we are introducing today will deal with tuberculosis in our own country. Only through enactment of both of these measures can we be sure of defeating this readily treatable and preventable disease. Today's bill is intended to fulfill the recommendations of the landmark report issued by the Institute of Medicine last year, entitled ``Ending Neglect: The Elimination of Tuberculosis in the United States.'' Our measure will create a national plan for the eradication of tuberculosis. It will enhance tuberculosis-related research, education and training through the Centers for Disease Control and Prevention. It will also expand support for vaccine research and for international tuberculosis research through the National Institutes of Health. In the United States, tuberculosis has been going through what the Institute of Medicine calls ``recurrent cycles of neglect'' by public health authorities, ``followed by resurgence'' of the disease. In the late nineteenth century, tuberculosis was one of the leading causes of death in America. As cities swelled with waves of European immigration, millions of individuals and families were forced into overcrowded tenements and unhealthy workplaces. Many fell victim to outbreaks of deadly infectious diseases. In 1886, the leading cause of death among infants was tuberculosis, followed by infant diarrhea. Although medical science and public health were in their infancy in those days, the need to combat tuberculosis was clear even then. In 1882, Robert Kock first isolated the organism that causes this disease, providing physicians and scientists with a microbial foundation for science-based public health action. In the early twentieth century, health advocates and physicians formed an association dedicated to fighting tuberculosis, which today is the American Lung Association. Their work helped to bring about more sanitary living conditions and workplaces for the poor, stronger public health laws, and the use of sanatoriums to treat people with tuberculosis. In this century, the possibility of actually eradicating tuberculosis arose following the development of effective antibiotics in the 1950s. But the country failed to capitalize on scientific opportunities or undertake the kind of broad public health campaign that we undertook so successfully against polio. As a result, scientific interest and public health funding for tuberculosis control waned in the following decades. After years of decline, specific Federal funding for tuberculosis control was actually eliminated in 1972. Our country paid the price for this complacency in the 1980s. A resurgence of cases and an alarming growth in the prevalence of drug- resistant tuberculosis strains challenged public health and shook the confidence of experts. Through great effort and difficulty, we renewed our national commitment to fighting tuberculosis. But the effort took longer than necessary, and the Nation suffered needless deaths and illness as we worked to bring the number of new tuberculosis cases to its current, all-time low. Today, we have a historic opportunity to eradicate tuberculosis in the United States. We have a generation of public health officials who have lived through and successfully combated the recent resurgence of the disease. And we have expert recommendations from both the Federal Advisory Council for the Elimination of Tuberculosis and the Institute of Medicine to guide our efforts. This legislation is supported by leading public health organizations, including the American Lung Association, the American Thoracic Society, the National Coalition to Eliminate Tuberculosis and RESULTS International. Its enactment can be an essential in achieving to fulfilling this important and long overdue public health goal, and I urge the Senate to approve it.

