Patty Murray

Mrs. MURRAY

Mrs. MURRAY. Mr. President, I have a great deal of admiration for the Senator from Maine, Ms. Snowe, who, in my time with her over the last several years in the Senate, has worked long and hard on behalf of women's health issues. I appreciate she is offering an amendment that we offered yesterday on this side which deals with the issue of drive- through mastectomies. The language is very similar to the language offered by Senator Robb from Virginia, along with myself, Senator Mikulski, Senator Boxer, Senator Landrieu, and Senator Lincoln. It was defeated on a 52-to-48 vote yesterday. We would have been delighted to work with our colleagues if they wanted to talk with us about a word or two about which they were concerned. We were not given that opportunity. The amendment was simply defeated. We stand very strong on this side that we need to make changes in the health care delivery system in this country so that the woman from the State of Washington the Senator from Maine talked about is not sent home after a radical surgery, a mastectomy, to care for herself when she is unable to do so. The doctor and the woman should make the decision based on the best medical judgment, not based on the bottom line from an HMO. I agree entirely with the Senator from Maine. Unfortunately, because it is offered in this way, what this amendment does is it gives us a Hobson's choice regarding women who have had a mastectomy because this amendment wipes out the amendment by Senator Dodd on clinical trials that we have debated for the last several hours on this floor, where we have talked about the need for women with breast cancer or ovarian cancer, or the gentleman with multiple sclerosis or the man with heart disease, or the young child with diabetes, to have access to clinical trials so they can get the best medical research possible. Organizations such as the National Coalition for Cancer Survivorship, Cancer Care Incorporated, Candlelighters, Childhood Cancer Foundation, Susan G. Koman Breast Cancer Foundation, National Alliance of Breast Cancer Organizations--and the list goes on--want the access to clinical trials that Senator Dodd's amendment offers because those are the clinical trials that will assure that women, maybe, in the future, will not have to have a mastectomy. I agree with the Senator from Maine. We want to make sure HMOs are not having drive-by mastectomies, where a woman is sent home. I commend her for the language of her amendment, except for the very first line, which cynically wipes out the clinical trials that Senator Dodd has offered.

Mrs. MURRAY. If the Senator will further yield, I understand that the Senator is a surgeon and has seen clinical trials and knows the benefit of them. I listened with respect to his arguments. But in this amendment, we are simply assuring that the patients will get the best care. And if the best care for their particular condition is a clinical trial that will not only benefit themselves but the rest of the people with that condition as well--and NIH has paid for the vast majority of this. I understand from CBO that 90 percent of insurance companies have been paying for clinical trials. The amendment ensures that won't go away. We are seeing more and more HMOs look at their bottom line and that benefit is being taken away. We want to make sure the insurance companies continue to pay their part. Certainly, a patient who goes in cannot afford to pay for that clinical trial, but they have been paying premiums for years. Shouldn't that be part of what they expect when they pay a premium to an HMO?

Mrs. MURRAY. I will be happy to yield.

Mrs. MURRAY. The Senator is absolutely correct. Not only will it hurt the health of the woman who has been denied access to the clinical trial who has ovarian cancer or breast cancer, but it also denies us, all the rest of us, access to good health care because we will never know whether or not that clinical trial works, which could then be available to the rest of us.

Mrs. MURRAY. In response to the Senator from Massachusetts, the doctors at the Fred Hutchinson Cancer Center are very concerned about their patients who are being denied access to medical care because they say these trials are what will not only help patients but will help them give the best care to all of their patients. They are not able to do the job we expect them to do any longer, not because of medical decisions they make but because of the decisions made by HMOs.

