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   What has been done with Congress in every instance that we have been through here, that we have been explaining, it is fair for the other side to present a united front, whether it is the employee facing the employer in the company town, whether it is the single purchaser of the fish or the large purchaser of the grain, and what is proposed in this bill is to do, even, more

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   Let me say this is completely in keeping with the other antitrust exemptions that we have created in the context of unequal bargaining power. But it is more narrow than virtually any of them, because it only will extend to the process of bargaining. It does not, for example in insurance, say the business of insurance is

   hereby exempt to the extent it is regulated by State law. That is a huge exemption.

   This bill will only exempt in the context of negotiating the medical professional who joins with another medical professional to tell the HMO we speak as one.

   Mr. GANSKE. Reclaiming my time, let us go back to this for a minute. Let us say you have a family practitioner out in a small rural town and he knows of some examples where this HMO has not treated his patients fairly; and he says, you know, I think also possibly through specific contract provisions as they relate to his relationship with the HMO, that, for instance, might gag him from telling the patients about their illnesses, if he says to that large insurer, you know, I think you ought to change that, but 80 percent or 50 percent of his patients are in that, do you think that that large insurer is going to bargain with them, is going to change their contract with him? No. They are going to say, as the gentleman said, take it or leave it.

   Mr. CAMPBELL. They will go next door.

   Mr. GANSKE. They will go next door, and so what we are looking at is an ability, and I think this is crucial, the gentleman has it in your bill, and we have to repeat this, the gentleman has in his bill a prohibition on strikes.

   Mr. CAMPBELL. Absolutely.

   Mr. GANSKE. Let us repeat that.

   Mr. CAMPBELL. There is a clear statement in the bill that there is no right to strike conferred by this bill.

   Mr. GANSKE. So that nobody tomorrow when we debate this can say that doctors, if we pass this bill, the Campbell bill will allow physicians to go on strike; is that right?

   Mr. CAMPBELL. That is right, no one can say that truthfully tomorrow.

   Mr. GANSKE. That is a good point. Now, what we are talking about then is for a group of physicians, for instance, that have seen abuses by that HMO to be able to get together, possibly to hire somebody to negotiate for them to go to that HMO and correct some of the abuses that they are seeing, and, say, look, as a group now, they have more equality in terms of this bargaining position. We want you to treat patients more fairly when, for instance, they go to the emergency room.

   Mr. CAMPBELL. Great example. I say to the gentleman, ought there not be some understanding that the HMO will cover the costs in the emergency room closest to the accident? Ought this not be a minimum sort of situation, and if a doctor insists on that and says I am sorry, we are not going to put that in your contract, take it or leave it, who cares more for the patient, the doctor who is the trained professional committed to a code of conduct regulated sternly by the State and by her or his own colleagues in caring for the patient, or the HMO. And I am not saying that they are all bad; I am not saying that they are most bad. But I am saying that they are differently motivated.

   Mr. GANSKE. Reclaiming my time, what we are dealing with is a situation, for instance, where it may not be a matter that is specifically in the contract that the physician has, but he knows that there are provisions in the contract that an employee might have that are preventing the patient from getting the needed care in an emergency.

   I will give my colleagues one example here. We have a little boy here who is 6 months old. One night about 3:00 in the morning, he had a temperature of about 104, 105. The mother and father lived south of Atlanta, Georgia. His mother gets on the 1-800 HMO number line, talks to somebody a thousand miles away, says my baby

   Jimmy has a temperature. He is really sick. He needs to go to the emergency room.

   The HMO reviewer, who has never examined the child, says, well, I guess I could authorize you to go to an emergency room, but the only emergency room we are going to authorize is one that is 70 miles away, 70 miles away. And if you go to any other one, then you can pay for it yourself. So Mom and Dad wrap up little Jimmy. They get in the car; they start their drive. 20 miles or 30 miles into the drive, they pass three emergency rooms that they should have been able to stop at, because Jimmy was really sick; but they were not health professionals, they did not know how sick he was.

   Before they got to the designated hospital, he has a cardiac arrest. Imagine, Dad's driving this little baby frantically, mother is trying to keep him alive. He is not breathing any more. His heart is not going. They finally screech into an emergency room. Mother leaps out of the car, screaming save my baby, save my baby. A nurse comes running out of the emergency room, gives him mouth to mouth resuscitation.

   They start an IV. They start medicines and somehow they get him back to life, but they were not able to save all of this little baby, because he ended up with gangrene in both hands and both feet as a consequence of that HMO's decision. He ends up having to have both hands and both feet amputated.