Mr. KENNEDY

Mr. KENNEDY. Mr. President, it is a privilege to join my colleagues Senator Stevens, Senator Inouye, Senator Hutchison, and Senator Corzine in introducing the Comprehensive Tuberculosis Elimination Act. This bipartisan legislation will provide enhanced authority and greater resources to State, local and Federal health officials to do all they can to combat this deadly infectious disease in our country. Tuberculosis is the world's leading infectious killer. Its growth has been propelled by the global HIV epidemic, and multi-drug resistant strains have become increasingly prevalent around the world. The World Health Organization estimates that more than one-third of the world's population is infected with tuberculosis. Every year, there are 8 million new cases of active tuberculosis and 2 million deaths from tuberculosis. This disease causes more deaths among women worldwide than all other causes of maternal death combined. These harrowing statistics illustrate the truth behind the saying that diseases know no borders. Senators Inouye, Stevens, and Hutchison and I have already introduced the Stop TB Now Act, which focuses on international tuberculosis control. The bill we are introducing today will deal with tuberculosis in our own country. Only through enactment of both of these measures can we be sure of defeating this readily treatable and preventable disease. Today's bill is intended to fulfill the recommendations of the landmark report issued by the Institute of Medicine last year, entitled ``Ending Neglect: The Elimination of Tuberculosis in the United States.'' Our measure will create a national plan for the eradication of tuberculosis. It will enhance tuberculosis-related research, education and training through the Centers for Disease Control and Prevention. It will also expand support for vaccine research and for international tuberculosis research through the National Institutes of Health. In the United States, tuberculosis has been going through what the Institute of Medicine calls ``recurrent cycles of neglect'' by public health authorities, ``followed by resurgence'' of the disease. In the late nineteenth century, tuberculosis was one of the leading causes of death in America. As cities swelled with waves of European immigration, millions of individuals and families were forced into overcrowded tenements and unhealthy workplaces. Many fell victim to outbreaks of deadly infectious diseases. In 1886, the leading cause of death among infants was tuberculosis, followed by infant diarrhea. Although medical science and public health were in their infancy in those days, the need to combat tuberculosis was clear even then. In 1882, Robert Kock first isolated the organism that causes this disease, providing physicians and scientists with a microbial foundation for science-based public health action. In the early twentieth century, health advocates and physicians formed an association dedicated to fighting tuberculosis, which today is the American Lung Association. Their work helped to bring about more sanitary living conditions and workplaces for the poor, stronger public health laws, and the use of sanatoriums to treat people with tuberculosis. In this century, the possibility of actually eradicating tuberculosis arose following the development of effective antibiotics in the 1950s. But the country failed to capitalize on scientific opportunities or undertake the kind of broad public health campaign that we undertook so successfully against polio. As a result, scientific interest and public health funding for tuberculosis control waned in the following decades. After years of decline, specific Federal funding for tuberculosis control was actually eliminated in 1972. Our country paid the price for this complacency in the 1980s. A resurgence of cases and an alarming growth in the prevalence of drug- resistant tuberculosis strains challenged public health and shook the confidence of experts. Through great effort and difficulty, we renewed our national commitment to fighting tuberculosis. But the effort took longer than necessary, and the Nation suffered needless deaths and illness as we worked to bring the number of new tuberculosis cases to its current, all-time low. Today, we have a historic opportunity to eradicate tuberculosis in the United States. We have a generation of public health officials who have lived through and successfully combated the recent resurgence of the disease. And we have expert recommendations from both the Federal Advisory Council for the Elimination of Tuberculosis and the Institute of Medicine to guide our efforts. This legislation is supported by leading public health organizations, including the American Lung Association, the American Thoracic Society, the National Coalition to Eliminate Tuberculosis and RESULTS International. Its enactment can be an essential in achieving to fulfilling this important and long overdue public health goal, and I urge the Senate to approve it.

