[Congressional Record Volume 163, Number 5 (Monday, January 9, 2017)]
[Senate]
[Pages S126-S151]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                               OBAMACARE

  Mr. McCONNELL. Mr. President, earlier today I had a good conversation 
up in New York with President-Elect Trump about a number of pressing 
issues. We talked about the upcoming Senate agenda, the President-
elect's nominees, and the way forward on repealing and replacing 
ObamaCare. As I told him, the Senate's focus this week will remain on 
the process to repeal ObamaCare and keep our commitment to the American 
people.
  ObamaCare has been a flawed system from the start, and things have 
gotten progressively worse over the last 7 years. From skyrocketing 
premiums to dwindling insurers in the exchanges, ObamaCare has corroded 
insurance markets across the country to a point that is simply 
unsustainable. That is why we are taking action to bring relief to 
countless American families who have been hurt by ObamaCare. 
Unfortunately, there are some who will never accept the realities of 
this failed partisan law. They seem more interested in messaging 
exercises than replacing ObamaCare with real solutions to improve 
health care. Catchy slogans, expensive campaigns, or messaging 
amendments are not going to undo the damage ObamaCare has caused.
  Our Nation cannot continue on this trajectory as ObamaCare continues 
to

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unravel at every level, leaving Americans to pick up the pieces.
  We may not be responsible for the damage of this law, but we are 
committed to bring relief nonetheless. We will continue working this 
week to pass the legislative tools necessary to begin clearing the way 
for repeal and then a different way forward that will lower costs and 
increase choices from where they are now.
  There is no quick fix to undoing the damage created by this broken 
and complex law, and repeal is just the first step in that process, but 
the sooner we act, the sooner we can begin bringing relief to those who 
need it. Let us continue working to keep our promise to the American 
people by passing legislation that will help us finally move beyond 
ObamaCare's broken promises.
  The PRESIDING OFFICER. The Senator from Massachusetts.
  Mr. MARKEY. Mr. President, I rise to speak about this impending 
attack upon the Affordable Care Act and the impact it can have on the 
hospitals of our country, in terms of draining revenue from them; on 
the issue of the impact on community health centers across our country 
and the impact it can have upon them; upon the impact that the repeal 
of the Affordable Care Act would have on the access of those who are 
addicted to opioids who need help for opioids, who are in a situation 
where they are going to need the Affordable Care Act, the access to 
coverage, so their problems can be taken care of.
  So this is no small threat. In fact, this goes right to the core of 
what started in Massachusetts back 10 years ago when we as a 
Commonwealth decided that care for people who needed health care was 
going to be made available to them. We have proven in Massachusetts 
that we are able to provide health care for 98 percent of our 
population, at the same time having an unemployment rate of 3.2 
percent, while simultaneously having the highest scores for kids in the 
4th, 8th, and 10th grades in math, verbal, and science, while having 
the strongest protections for the environment in the United States, 
while having an energy efficiency standard that is the tops in the 
United States.
  We have proved conclusively that it is possible to ensure that people 
do, in fact, receive access to the health care which they need while 
simultaneously discharging our responsibilities to the economy, to 
education, to the environment, to all of the other interests, all of 
the other important stakes that we have in our country to ensure that 
they are given the attention which they need.
  It would be tragic if what we did as part of the Affordable Care Act 
was to once again flood the emergency rooms of America with people who 
otherwise would have had health care coverage under the Affordable Care 
Act. That is a system we have used for 100 years, and it doesn't work 
because it winds up with the insurance rates of people who do have 
coverage going up in order to cover it. It winds up with the whole rest 
of the medical system, in a very chaotic way, being forced to deal with 
the consequences.
  If we begin simultaneously to defund the community health centers 
across the country and their ability to provide health care, then what 
we have is a cascading impact that ultimately hits those people who are 
the poorest, those people who are the most vulnerable. They are the 
ones who are caught in the crosshairs of this incredible, almost 
unbelievable attack which the Republicans are waging upon a health care 
system that has already transformed the lives of 22 million people in 
the United States.
