Jack Reed

Mr. REED

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 President, I ask unanimous consent that the order for the quorum call be rescinded.

Mr. REED

Mr. REED. I withdraw my objection.

Mr. REED. I yield the floor.

Mr. REED. Reserving the right to object, I do not intend to object, but I want to echo a comment of the Democratic leader. That presumption is that this flexible process will allow a sufficient number of amendments to come to the floor, that it will not be a process where one or two amendments are brought up and then through a series of extended second-degree amendments delayed?

Mr. REED

Mr. REED. Before yielding the floor, let me just say that I, along with my colleague from Oregon, must recognize Families USA and Ron Pollack for the inspiration and thoughtful analysis that helped propel this proposal. It is a good one. Frankly, we could do very well in this Senate this year if we could protect children through better managed care legislation and give all of our citizens a real voice in our health care decisions through an ombudsman program. This will be a very satisfactory and very successful endeavor for all of us in the Senate. With that, I yield the floor.

Mr. REED. Very quickly, we have been working, as the Senator knows, closely on the Reed-Wyden-Wellstone proposal, which was formally introduced as separate legislation. It is incorporated in the Democrat Patients' Bill of Rights. I know Senator Collins of Maine is very interested in this issue. I think she is also convinced that this is important and significant. Let me also say that the Senator from Oregon made reference to his experience as a senior advocate. There are, in fact, senior ombudsman programs throughout the United States which we support with the Older Americans Act. These programs have been very effective and are doing precisely what we want to do in the context of managed care. Again, we just adopted an ombudsman program for military personnel in the TRICARE system. It was noncontroversial. In fact, we have a great deal of expectation and hope that this will be helpful to our military families. We are working together across the aisle. I hope that we can also incorporate this provision in whatever Patients' Bill of Rights legislation that emerges. It is not designed to be a tool of litigation; it is designed to be a tool of conciliation. On those grounds, I am optimistic and hopeful. But, once again, let me finally conclude by thanking the Senator from Oregon not only for our colloquy this afternoon but also for his support, not only on this issue but so many others.

Mr. REED. Reclaiming my time, it is quite specific in the legislation. Again, the Senator is one of the contributors to this legislation, along with Senator Wellstone, and I thank him. The ombudsman, or the consumer assistance center, could not participate in litigation. Their scope of participation is informal and could include contacting the insurance company, explaining rights, advocating for the patient as an ombudsman, not as a lawyer, not as a litigator. Let me add one other point and then, again, yield to my colleague from Oregon. Interestingly enough, again I think he has identified an issue that we all can rally around. One of the great talents the Senator from Oregon brings to the Senate is an ability to be a bridge in so many different ways, i.e., the Education Flexibility Act--to find a mechanism that we all can agree upon. This is another one of these areas. Interestingly enough, a few weeks ago we passed with little controversy and with much enthusiasm the defense authorization bill that included an authorization for an ombudsman program to address the problems and complaints associated with military HMOs--the TRACER system--looking at the same problem that all of the Senator's constituents from Oregon face, and all of my constituents face, but in the context of military families and complaints, and legitimate complaints of military families. They cannot get the care they need. They cannot get the answers. They get the runaround. They do not get the support. In response to that, this body voted enthusiastically to authorize an ombudsman for the TRACER system. Frankly, both the Senator from Oregon and I are saying if it works well, or we think it is going to work well for our military families who are enrolled in an HMO that has a great deal of responsibility for them, why not give it a chance in the context of the private insurance HMO industry in the United States? I think that underscores what the Senator from Oregon has said. This is not controversial. This is helpful. This is practical. This is not about litigation, it is about making sure that people get answers, that people get results, and that people get the care. That is what I think we are all here to do. Again, I will yield.