Mr. KENNEDY

Mr. KENNEDY. Madam President, I reluctantly have to rise in order to oppose the amendments of my good friends on the issue of medical necessity. I outlined earlier in the day the basic judgment and basic history of how we reached the language that we have included in our bill. First, let us look at what will be the standard that is in both the McCain-Edwards bill, as well as in the Frist-Breaux bill. Effectively, both treat this particular issue of medical necessity the same. This is a result of the fact that this issue had been debated 2\1/2\ years ago when we considered the Patients' Bill of Rights here and in the House of Representatives. We tried to define the test on medical necessity during that period of time. What we resolved is to permit, at the time of the external review, the kind of test that we have included in our language here and in the Frist-Breaux language. This was actually the language which was agreed to in the conference last year, a conference that never resulted in an overall outcome of the legislation. Nonetheless, we had agreed on a handful of different areas of dispute. That was agreed to by my colleagues, Phil Gramm, Don Nickles, myself, and others, after a good deal of negotiation. It seems wise to continue that particular proposal because basically this is what we are doing. At the time of the appeal of any of these medical necessity issues, we are permitting for the standard of determination in our bill, on page 35: ``The condition shall be based on the medical condition of the participant.'' That is obvious. No. 1, what is wrong with the patient? And then it talks about ``valid, relevant, scientific evidence and clinical evidence, including peer- reviewed medical literature and findings, including expert opinion.'' Basically, the reason for that is to allow for the possibility that we find out there are new kinds of discoveries, new kinds of techniques, new kinds of treatments for various health conditions. In order to not use a stagnant kind of proposal, we included that language. This language which was agreed to is supported by the American Medical Association and other medical groups. So in the legislation that we have here in the McCain-Edwards proposal, which I support, and the Frist-Breaux proposal, which others including the President of the United States support, and in the agreement that was made by Republicans and Democrats alike, we agreed effectively to this language. This agreement occurred after considering all the different kinds of proposals. It raises questions of why we are today attempting to alter that particular proposal. The argument is, first of all, that we can offer three different options. One would be that the administration can propose an administrative group, a commission that can make some recommendations about what that standard would be. That may work out, but it may not work out very well if we have an administration that is not as sympathetic to the protection of patients' and doctors' decisions as we have tried to be in this undertaking. That is one way of doing it. Second, the results of State actions can be the criteria. In some States the protections have been very good, and other States have left a lot to be desired. I understand the basic thrust of this legislation is to establish minimum standards. If States want to have higher protections for consumers, they are welcome to do it. What we are trying to do is ensure that all Americans, all American families are protected. In the area of scope, all Americans being protected--actually, every Republican proposal that was considered in the House of Representatives included all Americans--we were attempting to ensure that there was going to be a minimum standard. However, we can use another standard, such as the good Federal employee standard to which the Senator just referred. It is interesting, though, that the Office of Personnel Management does not use the Federal employee standard on their reviews. What do they do? They do something very similar to what we have done. They permit the doctor to make the ultimate decision and not be bound by some definition. The reason for this is because they do not believe that that should to be the restrictive definition for all appeals. In turn, there is a Federal employee program of which all of us are a part. In our program if there is going to be an appeal, this is a different standard. Basically, it is a standard that permits the doctors to make the judgments and decisions. I find it difficult to be convinced at this hour. We waited a good deal of time. I know we were all pressed with the different proposals. I have had a chance to talk to my friend and colleague, Senator Nelson, on a number of different provisions. From personal experience, I can tell that this is a Senator who has spent a good deal of time on this legislation and has been willing to spend a great deal of time visiting with me and with others, and also talking extensively with the House Members who are interested in various provisions. I know a good deal of thought has gone into this matter. My final point is the underlying commitment of this legislation to make sure that doctors are going to make the decisions. Trained medical personnel and families are going to make these judgments and decisions. It seems to me that when we have included in the legislation's language--in fact, insisted on--permitting the doctor to use the best medical information and judgment of this decision making and will permit them to also take advantage of the latest ideas, new conclusions, new consensus of the treatment of various medical conditions, this is the best way rather than a review being bound up in some process. We do not know tonight, for example, whether the board is going to be overly sensitive to the consumers and patients. There is a wide variety of interpretations in many of the States. This is unlike other parts of this legislation where there is a difference between what we have proposed, what is included in Breaux- Frist, and what the President has recommended. In these areas, the McCain-Edwards proposal, the Breaux-Frist proposal, the conference committee by Republicans and Democrats alike, and the President have reached similar conclusions. This is one of the most important areas of the legislation. It seems to me what we have in the underlying legislation is completely consistent with what the President has indicated would be key to this legislation. Mr. President, I yield 10 minutes to my colleague.

Mr. KENNEDY. I thank the Senator because in his statement he has really summarized the importance of resisting this amendment. Those 40 percent of workers deserve these kinds of protections. These are not very unique or special kinds of protections. They are the commonsense protections we have illustrated during the course of this debate--access to emergency room care based upon a prudent layperson standard, protections of speciality care, clinical trials, OB/GYN, continuity of care and point of service. So patients are able to get the best in specialty care and formulary, the new medicines, and making sure their doctors, American doctors, are the best trained in the world. These doctors have committed their lives to benefit patients, and they are trained to do so trained to make the medical judgments. That is what American families believe they are paying for when they pay the premiums, but we have a group of HMOs that feel they can put the financial bottom line ahead of patient interests and shortchange millions of Americans. We should not let the 40 percent that will be affected by this amendment be excluded.

Mr. KENNEDY. Yes.

Mr. KENNEDY. I thank the Senator for his helpful comments.

Mr. KENNEDY. Well, according to the Congressional Budget Office and OMB it will be less than 1 percent a year over the next 5 years--much less, closer to 4 percent. So, effectively, it is 4 percent. As we pointed out earlier in the debate, under the alternative proposal that the President supports, it is effectively 3 percent over 5 years. As the Senator is pointing out, it is somewhat less than 1 percent a year against what the Senator from Colorado mentioned--12 percent last year and 13 percent this year. That is what is happening already, without these kinds of protections.