Mrs. MURRAY. Thank you, Mr. President. I thank my colleagues who have been on the floor talking about an issue this morning that I think is becoming more and more critical, and that is access to clinical trials, the amendment by Senator Dodd. It seems to me that in the Senate we have talked, in a bipartisan way, about making sure we have increased funding for NIH so we can have access to the best new research for diseases such as cancer, diabetes, and multiple sclerosis. A lot of great research is occurring right now at NIH. Members have said many times that needs to be increased. In fact, the Labor Committee has worked very hard, and I am very proud of the fact we have increased funding to NIH by almost 40 percent. However, today, citizens, taxpayers, who are paying the dollars for that increased research at NIH, are being routinely denied access to that new research when their HMO says they will not pay for a new clinical trial--these are new medications, new medical devices that have been researched and we have paid for the research through our own taxpayer dollars. But when it comes to our constituents, who have paid for this research, having access to the clinical trials, having access to this new research, they are not allowed because their HMO denies it. That is why I think this amendment is so important to the taxpayers of this country. I met recently with a number of cancer survivors in my own home State of Washington. Some of them were patients at the Fred Hutchinson Cancer Center, a very well known cancer research facility, one of the premiere centers in this country. The doctors and the patients told me about how they were routinely being denied access to these clinical trials--these people who have no other recourse, who may have MS or cancer or another severe illness, who have no other hope out there except for access to a clinical trial. It is their last chance at life and their doctors recommended it. The doctors at the Fred Hutchinson Cancer Center said: This is their chance at life, and their insurance company, their HMO, said: No, sorry; we're not going to pay for it. One of the things the doctors said, which made an impression on me, was that a patient was going to receive some kind of care with some kind of cost that their insurance company was going to have to pay for, and, in fact, the clinical trials, for the most part, cost less than the treatment this person was going to have. So they did not understand why the insurance company was going to decide which treatment they were going to have. They felt very strongly the doctors ought to be the ones deciding what kind of medical treatment this patient should be having. And the clinical trials were their best chance at recovery and hope for life. I hope the Members of the Senate will agree with Senator Dodd and the other sponsors of this amendment and allow people to have access to the research they have paid for by taxpayers when they need it, when they are victims of cancer, when they have MS, when they have diabetes, and allow them to have access to clinical trials. We will all win in the end because, without these clinical trials, we will not have the research we need to make sure these kinds of medical devices or these prescription drugs are then available to the general public as routine care that is paid for by HMOs. I commend my colleagues for their debate on this issue. I urge all of us who have said we are for increased funding at NIH and increased funding for research to now allow our constituents in this country access to that care. I thank the Senator.

Mrs. MURRAY. Mr. President, I am reclaiming my time.

Mrs. MURRAY. Mr. President, I am extremely concerned, as I am sure my colleague from Connecticut is as well, that an objection was heard and we were not able to just add this language directly to the underlying amendment on clinical trials, because what the Senator from Maine has now done is forced us into a vote where we would be voting against clinical trials in order for women not to have drive-through mastectomies. That is not a choice Senators ought to be having. In addition, what it says to women across this country is you have a choice, a mastectomy or a clinical trial. That is not a choice we should be offering. I really hope our colleagues on the other side of the aisle will reconsider their objection to this and we can work this out. The people of this country are watching this debate, asking whether or not we are going to move forward and give patients the ability to have the best care possible. If we can work out this amendment and add it to the clinical trials, we will have done the people of this country a service. Mr. President, I reserve the remainder of our time, and I yield.

Mrs. MURRAY. Mr. President, my colleagues have clearly spelled out the intent and necessity of this amendment so I will not take much time to go through its benefits. I came to the floor simply to urge my Republican colleagues to really think about how much more protection this amendment provides their constituents than their bill does. The so-called access to speciality care provisions in the Republican bill are nothing more than a statement on the importance of speciality care. They do not guarantee the care; they simply reiterate current insurance practices. During committee consideration of this legislation, a similar amendment was offered to ensure access to specialists and to ensure that patients could designate a specialist as their ``care coordinator.'' During that debate in committee, we heard a great deal about training and experience. We were told how an oncologist was a trained specialist in treating cancer regardless of the age or gender of the patient. We were told a neurologist was a trained specialist regardless of the age or gender of the patient. We were told the training was the same and practice experience was not important. I find this hard to believe, I ask my colleagues again: is there a difference between treating a child with cancer and treating an adult? Are the treatment regimes for a 3-year-old with a brain tumor the same as those for a 50-year-old? I doubt it. It seems likely to me that a cancer treatment regime for a 50-year-old could kill a 3-year-old. That treatment could render the child disabled or seriously impair his or her developmental progress. I urge my colleagues to talk to people at their children's hospitals, to their pediatricians, to their ob/gyns and to their cancer specialists. I have. And what I heard was that patients need to see the specialists most qualified and trained to deal with them and their specific illnesses. If your child had a brain tumor, would you want to be told there are no pediatric neurosurgeons or pediatric oncologists in your network, but that on page 215 of your physician directory you will find a list of the oncologists approved by the plan? I certainly wouldn't. I would want a specialist trained in pediatrics. The Republican bill does not allow for access to speciality care. It is that simple. You can say it does and in fact some of my colleagues may hope it does, but it does not. I can assure my colleagues that the language in both the bill and the committee report will allow plans-- not your specialist--to make the final determination on access and treatment. Here is what the committee report says: This section would NOT prevent a plan from requiring that the specialists adhere to a treatment plan if it: (1) is developed by the specialist in consultation with the patient and the patient's primary care provider; (2) is approved by the plan; and (3) meets the quality assurance and utilization review standards of the plan. What does this mean? It means that if the patient is lucky enough to get a specialist, that specialist--who is a trained and qualified doctor--could be required to meet the plan's treatment standards. So maybe you could see a specialist, but you might not be allowed to be treated by one. Yesterday we offered the Robb/Murray amendment to allow women direct access to their ob/gyns. It was defeated. Today we are offering a broader amendment in the hopes of giving all insured Americans the hope that they can get the best care possible for their sick or injured child. If we do not adopt this amendment, once again the patient loses and the insurance company wins. I urge my colleagues to support this amendment and yield back my time.