Mr. REED. I thank the Senator from Oregon for his very kind words. Let me also thank him for his help and support in working so closely with me and Families USA and others to ensure that this proposal will work for all consumers and for the insurance industry as well. Part of our attempt is to find answers before, as the Senator from Oregon has said, they wind up in court. My experience--I think your experience, too--is that people want their health care to be addressed. They don't want a lawsuit. They want to get their children cared for. They want their own health care. This is not an attempt to figure out some way to get involved in a messy multiyear litigation process. Yet if there are no mechanisms, such as an ombudsman and an internal/ external review process, if we don't have these mechanisms, that is where we inevitably will find ourselves. Let me quickly accept the Senator's invitation to lay out some of the details. First, it would be a State-based program, not a national program in the sense of some collective wisdom here in Washington, but each State could design their own ombudsman program. We would provide financial support. There would be some general guidelines for the states to follow. Basically, this ombudsman operation or consumer assistance operation would inform people about their plan options that are available and to answer other questions about a person's health plan. Frankly, one of the great dilemmas most of our constituents have is, they don't know whom to ask about health plans, what health plans are available. This would be a source, a clearinghouse, if you will, for that type of information. Then the ombudsman or the consumer assistance center would operate a 1-800 telephone hotline to respond to consumer questions and requests for information--again, such a necessary ingredient, for several reasons: First, the general befuddlement one experiences when you try to read a health plan contract. Two, I sense there is deep skepticism about the kind of response you expect to receive from your own insurance company about your rights and your benefits, if you get a response at all. Too many times I have heard constituents say they have just found themselves entangled in a voice mail hell, if you will. As you push one number and find one recording, you push another number and find another recording. The ombudsman program with the 1-800 number would serve as a place where you could get information and get it quickly. Then this objective ombudsman, or woman, as the case may be, would provide assistance to people who think they have a grievance. They would have an opportunity for a patient to go in and say: My plan said I could not have this procedure for my child. My doctor says my child needs it. Can you help me? Frankly, not only will the ombudsman help the individual consumer, but they will look at the plan, and they will conclude that under the terms and conditions of the contract, that is or is not covered. It won't be the insurance company protecting their own interest, it will be an objective agency that will be able to step in and advocate for consumer rights when they need to vindicate their rights and explain to them the limitations of the policy, when that is the case. That is the general outline. I yield the floor.

Mr. REED. I thank the Senator from Oregon. I want to make one final point about children, and then I would very much like to yield to the Senator. And I compliment him, too, on his efforts because we are working together on many of these issues, including children's health. One final point: Children's health is, I would argue, more dependent on environmental conditions than adults. Of course, there are certain situations in the workplace where adults are exposed to chemicals, and we try to deal with that in terms of regulations and standards. However, it is also important to recognize that children are particularly prone to environmental and sociological conditions. For instance, lead poisoning--it is an epidemic in so many cities. In my city of Providence it is an epidemic. But it is not just Rhode Island, it is across the country. For too long, we used lead paint in houses, and now we do not have enough HUD money to clean up homes that have lead-based paints. That is why so many children have lead paint poisoning. We have to recognize, for kids, is they these are important health problems. We have to be developing mechanisms so managed care organizations recognize these issues as health problems and that the Government recognizes them as health problems, and that they work together with linkages. My final point is, unless we pass the kind of language that we have in the Democratic alternative, we are not going to give the special needs of children the attention it needs and deserves. When we start collecting the data, when we start having the HMOs publish what they do for kids--what is their success rate with kids? How many kids with complicated conditions do they have enrolled in their program? When we start doing that, they are going to have an incentive to start talking to the schools and the local authorities about their patients because now they have a real visible, accountable incentive to do it. Just one final point: Again, Bruce Clarke, Gen. Bruce Clarke, one of the great combat leaders of World War II, said--and I remember this from my days at West Point--``A unit does well what its commander checks. If the commander doesn't check, you are not going to find that unit paying attention.'' We have not been checking on kids in HMOs in this country. I do not think they are doing particularly well as a result. When we start checking on kids specifically, as the Democratic alternative does, then we will start doing much better, I think we will start doing well. I yield to the Senator from Oregon.

Mr. REED

Mr. REED. In a sense, the only protections in the Republican bill are protections for the insurance industry. They are completely without risk. All of their patients, all of the people they directly insure, where they directly assume the risk, are exempt from coverage by this legislation. The Democratic bill covers all of those who are private-insured HMOs throughout the United States. If the logic is these protections are good enough and necessary enough for those in employer-sponsored self- insured plans, why aren't they good enough, important enough, necessary enough, for those who are direct insurers of HMOs? The answer, frankly, is that the legislation has been designed to protect the insurance companies from any additional risk. It is fine if we put it on employers; it is fine if they have to pay extra or if they have to do these things. However, the only consistent pattern if you look at the coverage, this is not a patients' protection bill; this is an insurance industry protection bill. I yield to the Senator for her comments.

Mr. REED. I thank the Senator from California. Let me follow up and perhaps engage in a brief dialog. I think the Senator from Minnesota made a good point about the heart of the Republican legislation. The most telling point, in my view, is the coverage. It simply covers one-third of the eligible private-insured individuals throughout the country. As I understand the legislation, it is aimed at those self-insurers. These are businesses that contract with HMOs simply to manage the health care of their employees, so the only people who will directly be impacted by their legislation are those individuals who are essentially insured by their employers directly through self-insurance.

Mr. REED

Mr. REED. Madam President, I ask unanimous consent that the order of the quorum call be rescinded.