Mr. KENNEDY. Yes.

Mr. KENNEDY. The Senator is correct. I will make the case tomorrow, but it is my judgment that you will find that there are greater abuses in the areas of these smaller companies, smaller HMOs, appealing to smaller companies, rather than some of the larger HMOs which are tried and tested and have the reputation within a community to try and defend. We have had many that do a credible job, but you are going to find, I believe--and I will get to this more tomorrow morning--that the workers who are the most vulnerable are going to be workers in these plants.

Mr. KENNEDY. The Senator is quite correct on this. That, of course, raises competitive situations. You are going to have competition on the dumbing down of protections for employees, rather than establishing a standard in competition in terms of the quality of the product. It is a race to the bottom, so to speak.

Mr. KENNEDY

Mr. KENNEDY. Mr. President, I ask unanimous consent that the Subcommittee on Strategic of the Committee on Armed Services be authorized to meet during the session of the Senate on Tuesday, June 26, 2001, at 10:00 a.m., in open session to receive testimony on the Department of Energy's fiscal year 2002 budget request for the Office of Environmental Management, in review of the Defense authorization request for fiscal year 2002 and the future years defense program.

Mr. KENNEDY. Mr. President, I ask unanimous consent that the Permanent Subcommittee on Investigations of the Committee on Governmental Affairs be authorized to meet on Tuesday, June 26, 2001, at 10:00 a.m. for a hearing entitled ``Diabetes: Is Sufficient Funding Being Allocated To Fight This Disease?''

Mr. KENNEDY. Mr. President, I ask unanimous consent that the Committee on the Judiciary Subcommittee on the Constitution be authorized to meet to conduct a hearing on ``Should Ideology Matter? Judicial Nominations 2001'' on Tuesday, June 26, 2001 at 10:00 a.m. in SD226. No witness list is available yet.

Mr. KENNEDY. Mr. President, I ask unanimous consent that the Committee on Indian Affairs be authorized to meet on June 26, 2001, at 10:30 a.m. in room 485 Russell Senate Building to conduct a Hearing to receive testimony on the goals and priorities of the Great Plains Tribes for the 107th session of the Congress.

Mr. KENNEDY. Mr. President, I ask unanimous consent that the Committee on Foreign Relations be authorized to meet during the session of the Senate on Tuesday, June 26, 2001 at 2:30 p.m. to hold a nomination hearing as follows: nominees Panel 1: The Honorable Margaret DeBardeleben Tutwiler, of Alabama, to be Ambassador to the Kingdom of Morocco. The Honorable C. David Welch, of Virginia, to be Ambassador to the Arab Republic of Egypt. The Honorable Daniel C. Kurtzer, of Maryland, to be Ambassador to Israel. Panel 2: The Honorable Robert D. Blackwill, of Kansas, to be Ambassador to India. The Honorable Wendy Jean Chamberlin, of Virginia, to be Ambassador to the Islamic Republic of Pakistan.

Mr. KENNEDY. Mr. President, I ask unanimous consent that the Committee on Finance be authorized to meet during the session of the Senate on Tuesday, June 26, 2001 to hear testimony on the U.S. Vietnam Bilateral Trade Agreement.

Mr. KENNEDY. Mr. President, I ask unanimous consent that the Committee on Energy and Natural Resources be authorized to meet during the session of the Senate on Tuesday, June 26 at 9:30 a.m. to conduct a hearing. The committee will receive testimony on proposed amendments to the Price-Anderson Act (Subtitle A of Title IV of S. 388; Subtitle A of Title I of S. 472; Title IX of S. 597) and nuclear energy production and efficiency incentives (Subtitle C of Title IV of S. 388; and Section 124 of S. 472).

Mr. KENNEDY. Mr. President, I ask unanimous consent that the Committee on Commerce, Science, and Transportation be authorized to meet on Tuesday, June 26, 2001, at 9:30 am on the nominations of Sam Bodman (DOC), Allan Rutter (FRA), Kirk Van Tine (DOT), and Ellen Engleman (DOT).

Mr. KENNEDY. Mr. President, I ask unanimous consent that the Committee on Banking, Housing, and Urban Affairs be authorized to meet during the session of the Senate on June 26, 2001, to conduct a hearing on the nomination of Donald E. Powell, of Texas, to be Chairman of the Board of Directors of the Federal Deposit Insurance Corporation.