  It is unimaginable to me that we could be in that kind of discussion 
right now on the floor of the Senate, but I understand it. This is 
ideological. It is something that is completely and totally detached 
from the reality of the benefits of the Affordable Care Act, as they 
have in fact already positively affected tens of millions of families 
inside the United States.
  This week we are about to have an incredible battle waged against the 
Affordable Care Act. Understand this, right in the crosshairs are the 
hospitals of our country, not just the famous, big hospitals we all 
know the names of but Catholic hospitals across our country, hospitals 
that provide the service for people now under a much more orderly 
system than they would have done if we had never put the Affordable 
Care Act on the books in the first place.
  At the forefront of all these issues, though, is this largest of all 
public health epidemics that has ever faced the country, the heroin and 
prescription opioid epidemic, like OxyContin, which is claiming the 
lives of more than 90 people every single day across this country. In 
Massachusetts alone, when all the final numbers have been gathered, 
2,000 people will have died in the State of Massachusetts in the year 
2016, and 1,500 of them will have been found to have had fentanyl in 
their blood system. This is an epidemic of unbelievable proportions. 
Fentanyl is the Godzilla of opioids. It is powerful and deadly and 
knocking people down the streets all over Massachusetts, all over New 
England, and all over our country. People are being robbed of their 
potential and God-given abilities from this epidemic that knows no 
socioeconomic, ethnic, or political boundaries, and Congress has 
recognized the importance of tackling the Tsunami of heroin and 
prescription opioid addiction that is laying waste to these 
communities.
  Just 1 month ago, on the Senate floor, Republicans and Democrats came 
together and passed a bill to provide $1 billion in new resources to 
States to address the opioid crisis, resources that can be and are 
being dedicated to increasing access to treatment for opioid use 
disorders. Yet, today, pending before the Senate is a Republican budget 
whose entire premise is to repeal coverage for the exact same 
vulnerable people who need access to treatment. Not only is that 
nonsensical, it is downright cruel for all those families and 
individuals who finally felt a sense of hope, the hope that new 
resources could mean the difference between life and death for their 
loved ones. If you kicked this policy in the heart, you would break 
your toe. That is how heartless it is going to be in terms of its 
impact upon ordinary families. With this budget, Republicans are 
repealing the hope that has given families a reason to ensure that they 
will have the coverage. This is going to make the problem even worse.

  Medicaid pays $1 out of every $5 for substance use disorder treatment 
in the United States. Without Federal investment in the Medicaid 
program, States like Massachusetts, New Hampshire, Ohio, West Virginia, 
and Kentucky, which are bearing the brunt of the opioid epidemic today, 
will have to find even more money in their already dwindling State 
budgets to aid those who need treatment. We all know what happens in 
this scenario when States cannot find that money. The most vulnerable 
among us, the ones who don't have a voice, are the ones who will suffer 
the most.
  The repeal of Medicaid expansion would rip coverage from an estimated 
1.6 million newly insured individuals with substance use disorders. At 
the same time, repeal will put big insurance companies back in charge. 
If the Republicans have their way, insurance companies would be able to 
discriminate against people, including individuals with a preexisting 
condition like an addiction disorder. OxyContin, heroin, fentanyl 
coverage--gone under the proposal the Republicans are making on the 
Senate floor this week.
  Let's recognize that the Republicans are not just repealing 
ObamaCare; they are repealing hope. Those suffering from addiction 
don't have time for Republicans to come up--possibly, maybe, 
potentially soon, sometime, in the indefinite future--with a 
replacement plan.
  There are 1.6 million people who have insurance for substance 
disorders right now for heroin, for OxyContin, for fentanyl. These are 
the people who could potentially die because they don't have medical 
coverage. What is the plan the Republicans have to deal with these 1.6 
million people who are already under a substance disorder medical 
coverage plan? What is their plan for these families who are already 
desperate for the medical help they are going need in order to stay 
alive, in order to get the help they and their families need? Those 
families know that any delay in a replacement being put on the books 
could be the difference between getting clean or getting buried.