Mr. REED. I thank the Chair. Madam President, I want to spend a few moments talking about aspects of the Patients' Bill of Rights, which is an amendment to the agricultural appropriations bill before us this afternoon. We are faced with a very clear choice: Are we going to finally debate and consider in some detail a Patients' Bill of Rights which will give every American a clear opportunity to have the kind of quality health care we all support and we all want them to have, or will we continue to be shut out, will we continue to avoid confronting a critical issue which, to the people of Rhode Island, is probably one of the most critical issues they face. If one goes to the people in my State and talks to them about their concerns, particularly since there has been an economic revival, a primary concern for them is whether they will have adequate health care for their families and themselves, particularly for their children, when they need it. One of the aspects of the Democratic bill, which I think is very salutary and commendable, is with regard to accountability. It provides not only for internal and external review, but also for patient advocacy and patient protection. There are three procedural points that should be included in any Patients' Bill of Rights. First, there has to be clear liability directed against a health plan if they make mistakes in the care of their patients. One of the great ironies of our system is that physicians can be sued for their malpractice, yet insurance companies are invulnerable to such suits. To put it in balance, since so many health care decisions are now being made not by physicians but by review specialists, accountants, and analysts, the insurance company itself should also be liable for its decisions. We also have internal and external appeals processes so there is no rush to the courthouse, but an individual can get relief quickly and efficiently for a health plan decision. When people are dealing with their health insurer, all they want is the best care for themselves and their families. They want their medical problems to be resolved, they want access to the specialists they need, and they want the plan to respond to their needs. In fact, they simply want what they paid for. There is another aspect to consider--that is to help consumers negotiate through the intricate maze of health insurance rules and regulations and to give them the leverage that will level the playing field between health care consumers and the bureaucrats who run health care plans. Toward that end, Senator Wyden, Senator Wellstone, and I have introduced a separate legislation which would provide for a health care consumer assistance, or ombudsman program, in every State. It would establish a mechanism whereby States would be able to provide information and counseling services to assist health care consumers. This provision has been incorporated in the Patients' Bill of Rights, and it is a necessary provision because people are not getting the information they need to make the health care system work effectively for them. For instance, studies show that the existing appeals process, both internal and external, are being underutilized. In fact, there is a very deep suspicion, not only in my mind but the minds of many, that health plans make it almost impossible to get adequate review. They put up procedural hurdles. They have set up a series of barriers that leave the average consumer without any redress and, as a result, they become frustrated and give up. Another suspicion which undermines the faith in the managed care industry is that this frustration is a deliberate, calculated attempt by companies to reduce their costs. They are hoping that the consumer, rather than pressing for their rights, will just go away, will give up, and will accept whatever the health plan offers. I believe we can improve this system dramatically if we have consumer assistance centers in place throughout the United States. These systems will help consumers understand their rights, and will also help to understand in some cases where they do not have a legitimate grievance. One of the virtues of this approach is it will give a consumer of health care an objective place to get an answer. Today some people call the insurance company, where they get different answers and they may get suggestions of what the contract does and does not cover. Unfortunately, it seems that they get everything except straight answers. As a result, they do not have confidence in the health care system. Consumer assistance, or ombudsman centers that are administered by States can restore a measure of confidence in the system. Interestingly, this Senate is already familiar with the concept of a health care ombudsman, and at the time, it was supported virtually unanimously. On the Armed Services Committee, we have been studying the issues of managed care in the military, the TriCare system. Many of the complaints with the TriCare system are the same types complaints we hear about managed care in general: Quality is not good, we can't get care, we can't get answers. As a result, we responded in the defense authorization bill this year. One of the things we did was create within the TriCare system an ombudsman program, an advocacy program, so when military men and women have questions about their families' health, they do not have to get the runaround from the local insurance company; they can go to the ombudsman who can give them help, support, and assistance to get their claim resolved or, in some cases, to explain that the insurance company is well within its rights to make the decision they made. I find it interesting and ironic that an ombudsman provision could sweep through the defense authorization bill and be endorsed as something not only noncontroversial but terribly helpful. Yet, as we consider managed care reform, we are struggling with this issue, among many others. My view is simple: If it makes sense for our military personnel--and we are all committed to giving them the best health care--we should have the same type of sensitivity for the broader population of our country. That is why the Reed-Wyden-Wellstone bill, which is part of the Democratic managed care initiative, is an integral part and one that should be considered, debated, and, I hope, adopted when we get-- we hope--to the debate and the votes on managed care. Our consumer assistance, or ombudsman, program would perform several functions. First, let me point out that our proposal would establish a competitive grant program for States. It would give them the flexibility to set up a program according to their best sense of how to be of assistance and also that it be cost effective. They would, however, be required to meet certain general guidelines. One of the functions of the ombudsman, would be to inform people about health care plan options that would be available. There are lots of examples where consumers do not find out about their health care coverage until they have a health care crisis. I was reading the case of a mother who had a daughter who required eye therapy. The daughter was suffering from autism. One of the complications of that disease is eye problems which requires detailed exercises for the eyes. If that is not done, the child rapidly loses the ability to see, the ability to function appropriately. She went to her health plan and said: I was told to ask you to give my daughter a referral to an eye specialist for therapy. They said: No; you can't do that, because it is not covered under your contract. She went back and read the contract--all the fine print, all the pages and pages and pages--and discovered, much to her disappointment, much to her chagrin, that indeed this was an excluded service. The