Mr. KENNEDY

Mr. KENNEDY. Mr. President, I welcome this opportunity to recognize a number of schools that are doing an excellent job of encouraging community service by their students. The Nation has always relied on the dedication and involvement of its citizens to help meet the challenges we face. Today, the Corporation for National Service works with state commissions, non-profits, schools, and other civic organizations to provide opportunities for Americans of all ages to serve their communities. Learn and Serve America, a program sponsored by the Corporation for National Service, supports service-learning programs in schools and community organizations that help nearly a million students from kindergarten through college meet community needs, while improving their academic skills and learning the habits of good citizenship. Learn and Serve grants are used to create new programs, replicate existing programs, and provide training and development for staff, faculty, and volunteers. This year the Corporation for National Service has recognized a number of outstanding schools across the country as National Service- Learning Leader Schools for 2001. The program is an initiative under Learn and Serve America that recognizes schools for their excellence in service-learning. These middle schools and high schools have earned their designation as Leader Schools. They serve as models of excellence for their exemplary integration of service-learning into the curriculum and the life of the school. I am hopeful that the well-deserved recognition they are receiving will encourage and increase service- learning opportunities for students in many other schools across the country. The 2001 National Service Leader Schools are: Vilonia Middle School, Vilonia, AR; Chico High School, Chico, CA; Evergreen Middle School, Cottonwood, CA; Telluride Middle School/High School, Telluride, CO; Seaford Senior High School, Seaford, DE; Space Coast Middle School, Cocoa, FL; P.K. Yonge Developmental Research School, Gainesville, FL; Douglas Anderson School of the Arts, Jacksonville, FL; Lakeland High School, Lakeland, FL; Dalton High School, Dalton, GA; Sacred Hearts Academy, Honolulu, HI; Moanalua Middle School, Honolulu, HI; Unity Point School, Carbondale, IL; Jones Academic Magnet High School, Chicago, IL; Valparaiso High School, Valparaiso, IN; Ballard Community High School, Huxley, IA; Lake Mills Community High School, Lake Mills, IA; Glasco Middle School, Glasco, KS; Spring Hill High School, Spring Hill, KS; Boyd County High School, Ashland, KY; Garrard Middle School, Lancaster, KY; Harry M. Hurst Middle School, Destrehan, LA; Drowne Road School, Cumberland, ME; Rockland District High School, Rockland, ME; Leavitt Area High School, Turner, ME; Gateway School, Westminster, MD; Millbury Memorial High School, Millbury, MA; Garber High School, Essexville, MI; Onekama Middle School, Onekama, MI; Tinkham Alternative High School, Westland, MI; Moorhead Junior High School, Moorhead, MN; Harrisonville Middle School, Harrisonville, MO; Pattonville High School, Maryland Heights, MO; Middle Township High School, Court House, NJ; Benedictine Academy, Elizabeth, NJ; Delsea Regional High School, Franklinville, NJ; Hoboken Charter School, Hoboken, NJ; Iselin Middle School, Iselin, NJ; Christa McAuliffe Middle School, Jackson, NJ; Notre Dame High School, Lawrenceville, NJ; North Arlington Middle School, North Arlington, NJ; West Brook Middle School, Paramus, NJ; Ocean County Vocational Technical School, Toms River, NJ; The Bosque School, Albuquerque, NM; Carl Bergerson Middle School, Albion, NY; Madison Middle School, Marshall, NC; Ligon Gifted and Talented Magnet Middle School, Raleigh, NC; Fort Hayes Metropolitan Education Center, Columbus, OH; Clark Center Alternative School, Marietta, OH; Ripley High School, Ripley, OH; Perry Middle School, Worthington, OH; Miami High School, Miami, OK; Alcott Middle School, Norman, OK; Yukon High School, Yukon, OK; Franklin Delano Roosevelt Middle School, Bristol, PA; Chapin High School, Chapin, SC 29036; Summit Parkway Middle School, Columbia, SC; Palmetto Middle School, Williamston, SC; Henry County High School, Paris, TN; Cesar Chavez Academy, El Paso, TX; Dixie Middle School, St. George, UT; New Dominion Alternative School, Manassas, VA; Kamiakin Junior High School, Kirkland, WA; Student Link, Vashon, WA.