   Now, the point of the gentleman's bill I say to the gentleman is this. Let us say I am the family doctor , and I find out that this HMO has treated my patient this way, and I hear from some other fellow physicians that they have done the same thing; and we say, you know, we are not incorporated together. We are not salaried physicians. We are just individual physicians out there, but we know there is a problem with this HMO, the way they are treating babies like this.

   We say to the HMO, unless you change your emergency room policy, we are not going to sign up with you. Under current law, that group of doctors advocating on behalf of their patient could be sued under antitrust. Is that not right?

   Mr. CAMPBELL. It is absolutely right. I say to the gentleman, they could be sued by the Federal Trade Commission. They could be sued by the Department of Justice. They could also be sued by the HMO, which would calculate for the year, let us say, how much additional costs the HMO had to pay out over what the contract would have been if they had only access to the emergency room 70 miles away, and multiply that additional cost by three, it is trouble damages in antitrust, plus the HMO would get its attorneys fees, because prevailing plaintiffs, not prevailing defendants, only prevailing plaintiffs get their attorneys fees in antitrust.

   Mr. GANSKE. Let us deal with some of the myths about the Campbell bill. Some people say that this would allow price fixing. I wonder if the gentleman would like to address that issue.

   Mr. CAMPBELL. Well, indeed, when we are speaking about doctors presenting a united front, it is going to impact the compensation that they get. It just has to. If you are a family physician and you are being forced to accept a per-patient capitated rate, that means you see 20 patients per hour, you are not the same family physician that you wanted to be when you graduated from medical school. And in most instances, you are not really adequately providing health care.

   It is impossible, impossible to divide the question of compensation from the question of care. That, however, leaves us open to criticism by the unfair, to create traps for those who would use the trap. It is unavoidable if you are going to get better care that you are going to have to have some payment for the better

   care. You cannot repeal the law of economics any more than you can repeal the law of physics.

   Mr. GANSKE. What the gentleman is saying is that some may try to narrow the law to only deal with nonfiduciary matters, but I believe what the gentleman is saying is that an HMO can set a fee so low as to effectively deny the treatment.

   Mr. CAMPBELL. The gentleman is absolutely right. And we anticipate an amendment to this extent being offered tomorrow. And on its first blush, it will sound good. It will say none of this antitrust immunity shall extend to the question of compensation. It is, however, a gutting amendment, a killer

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   Mr. GANSKE. I go overseas and I do cleft lip and palate operations in Third World countries where the families cannot afford it. But I will tell you what, people are spending an awful lot of money in this country for their health insurance. It ought to mean something when they actually get sick and need it, for instance, a child. And it ought to be covered at a level that would not preclude a person from getting it.

   But I want to go back to one thing, and that is that under the gentleman's bill, price fixing or fee setting by physicians is still illegal, and that is because what we are talking about is a group of physicians being able to negotiate with an HMO, but we are not talking about that group of physicians being able to set fees across the board. Is that not correct?

   Mr. CAMPBELL. The gentleman is absolutely right. The extent of the immunity is in the context of bargaining. And even today, I heard a related myth, that this will be a wholesale antitrust exemption and would allow doctors to join in a boycott, a boycott of a particular pharmaceutical company, Merck was mentioned because it was in the news, the argument about price fixing, the argument that doctors could get together and agree that no nurse anesthetist would practice.

   Those are all false. The exemption is specific to the practice only of bargaining; and to make it even more clear, we added an amendment that even in the context of bargaining it shall not be permitted as an exemption from the antitrust laws to agree to exclude any other professional from their scope of conduct, and we have our colleague from the other side of aisle, the gentleman from New York (Mr. NADLER), to thank for working out that amendment. The Nadler amendment is part of this bill. So price fixing at the patient level, not permitted. Exclusion of other professionals, not permitted. Barring the doctor's right to choose a pharmaceutical of his or her choice, not permitted. And, yet, I suspect in fear, we will hear about those tomorrow.

   Indeed, with my colleagues' indulgence, let me say that I woke to a fascinating circumstance yesterday. I heard my name mentioned in an ad on the local radio station in Washington D.C. And I had no idea I was so evil, but the Campbell bill was being described as OPEC for doctors, and this is actually the first thing I heard after waking up. The Campbell bill is OPEC for doctors; call your Congressman and oppose the Campbell bill.

[Time: 19:45]

   Well, being Campbell, this did get me out of bed very quickly.

   My own view, is that, as I described, OPEC is the scariest cartel because Americans know about price-fixing by petroleum companies. This bill is restricted to the bargaining context. And I am grateful, I suppose, that people are mentioning my name, and hopefully they will spell it right, but I am not running for office in the District of Columbia.