point is, if there is a place that parents or anyone can go to beforehand and say: I have a daughter who has a condition, and there are complications with her sight, and other things; what advice do you have for me about plans? what are the best plans? what knowledge do you have about the plans that are available to me? that would be an immense help to the families of America. The other thing that would be created is a 1-800 telephone hotline to respond to consumer questions. Again, why don't we have this? Why don't we have a place where a consumer can say: I have just talked to my health care plan; they told me I can't do this? Why can't we have at least a hotline? In effect, we have lots of little fragmented hotlines. Every one of our offices is a 1-800 hotline for people who are frustrated with their health care. We do it in an ad hoc way. We try to help our constituents. But, frankly, we could do it better and more consistently through an ombudsman program. Also, what we want to do is help people who think they have been improperly denied care. We want to help them, and not in an adversarial way, but to provide technical advice. It could be helping them write a letter to the insurance company to make an appeal, or explaining their appeal rights to them. As I said before, many people simply do not understand their appeal rights. It could be that insurance companies do not want them to understand their appeal rights, that they would like them to walk away frustrated, but it not costing the insurance companies any extra money. So for all these reasons, I think an ombudsman program is an absolutely critical part of any managed care reform. One other reason why an ombudsman program is important is that it could be a way to reduce the potential for litigation. This could be a way to solve problems before they get to the point that the only alternative a consumer thinks he or she has is to get a lawyer. This could be a way to make the system work better without running the risk--and I know this risk is conjured up by the insurance companies every day--of litigation run amok across the United States. So for many reasons, I believe an ombudsman program makes so much sense. This is not a theoretical response to hypothetical problems. Let me offer a couple of real cases which beg for the kind of consumer assistance we are suggesting in the Democratic alternative. This is the story of Ms. Carolyn Boyer. Ms. Boyer is a 50-year-old woman who has been battling breast cancer for about 6 years. Like so many patients, she has had to wage a separate battle with her insurance company. Time and time again, her health plan has tormented her with payment followups and a host of bureaucratic hurdles that prevented her from getting timely payment for the services she needs. This is one example. In the spring of 1996, Ms. Boyer received a bill for a bone scan from Washington Sibley Memorial Hospital. She learned that the total cost of the scan was $711.50 and that her portion of the bill, the copayment, was $142.30. She paid her portion of the bill. Thirteen months later, Ms. Boyer received a balance due notice from Sibley Hospital for $569.20, the amount the hospital had indicated was covered by the insurer a year earlier. Then she got a bill from Sibley a few days later for the entire $711. This was now a battle about who was at fault. Of course, the hospital said it was the insurance company; the insurance company said it was the hospital. Nevertheless, Ms. Boyer struggled through this situation. She had already paid her portion, and now she was going to have to pay more than the original cost if she responded to the last bill. Now, 3 years later, after much travail, the insurer has paid their full original amount. In fact, they gave Ms. Boyer a refund for the $142.30 she had paid. This is a daily occurrence. For every one of our constituents, if you ask them, either it has happened to them or it has happened to someone close to them. One of the interesting things about this is, I suspect strongly that the reason Ms. Boyer was successful in her battle with the insurance company was that at the time of her diagnosis she was a lobbyist for the Health Insurance Association of America. She knew a little bit about the way HMOs and insurance companies work. Before that, she was a lawyer for the Internal Revenue Service. Ask yourself, what about the truck driver who is confronted with this dilemma? Ask yourself, what about the single mother with children? When they are confronted with this dilemma, where do they go? What kind of legal expertise can they call upon? The answer is, very little or none at all. As a result, they often do not get the care they need, or they pay what they should not pay, or they end up paying all they have, and many of them find themselves almost in bankruptcy, if not worse. The protections that are built in the Democratic Patients' Bill of Rights will help these people. They will give them access to people who know how to deal with the insurance companies--not unfairly, but objectively. Let me give you another example of how these ombudsman programs have been helpful. The Rafferty family in Sacramento, CA, were able to get their problem resolved after they appealed to the California Health Rights Hotline. The metropolitian Sacramento area has its own hotline to address problems and questions with managed care plans. In September 1998, Lynmarie Rafferty gave birth, by cesarean section, to premature twins, Paige and Hannah. Each only weighed 2 and a half pounds. The girls were admitted to the hospital's neonatal intensive care unit in a very medically fragile condition. The Raffertys had chosen the hospital in part because of its intensive care facilities and its location close to their home. Two weeks later, the Raffertys received a call from their health plan's medical director. He informed them that Hannah and Paige were going to be transferred to another hospital that day--not in a few days, but that same day. He told the Raffertys that if the newborns were not transferred on that day, the plan would not pay their hospital bill. The family was devastated. They had two premature babies in fragile medical condition suddenly being ordered out of the hospital. And if they didn't leave, then the thousands and thousands of dollars in bills that the Raffertys thought were being paid by the insurance company would suddenly be their bills. They also had another young child at home, and the proximity of the new hospital was much further away than the hospital where the twins were currently hospitalized. Well, the Raffertys went to the plan, told them of their concerns, but to no avail. They went to the physician. Finally, they called the California health rights hotline. The hotline reviewed their plan's contract and informed the Raffertys of their rights. Then the Raffertys said to their health insurance plan: We are not going to give consent to moving our daughters. The plan still fought them and said: These babies have to leave. Fortunately, with the help of the hotline, the Raffertys were able to draft an appeal letter outlining the reasons why transferring the newborns would violate their rights. Finally, the health plan backed down and accepted the responsibility for the care of the children, which at that point was over $80,000. Now, can you imagine where a struggling young family, with a child at home and two newborns, were going to get $80,000, if the insurance company had prevailed, if there was no hotline, if there were no advocates? I believe very strongly that this kind of patient protection should be an integral part of the legislation we consider for managed care reform. The Democratic alternative provides those types of protections. It provides