  This repeal effort is the worst kind of bait and switch. It is 
happening at a

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time when the American people can least afford it. Repeal is being done 
at the same time the Republican budget gives billions, tens of 
billions, hundreds of billions of dollars to corporations and to the 
wealthy in tax breaks. So look at that as the balance we are talking 
about: 1.6 million people who have an addiction, a substance abuse 
problem, lose their coverage, but billionaires and corporations get the 
money through tax breaks that are going to be saved from cutting those 
programs for those who have a medical problem. That is immoral, ladies 
and gentlemen. That is plain and simply immoral.
  You cannot give tax breaks to the wealthiest in our country until you 
take care of those who are the sickest, until you take care of those 
who are most in need, until you take care of those with substance abuse 
disorders in our country. It is immoral to cut the programs so you can 
give tax breaks to the wealthiest within our society.
  We will not save lives and stop this scourge by paying lip service to 
providing treatment, but this is not the only casualty of this 
misguided budget before us. The hospitals that each and every one of 
our constituents depends upon are also at risk. The Affordable Care Act 
became law in no small part due to the support of those hospitals 
across the country. During that debate they knew full well the impact 
that a lack of insurance had not just on individuals but on the entire 
health care system.
  The hospitals are on the frontlines of witnessing the financial 
burden that uninsured patients have on the system. We tell them they 
can never turn away a patient in need; then, when these patients cannot 
afford to pay for the care, it is up to the hospitals to foot the bill. 
So the hospitals told us that if we worked to reduce the number of 
uninsured they had to care for, then they would help us pay for 
improving the entire system.
  They did pay, in no small part. That is why we have a new system in 
our country. As part of the ACA, the hospitals agreed to give up over 
$150 billion in payment reductions between 2010 and 2019. Those payment 
reductions came largely from Medicare and were attacked relentlessly by 
opponents of ObamaCare as an act to destroy the program, but the 
prophesied destruction did not occur, and the impact on Medicare has 
been quite the opposite.
  Since passage of the Affordable Care Act, Medicare has seen its 
lowest per-member rate of spending growth in its 50-year history. 
Premiums paid by enrollees in Medicare Parts B and D have gone down. 
Perhaps most importantly, the savings have contributed to keeping our 
promise to America's seniors by ensuring that the program will continue 
to be there for them. Medicare's projected insolvency in the year 2017 
has been extended for over a decade. All of this is possible, thanks to 
America's hospitals.
  Here is what the Republicans are saying to Grandma and Grandpa: Yes, 
the Affordable Care Act extended the solvency of Medicare 10 years 
beyond 2017. We are repealing that bill. So, insolvency comes almost 
immediately to the Medicare system. What a great signal to send to 
Grandma and Grandpa this year with this bill on the Senate floor: 
insolvency of the Medicare system, the one thing that Grandma and 
Grandpa, and, by the way, everybody else inside every family in America 
is depending upon to take care of Grandma and Grandpa.
  So will the budget before us return the savings they are expecting 
from this bill to the hospitals to help them cover the cost of Grandma 
and Grandpa? No. For that to happen, Medicare costs will go up. Higher 
costs will lead to higher premiums for every enrollee in Medicare Parts 
B and D. These higher costs will also be realized in the entirety of 
the Medicare Part A program, reducing the time of insolvency from 2028, 
down to 2024, 2023, 2022, or even earlier.
  Those results are unacceptable to the Members of this Chamber and to 
their constituents, so it is now going to be a historic debate that we 
have. We can decide instead to simply not cut off the 20 million 
Americans from the insurance they need. We can ensure that hospitals 
have the resources to focus on the care for patients when it matters 
most. We can keep the promise to America's seniors that Medicare will 
be there to cover their needs when necessary.
  I thank the Presiding Officer.
  I yield the floor.
  I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The senior assistant legislative clerk proceeded to call the roll.
  Ms. CANTWELL. Mr. President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The PRESIDING OFFICER (Mr. Cassidy). Without objection, it is so 
ordered.