Mrs. MURRAY. That is correct.

Mrs. MURRAY. Will the Senator yield for a question?

Mrs. MURRAY. Mr. President, I appreciate the Senator yielding for just a quick question. Isn't it true that insurance companies, until recently, did pay for clinical trials, and it wasn't until we moved to the HMO era that we are now in that we are being denied access to those?

Mrs. MURRAY. Mr. President, is this on my time? I do have the floor.

Mrs. MURRAY

Mrs. MURRAY. Mr. President, I rise as a sponsor of this amendment to protect women's health. This amendment offers true security to women; it deals with women's access to health care and women's treatment when they receive that care. This amendment ensures women get more than just routine care when they visit their obstetrician/gynecologist and it protects women against the pain and danger of so-called drive-through mastectomies. While the underlying Republican bill does allow access to OB/GYN care, the HELP Committee went to great lengths to ensure women only had access for routine care--and nothing more. Let me quote from the committee report, ``The purpose of this section is to provide women with access to routine OB/GYN care by removing any barriers that could deter women from seeking this type of preventive care.'' While the Republicans recognize the need for direct access, the language of their bill and their report makes it clear that direct access is guaranteed only for routine care. Let me explain what that means. If during a routine examination, a woman's OB/GYN finds a lump or an inconsistency in her breast, the OB/ GYN would not be allowed to refer the patient for further examination. Instead, the woman would have to go back to the gate keeper and hope that her primary care physician approved the referral. We should all agree this is a waste of time and energy--time and energy that would be better spent dealing with the potential breast cancer. A recent study conducted by the American College of Obstetricians and Gynecologists shows that managed care plans are keeping women from receiving the health care they need and seeing the providers they choose. Sixty percent of all women who need gynecological care and 28 percent of all women who need obstetric care are either limited or barred from seeing their OB/GYNs without first getting permission from another physician. Once the patient is able to gain access to her own OB/GYN, she is forced to return to her primary care gate keeper for permission to allow her OB/GYN to provide necessary follow-up care almost 75 percent of the time. What my Republican colleagues fail to understand is that women need OB/GYN care for much more than simple routine care. They also fail to understand the important relationship between a woman and her own OB/ GYN. OB/GYN providers are often a women's only point of entry into the health care system. Our amendment would allow women direct access to OB/GYN care and follow-up care as well. It would also allow a woman to designate an OB/ GYN provider as her primary care physician. We know historically that women have not been treated equally in receiving health care. We know that some physicians do not treat women with the same aggressive strategies as they treat their male patients, especially when women complain about depression or stress. What we do know is that OB/GYNs have traditionally been strong advocates for women's health. They understand the physical and emotional changes a women experiences throughout her life. The 1993 Commonwealth Fund Survey of Women's Health found the number of preventive services received by women, including a complete physical exam, blood pressure test, cholesterol test, breast exam, mammogram, pelvic exam, and pap smear, are higher for those whose regular physician is an OB/GYN than for those whose primary care doctor is not. Women are simply afforded greater access to preventive and aggressive health care services with OB/GYNs. I am not sure why some of my Republican colleagues want to deny unobstructed access to important health care services for women. It cannot be about costs. The Congressional Budget Office estimated that the cost of direct access and primary care by OB/GYNs as only 0.1 percent of premiums. If my colleagues are so concerned about costs, can't they at least guarantee that women get the quality health care they pay for? This amendment ensures they will. The other important provision in this amendment prohibits drive through mastectomies. It is outrageous that current trends in health care could force women to endure a mastectomy on an outpatient basis. It is wrong to send these women home to deal with the emotional and physical pain of the operation--as well as with the responsibility for draining surgical wounds and performing other post-surgical care. These women should not be abandoned during their time of need. However, our amendment does not require a woman to stay in the hospital. Our amendment does not require a hospital stay for a set number of hours. Our amendment does require that the physician, in consultation with the patient, decides how long the woman should remain in the hospital. The physician determines what is medically necessary and what is in the patient's best interest. I cannot believe there is anyone in this chamber who would want to see a loved one go through a mastectomy and be forced by her insurance company to go home immediately. If we have any compassion at all we should adopt this provision. Let me respond to one criticism I've heard about this amendment from insurance companies. Some have claimed they do not have a policy of drive through mastectomies. I commend them and hope they would support this amendment to prohibit this cruel practice by other companies. I would also add that while most insurance companies may not engage in this kind of outrageous behavior today, how can we insure they will not tomorrow? Our amendment is about protecting and improving women's health. For that reason, the College of Obstetricians and Gynecologists support it. If my colleagues truly consider themselves champions of women's health, they must vote for this amendment. I can assure you that women will not be fooled by the empty promises in the Republican bill. We know the difference between routine and comprehensive OB/GYN care. We know how traumatic and life-altering a mastectomy can be. We know we need real protection and this amendment provides it. Mr. President, I especially thank Senator Robb for his leadership on this issue. He is right. There are only nine women in the Senate. We shouldn't have to rush to the floor to defend all of the women in this country every time an issue comes up that affects women's health. This is an issue that affects men as well. It affects their daughters, their wives and mothers, their aunts. I appreciate Senator Robb and his leadership in making sure that women are protected when it comes to their health care. Senator Robb did an excellent job of outlining what our amendment does. It does two basic things: It allows a woman the right to choose an OB/GYN as her primary care physician. As every woman in this country knows, their OB/GYN, their obstetrician/gynecologist, is the doctor they go to, whether it is for pregnancy, whether it is for breast cancer, whether it is for health care decisions that affect them later on in life. We want to make sure that women have access to those doctors without having to go back to a primary care physician. When a woman is pregnant and she gets an ear infection, she may be treated dramatically different than someone else who has an ear infection, for example. A woman needs to have access to the OB/GYN, and this amendment Senator Robb and I and the other Democratic women are offering assures the woman that access. Secondly, it deals with the so-called drive-through mastectomy legislation where too many HMOs today are telling a woman after this radical surgery----