for internal reviews and external reviews that are objective, not a situation where the insurance company has picked the individuals who reviewing their own decisions, but truly objective. It also applies the principle that if the insurance company has caused grievous harm, they, just like the doctor, should be liable before a court of law. It also goes a step further and says: Let's see if we can prevent these troubles before they start. Let's create consumer assistance centers. Let's create an ombudsman who can work with individuals and try to resolve their claims long before they reach the stage where it is a matter of life or death or a matter of financial ruin. I believe our greatest responsibility today is to move on to this debate in a meaningful way, to talk about the issues of health care, to debate them because there are points of difference that are principled and we should vigorously discuss and debate them. But we have to get into that debate. The health of America depends upon it. I will mention one other area which I am particularly concerned about. I have spent some time talking about the issue of the appeals process, the procedural protections that we have to build in to any patient protection legislation that moves forward. There is one other area of concern, among many, but one that particularly concerns me. That is that we have to have legislation that is particularly sensitive to the needs of children. The Rafferty example is a good one: Two premature babies who basically are being threatened with eviction from the hospital. We need to be dealing with the issue of children's health care in the managed care system. We have to recognize, and too often we don't, that there is a difference between adults and kids. Kids are different. They are particularly different when it comes to health care. Let me suggest some important differences which argue for special treatment for children within managed care reform legislation. Once again, I believe the Democratic alternative incorporates these special treatments. First, children are developing. This is not an issue that is confronted in the context of adults who are ill. So developmental issues immediately and automatically create differences in the way children must be dealt with. Between birth and young adulthood, children change and grow. They develop intellectually. They develop physically. These developmental issues are seldom part of the equation when it comes to making decisions about managed care because their models deal with adults. Their models deal with very specific adult diseases and adult outcomes. For one reason, they can measure them much better. Many times families are faced with extreme difficulties in getting care from their HMO because the rules that are set for adults don't work for kids. Take, for example, the rule which is common in managed care, that you can only have two sets of crutches in the course of your contract, or year or two. That is fine if you are a fully grown person, if you are an adult. But if you are a developing child, you are going to need different types of crutches, because you are going to get bigger, we hope. The same thing is true with wheelchairs. Children with spina bifida have changes in their bodies and changing needs, much more so than adults. These rules, arbitrary as they may be for adults, are completely inappropriate for children because of this developmental issue. We have to recognize that. The other thing we have to recognize is, symptoms in children which might be dismissed in adults as minor could be the precursors to significant problems down the road that won't develop and be truly obvious for years ahead. That is another reason why children have to have access to pediatric specialists, not general practitioners, who are used to seeing adults. And if you have some sniffles, you don't feel right, take two aspirins and get some rest, that could mean something much more significant and much more serious in a developing child. There is another issue, too, with respect to children that makes them quite different from the grownup population. They are dependent. One of the major measures of health care outcomes in the United States is independent functioning. Can the person function independently? Can they get up and move about? When you are talking about children, they are, by definition, dependent--dependent on adults; in many cases, they are dependent upon adults to explain their medical problems. It takes their parents or the care givers to explain to the physician what is wrong in many cases. That is a difference that seldom is appreciated in managed care plans because they don't have the kind of pediatric specialists or pediatric primary care providers that are so necessary. The patterns of injury are different between adults and children. The good news is, the children are generally very healthy. But the bad news is, when a child has a serious disease, it is usually a combination of many different conditions, unlike serious adult diseases which are typically a single disease. Again, these complicated, interrelated conditions that threaten development argue for access to pediatric specialists early in the process. That doesn't happen. It doesn't happen enough in managed care plans. The answer is not because managed care executives don't like kids; managed care executives have some sort of animus towards children. It happens because of dollars and cents. If you have a very small pool of sick children, why are you going to go out and make arrangements to have pediatric specialists in your care network? That is a lot of overhead for just a couple of kids. We have a market failure. We have a situation in which the market dictates to these companies to do something which in the aggregate harms greatly the health of the American child. That is why we have to act. Again, this is all part of the Democratic alternative. This is part of what we have to do. In addition, I would add that we need to develop quality measures that actually track children's health, in addition to adult health. We have to go beyond some of the simple things, such as immunization rates. We need to get into more complicated measures and make parents aware of these statistics so they make informed choices about their health plans. Another thing health plans need to begin doing more is looking at children in the context of some of exposures that are unhealthy, but are not directly, traditionally medical; environmental exposures like lead poisoning; community exposures like violence, and the stress and strain of living in difficult circumstances. Our HMOs have to also begin to think about how, then, they can do what we all thought they were going to do originally-- emphasize preventive care, particularly with kids, coordinate not just with their own physicians and medical providers in their networks, but with the schools and community-based care centers, all of the institutions that must be allied together to help the children of America. Once again, the legislation that we have introduced--the Democratic Patients' Bill of Rights--does this. I can't think of two more compelling reasons to move to this legislation in a meaningful way than the opportunity to give every family a true voice in their health care through the procedural reforms that we have introduced and to give every child in this country the opportunity to get the best health care they can possibly get. I think we owe it to the people who sent us here. I hope we can find a way to move beyond this deadlock and move to vigorous debate on the Patients' Bill of Rights. If we do that, then we will be serving very well the interests of the American people. I yield the floor. Mr. KENNEDY addressed the Chair.