   Mr. GANSKE. Reclaiming my time, I have to laugh that they are calling this bill a doctors cartel, because when we look at the oil cartel, we have 11 OPEC countries controlling the cost and access of 40 percent of the world's oil. What we have in this country is we have a managed care cartel where seven giant insurers and the Blues control costs and access of over 50 percent of the U.S. health care market. OPEC nations utilize their oil production policies to control the market, the price and the profit of oil. And that is exactly what the managed care cartel does.

   But I think we should also go onto this issue of, well, is the Campbell bill just going to mean that physicians are going to become unionized. I find this the most amazing misunderstanding of the gentleman's bill, because the gentleman's bill, H.R. 1304, would allow physicians and other health care professionals to negotiate with insurers without forming a union.

   Let me tell my colleagues on the Republican side of the aisle that if they want to see physicians become a union, then they should vote against the Campbell bill. Because if we take those physicians out there in those small communities where they are just squished in any type of consumer care problems with the HMOs, and the only recourse they have is to join a health group and become salaried physician, then in that circumstance, under the current law, then they can form a union.

   If we do not pass the Campbell bill, I will make a prediction. I will predict that we will see an acceleration of physicians into unions. The Campbell bill is a preventive piece of medicine in terms of physicians becoming unionized.

   Mr. CAMPBELL. I am pleased that the gentleman made it very clear, particularly for our colleagues on the Republican side. I want to add a word for our colleagues on the Democratic side, however, as well.

   I have been very pleased with the support that we have had from several unions who have said, even though this undercuts the attractiveness of a union, we recognize and we are happy to see the benefit of collective bargaining. And we have actually had support from the American Federation of State, County, Municipal Employees Union for that concept. So to make it clear, it actually provides some of the benefits of being in a union and, hence, makes it less attractive to be in a union.

   Nevertheless, it is my delight to report that it is supported by over 100 Democrats as well as just under 100 Republicans. We have about 90 Republican cosponsors and about 120 Democrats.

   May I say one extra thing, too, at this moment, because it is important. The American Medical Association is supporting the bill. So also is the National Medical Association. And let me just take a moment on that. The National Medical Association was organized as an alternative for medical doctors of the African American race. That was its origin. And there are parts of our history in this area, as in so many others, where there was the practice of discrimination. It has been a source of great pride and support to me that the medical association most connected with increasing the prominence and opportunity for African

   Americans in our country has endorsed this bill.

   Their president has testified in favor of this bill; and he believes, and has said in testimony, that this will yield increased quality of service in those communities that may not get the maximum attention. So on the question of, let me say the traditional issues of importance to all of us, but sometimes more identified on the Democratic side, we are proud of the support that we have.

   Would the gentleman indulge me one second.

   Mr. GANSKE. I wonder if the gentleman would address the issue, because I am sure we will hear about this tomorrow, the issue of the cost of the gentleman's bill. I know there was an initial Congressional Budget Office analysis of the bill which was incorrect in several of their assumptions, and I will bet the gentleman can fill me in on the details of that.

   Mr. CAMPBELL. Well, indeed. What reminds me of this was the radio advertisement that I referred to. The advertisement now running in Washington, D.C., says that one estimate says that this will increase cost 15 percent. No, that is not correct.

   The Congressional Budget Office assessment is that the ultimate effect to the patient will be six-tenth's of 1 percent. Six-tenth's of 1 percent. Now, I have good reason to believe that is wrong because they do not measure quality. And if quality is improving, which it surely will under this bill, any measurement of cost-per-unit quality will likely drop.

   But let me explain how 15 percent came to be. The Congressional Budget Office said, well, we have to make some assumption as to what the initial increase in compensation to the doctors will be. Let us just assume that the studies of industrial unions, which show that members of industrial unions make roughly 15 percent more than individuals in that same calling who are not members of industrial unions, let us assume 15 percent.

   Mr. Speaker, it was done on no more basis than that. But it started there, and then it came down to six-tenth's of 1 percent after figuring the following.

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   Mr. GANSKE. Okay. So they originally said that the cost was going to be how much?

   Mr. CAMPBELL. They said that the reimbursement to the physician was 15 percent. But their original estimate of the cost was 2 percent, and I pointed out a couple of errors in their analysis.

   Mr. GANSKE. And now the CBO is saying that the cost would be six-tenths of 1 percent.

   Mr. CAMPBELL. Six-tenths of 1 percent.

   Mr. GANSKE. Six-tenths of 1 percent. And I would point out that that is probably an accurate figure. I think that there would be a very small increase. And the reason why there would be a very small increase is because, quite frankly, when groups of physicians get together to negotiate with those HMOs, especially concerning those consumer practices that affect whether a patient can get the type of treatment that they need, let us say on the medical-necessity issue, then I think there would be a little bit of an increase in cost because, quite frankly, I think a lot of HMOs have been denying appropriate care, and that care is going to cost a little bit more.

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