Mrs. MURRAY. Too many women today are told they need to go home before they are ready to take care of themselves or their families. This amendment doesn't designate a time. It says the doctor will determine whether that woman is ready to go home after this radical surgery. I commend my colleagues for this issue. I urge the Members of the Senate to stand up, finally, for women's health and vote for this amendment.

Mrs. MURRAY. I ask unanimous consent for an additional 30 seconds.

Mr. MURRAY

Mr. MURRAY. Mr. President, I am pleased to join with Senator Graham in support of access to emergency room care. During consideration of a Patients' Bill Rights in the Health, Education, Labor and Pensions Committee, I offered a similar amendment in an effort to prevent insurance companies from denying access to life saving emergency care. Unfortunately, my amendment was defeated on a straight party line vote. I had offered the amendment because of problems that I have heard from emergency room doctors and administrators about creative ways insurance companies seek to deny access to emergency care. I offered the amendment because I have seen in my own state of Washington the inadequacy of simply saying care is provided if a prudent lay person deems it an emergency. We have a prudent lay person standard in the State yet we have seen where patients are turned away and reimbursement is denied. The big flaw with the Republican bill regarding emergency room care is the lack of coverage of poststabilization care. This is the key different between our bill and that offered by the Republican leadership. We recognize the importance of not only administering emergency services but stabilizing the patient as well. Let me give my colleagues an example of the important of poststabilization care; you rush your sick child to the emergency room with a fever close to 105. The fever escalates quickly and without warning. The emergency room doctors and nurses are able to control the fever and stabilize the child, but are concerned about determining the cause of the fever. They recommend poststabilization treatment to determine what caused the child to become so ill so quickly. The insurance company denies this treatment and the parents are told to take their child home and hope to get into see their own primary care physician the next day. Later that evening the child's fever escalates and the child begins to have seizures as a result. The child is then admitted to the hospital for more expensive acute care. Why was follow-up poststabilization care not provided? What are the long-term effects on the child? Did the insurance company save a dime of the premium paid by hard working Americans? No, in fact their callous behavior resulted in additional costs that could have been prevented. I cannot imagine anything more frightening than holding a child who is experiencing uncontrollable seizures because their tiny body could not endure the impact of a high raging fever. Poststabilization is essential. I urge any of my colleagues who think the Republican bill is sufficient to talk to ER doctors and nurses. Ask them how a patient is treated when brought into the ER. Let me give you another example that was discovered by the insurance commissioner's office in Washington state: A 17-year-old victim of a beating suffered serious head injuries and was taken to an emergency room. A CAT scan ordered by an ER physician was rejected by the insurance company because there was no prior authorization for this test. In other words, we can stabilize the patient, but cannot do any post stabilization treatment to determine the extent of the injuries without seeking authorization from an insurance company hundreds of miles away. Another example, in a state with a prudent lay person standard: The insurance commissioner's office found that an insurance company denied ER coverage for a 15-year-old child who was taken to the emergency room with a broken leg. The claim was denied by the insurer as they ruled the circumstances did not constitute an emergency. This is outrageous. A broken leg is not an emergency? By any standard, prudent lay person or medical standard, treatment of a broken leg would be considered an emergency. I use these examples of real people and real cases to illustrate the flaws in the Republican bill. You can say you cover emergency room care and you can keep saying it hoping that it is true. But, unfortunately, the Republican bill does not provide adequate emergency room coverage. I was disappointed in the HELP Committee markup when my amendment was defeated. I had truly hoped that we could reach a bipartisan agreement on emergency room care coverage. I had seen that we could reach a bipartisan agreement when it came to Medicare and Medicaid beneficiaries. We approved these very same provisions for these beneficiaries during consideration of the Balanced Budget Act of 1997. I had assumed that we would give the same protections to all insured Americans. It was a priority in 1997 and should be a priority in 1999. We have spent a great deal of public and private resources to build an emergency health care and trauma care infrastructure that is the envy of the world. This infrastructure has saved millions of lives and provides a standard of care that is hard to beat. Yet policies focusing on restricting access to this care threaten the very infrastructure of which we are so proud. The ER doctor must be the one to administer care without fear of insurance company retaliation. I urge my colleagues to support this amendment to provide 160 million insured Americans with access to state-of-the-art emergency room and trauma care. Please do not close the emergency room doors on these families.