Mr. REED. Madam President, I ask unanimous consent that the order of the quorum call be rescinded.

Mr. REED

Mr. REED. I do agree. I have been listening to Senator Feinstein's very eloquent and thoughtful comments about the need for access to specialists and the need to have a physician make a decision about your health care and not an accountant.

Mr. REED. I agree completely. The Senator is absolutely right. Both the perception of an unfair, unbalanced procedure, and I would also argue the reality, ultimately, will be such that you are not going to get a fair evaluation of your claim. I cannot conceive of a company--and the HMOs are famous now for their concern for the bottom line--that would go out of its way to retain people who are sensitive to the needs of patients versus the needs of the company and its bottom line. They will pick reviewing authorities who will invariably decide that this expensive procedure, or this inexpensive procedure, is not needed by a patient. What you are doing also is creating a degree of cynicism about the whole process of appeals. As a result, rather than making a sound, objective, external evaluation of the merits of the case with all the evidence and telling the patient, no, this is not necessary for you, or, yes, it is, a huge legal, bureaucratic labyrinth is created, at the end of which you find yourself facing somebody who basically works for the HMO.

Mr. REED. The Democratic legislation tries to create, and I think succeeds in creating, a situation where there is an external review where a party who is not beholden to the HMO, an individual reviewing authority outside of the company will review external appeals. It would be truly independent and there would not be a conflict of interest, and that, I believe, is the appropriate way to proceed. By creating an independent external review procedure, it will, No. 1, strengthen the confidence of consumers that they are getting a fair shake and, No. 2, it will lead to better judgments about the type of health care that should be necessary.

Mr. REED. Certainly.

Mr. REED. Mr. President, I take this opportunity to talk about the Patients' Bill of Rights in one particular area. That is the area of appeals, both internal appeals and external appeals. Both versions of this legislation, both the Republican proposal and the Democratic proposal, purport to have provisions for appeals of denial of service to consumers of health care in HMOs. Looking closely at the proposals, we find that the Republican process is significantly deficient. We will hear discussions about these various proposals, but I will highlight a couple of the areas which suggest the deficiencies that are inherent in the Republican proposal versus the Democratic proposal. First, under the Republican plan, an internal review--one that is being conducted by the HMO itself--that reviewer is restricted from looking at all the evidence in a case. For example, if a patient thought they were not receiving appropriate care, they might go to another physician outside of their network and ask for an opinion. That type of information cannot be used by the internal reviewer to make a judgment about the decision rendered by the HMO. This narrowly restricted access to information prejudices the review process against the patient. It also leads to something I think is evident today and would be even more pronounced in the future, a growing cynicism that the managed care companies simply want to protect the bottom line, not the health of the patient. I strongly suggest the internal review process in the Republican legislation is deficient since it will not allow, essentially, a de novo review of the case by the reviewing authority. The second weakness with respect to the Republican proposal is with regard to external reviews. External reviews are reviews which are conducted by an outside party. Under the Republican plan, a review could only be conducted if there is a claim that some type of medical necessity has been violated, or the proposed treatment is experimental--again, two very narrow grounds. A patient cannot have an external review if the claim is about contractual rights. In the world of HMOs, it is so easy for the HMO to claim: This is not really an issue of medical necessity. It is not an issue even of innovative treatment. This treatment is just not covered under your plan. These contracts are pages and pages of small print. When the average consumer or family tries to figure out what the contract says, they are no match for the reviewing authorities and spokespeople for the HMOs. As a result, there is a very real possibility an aggrieved party will never get an external review. They will be buried in a barrage of verbiage indicating ``it is not covered in the contract'' or it ``doesn't meet our definition of medical necessity.'' I refer to the text provided by my colleague from California where part of the definition of ``medical necessity'' included the low-cost alternative in the provision of services. All of this, in my view, is an invitation to endless argumentation about legalisms at a time when people need a prompt response to a health care crisis in their family. There is another deficiency with respect to the external review provisions. Under the Republican proposal, the HMO actually picks the reviewing authority. Now that just does not sound fair. If it does not sound fair to us, it will certainly not sound fair to the families of America.

Mr. REED. I ask unanimous consent to speak for 10 minutes as if in morning business.

Mr. REED. The Senator is exactly correct. The way the appeals process is drafted in the Republican legislation, a child who has a serious cancer might be offered the services of an oncologist for adults. In the view of the plan, that would be adequate, sufficient for the purposes of the medical necessity. As a result, the parents of the child, who want access to a pediatric oncologist, may not even get the chance to even protest internally, externally, or in any way. That is wrong. Frankly, I have been trying to learn as much as I can about pediatric specialties. I, like so many people, once thought an oncologist is an oncologist is an oncologist like a rose is a rose is a rose. It turns out pediatric oncology is a very specialized part of medicine. I was talking to a specialist recently who pointed out the case of a young child who was discovered with a particular type of cancer and was treated by an adult's oncologist using what is standard procedure for an adult. In fact, using the adult procedure produced additional problems for the child and only further complicated the situation. As a result, the child has to have an additional regime of chemotherapy. All of this could have been avoided, of course, had that child seen a pediatric oncologist immediately. The provisions in this legislation do not give a fair chance to appeal a denial of access to a specialist like the case I have just outlined. They do not give Americans, but particularly children, a fair chance to get good health care. That is what we want to do and should do.

Mr. REED. I am happy to yield to the Senator from Massachusetts.

Mr. REED. Mr. President, I yield the floor.