Mrs. MURRAY

Mrs. MURRAY. Will the Senator from Vermont yield for a question?

Mrs. MURRAY. I thank the Senator. I was listening to his discussion about the Republican bill. The current pending amendment, the Robb-Murray amendment, allows women access to OB/GYNs as their primary care physicians. Will the bill the Senator is discussing provide direct access for all of those women who are not in self-insured programs in this country?

Mrs. MURRAY. All women in this country who are not in self-insured programs will have access under the amendment you are going to be offering?

Mrs. MURRAY. Then I can assume that the women who are not in self- insured programs will not be covered by the Republican amendment.

Mrs. MURRAY. Will the Senator from Vermont yield for a question?

Mrs. MURRAY. Will the Senator yield for a question?

Mrs. MURRAY. Thank you, Mr. President, Again, I thank my colleague from Virginia, Senator Robb, and all of the women and men on the Democratic side who have come out to speak for the Robb-Murray-Mikulski-Boxer amendment, which is so essential to women in this country. I am astounded that the Republicans have fled the Chamber and have not returned to either agree with us in fighting for women's health or to explain why they are going to vote no. I was astounded in committee when I offered this amendment and it was defeated on a partisan vote. Where are our colleagues on the Republican side who have come before us so many times and said that they are going to be there at the Race for the Cure? Where are the men of the Senate, when they have been there so many times, saying: You bet we stand for women's health. This is a women's health issue. Young girls go to a pediatrician until they are 12, 13, or 14. At that time, they change doctors, not a primary care physician but an OB/GYN. Why should they be subjected now to HMO rules that say: We are going to change this, and you are going to have to go to a primary care physician in order to be sent to an OB/ GYN? OB/GYNs are our primary care physicians. As I stated this morning, if you are pregnant and have a serious cold or ear infection, or any other challenging problem that develops when you are pregnant, you will be given a different medication, a different procedure that you need to go through than if you are not pregnant. Your OB/GYN is your primary care physician from the time you are a teenager until the time you reach menopause, whether you are there because you are pregnant or there because a physician is examining you to determine treatment. But you are there. The OB/GYN is your primary care physician. This amendment will guarantee it. As Senator Mikulski so eloquently stated, a woman who has a mastectomy should not be sent home too soon whether she is 25 years old or 80 years old. In this country, on a daily basis, women are sent home too soon because it is considered, by HMOs, to be cosmetic surgery. This is not cosmetic surgery. A mastectomy is serious surgery. Women should be sent home when their doctor determines they are able to go home. That is what this amendment is about. We urge our colleagues on the other side to vote with us, to join with us in being for women's health care. I thank my colleagues who have been here to debate this issue. I especially thank Senator Robb, who has been a champion for all of us. I look forward, obviously, to the adoption of this amendment since no one has spoken out against it.

Mrs. MURRAY. Not the self-employed. That is the answer.