Mr. REED

Mr. REED. Mr. President, I rise today to honor Sister Mary Reilly, an important figure in social progress and education in Rhode Island for the past fifty years. Since joining the Sisters of Mercy in 1948, Sister Mary Reilly's mission has always focused on helping individuals of modest means meet their basic needs and improve themselves through education. Whether in the heart of Providence, or in the classrooms of Honduras and Belize, or in her forthcoming work in New York City, these are the constants of Sister Mary Reilly's career ministry. To be sure there have been many changes for Sister Mary Reilly. Indeed, she recently told the Providence Journal that her life has been filled with beginnings. Born in Providence, she began her career with the Sisters of Mercy as a teacher there, first at St. Mary School and then at St. Mary Academy at Bay View. Later, she was able to fulfill one of her goals by becoming a missionary and teaching in Central America. Returning to Rhode Island in 1970, Sister Mary Reilly began establishing the groundwork for institutions that have become a significant part of Rhode Island's landscape for social improvement. She was among the founders of McAuley House, a soup kitchen serving the homeless in Providence; the Good Friday Walk for Hunger and Homelessness; the COZ (Child Opportunity Zone), an innovative community effort to link schools with critical social service agencies and non- profit organizations; and the Annual Walk for Literacy. Sister Mary Reilly was also among those who began the Washington lobby, NETWORK. However, the endeavor to which Sister Mary Reilly is most closely linked is Dorcas Place, which she helped found nearly 20 years ago with her colleague Deborah Thompson. Dorcas Place began as a literacy center for low-income young women. As Sister Mary Reilly and other leaders at Dorcas Place saw the need to address a greater array of issues in the community, the center grew to include women and men and took on a host of issues including literacy, employment and training, parenting, and advocacy. It has reached out to other organizations from Salve Regina University, with which Dorcas recently joined to create a certificate program for low-income and welfare dependent individuals, to Fleet Bank, to Rhode Island Legal Services, to the Rhode Island Department of Health, and many others. From a small corps of volunteers at first, Dorcas Place has grown to include 65 volunteer tutors and nearly 50 mentors. While all of this is the result of a team effort, Sister Mary Reilly certainly deserves the lion's share of the credit. She has indeed been the inspiration behind this wonderful organization. Given Sister Mary Reilly's role in influencing the climate of social progress in Rhode Island, it was with great sadness that many Rhode Islanders learned of her decision to resign her post as Executive Director of Dorcas Place. She leaves to embark on a year's sabbatical in New York to work with other Sisters of Mercy who are following-up on the historic 1995 United Nations' Beijing Women's Conference. For Sister Mary Reilly, it is another beginning, and we know that she will not be far from Rhode Island or from Dorcas Place. Her legacy of good will and service to others will foster the continuation the work important work at Dorcas Place, and I join all of her colleagues in wishing her well in her newest adventure. We all hope to see her in Rhode Island again before long.

Mr. REED

Mr. REED. Mr. President, as I look at the Republican proposals, they are deficient in many ways. Of particular concern to me is the way this proposal mistreats children. The Democratic proposal, the proposal we would like to not only debate but also to vote on, emphasizes the need to protect the children of America. I hope we all can agree that at the end of this Congress at least we can provide adequate protections in managed care for children. Don't just take my word for it. Take the word of organizations including the American Academy of Pediatrics, the American Association of Children's Residential Centers, the American Academy of Child and Adolescent Psychiatry, the Children's Defense Fund, the Child Welfare League of America. All of these organizations support unequivocally the Democratic Patients' Bill of Rights. This is the legislation we know and they know will protect the children of America. There are three key points that are terribly important with respect to the differences between the Republican proposal and the Democratic proposal. First, our legislation will assure access to pediatric specialists. In the world of medicine today, it is not just sufficient to visit an oncologist if you have cancer and you are a child, because pediatric oncology is a particular specialty that is necessary for children who have serious cancers. Second, our legislation provides clearly expedited review procedures if child development is threatened--not just their life but their development. This is a critical issue that is virtually unique to children. This is something we have to protect and ensure. Third, we also have provisions within our legislation that will measure outcomes in terms of children, so that when parents are trying to determine what plan is best for their child, they can actually look at measured results: How well this particular plan did--not with a large population of adults, but particularly with respect to children. The Republican plan has some fuzzy language regarding pediatricians and specialists. Clearly and unequivocally, there is language in the Democratic legislation that guarantees children access to providers who are trained to take care of them, access to pediatric specialists, expedited review procedures in the case of developmental difficulties for children, and also outcome measures that actually take children into consideration. These are critical issues that have to be included in any managed care legislation we pass on the floor of the Senate. What did the American people think about that? I have listed August organizations like the American Academy of Pediatrics in support of this measure. Let me tell Members what the American people think. In February of 1999, a survey by Lake Sosin Snell Perry and Associates and the Tarrance Group--one a Democratic polling firm, the other a Republican polling firm--revealed 86 percent of voters surveyed favored having Congress require health plans to provide children with access to pediatric specialists and hospitals that specialize in treating children. That is an overwhelming example of what the American people are asking: Protect their children, and give them access to pediatric specialists. Let them choose, as mothers and fathers, pediatricians to be primary care providers for their sons and daughters. Not only do the American people demand these provisions, they will also pay for them. Seventy-six percent of the voters surveyed said they would pay for these protections, ``even if it increased health insurance costs for families with children by $100 a year.'' They want these protections. Only the Democratic version gives them these protections.