  Ms. CANTWELL. Mr. President, I look forward to having this discussion 
this afternoon about the Affordable Care Act and the many votes and 
actions that are going to be taking place. I especially look forward to 
having this discussion with the Presiding Officer because I know his 
State is greatly impacted by the health care delivery system and its 
shortfalls, and I look forward to discussing with him some of the many 
ideas that our colleagues have.
  I will say this at the outset of my comments. I am willing to work 
with anybody to improve our health care delivery system. I am willing 
to discuss with anybody what we need to do to improve the quality of 
health care for Americans, and I am specifically interested in making 
sure that we improve the outcomes of many Americans' health care and 
that we also lower costs.
  It has been the hallmark of what the Northwest health care delivery 
system has been all about. Yes, that is right. We get less money and 
deliver better outcomes. It is not because we all like to hike, 
although there are many Washingtonians who like to hike. It is because 
we have had to make do with less, and we have built a better system. We 
hope the rest of the country can move forward along similar lines.
  So I am here to talk about the Affordable Care Act and the many 
aspects of it that are so important to our Nation in actually slowing 
health care costs and reducing our deficit. That is one of the 
cornerstones of why we did delivery system reform and why we did health 
care reform. We needed to slow the rate of health insurance increases, 
and we needed to lower the costs for us as a nation as well for the 
private sector. That was the task at hand. So to my colleagues who are 
ready to repeal all that, I ask you to wait. I ask you to stop and 
think about what we are doing, and before you repeal, think about what 
we are going to put in its place because this is such an important 
issue.

  What does the Affordable Care Act mean? One of the aspects that I 
think is getting lost in this debate is that people are talking about 
what has happened in a percentage of the individual market. They are 
talking about the plans as they related to last October and what 
happened with rate increases. Some people said: Oh, well, a lot of 
providers went out and offered a lot of low-ball coverage costs and 
came back with higher rates later. Some people said: Some of the pools 
aren't big enough. Some people said: Well, the coverage we are going to 
guarantee is going to help. But the issue is that the Affordable Care 
Act is much more than just what we tried to do in the individual 
markets. It is about providing affordable coverage, but it is also 
about reducing costs, improving the health care delivery system, 
protecting women's health, and saving the taxpayers money. I hope my 
colleagues on the other side of the aisle will think about all of these 
issues--providing affordable coverage, reducing costs, improving the 
health care delivery system. I warn my colleagues that if you repeal 
the Affordable Care Act and take away its improvements to the delivery 
system, you are going to balloon the deficit, and that is something 
that we cannot afford.
  What am I talking about when I say ``affordable coverage''? Well, 
let's take Washington State, for example. I am sure the Presiding 
Officer could take his State also, but in our State, there are 3 
million Washingtonians with preexisting conditions who are guaranteed 
coverage; there are 50,000 young adults who can keep coverage through 
their parents' plans; and more than 600,000 Washingtonians have been 
covered by the Medicaid expansion.

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  To me, the Medicaid expansion is about simple math. Medicaid is 
expanded because it is the most cost-effective, economical way for that 
population to get health care coverage and to be part of the health 
care system, keeping our costs down and keeping that population 
healthy.
  Depending on what State you are from and what philosophy you have as 
an individual, you may not be for Medicaid expansion. There have been 
many times that across the aisle we have been able to come to terms on 
Medicaid expansion and on the CHIP program because we believe that 
having a healthier population is a good economic policy for our Nation. 
After the Affordable Care Act implementation, we actually have results, 
studies, and analysis by various States in the Nation that have said 
that expanding the Medicaid population has helped our economy and has 
helped our States overall. So I would say to my colleagues, please do 
not repeal the Medicaid expansion. Please do not put these people back 
on the street with their health care problems and health care issues 
and increase the cost of uncompensated care. That is not a strategy.
  What else do we want to do? We want to drop the rate of uninsured 
Americans. The Affordable Care Act has done that, decreasing by more 
than 40 percent the number of uninsured Americans. Less than 9 percent 
of Americans are now uninsured. In our State, the uninsured rate has 
dropped to 5.8 percent, which is a nearly 60-percent decrease. For us 
in the State of Washington, we have more people covered. The Affordable 
Care Act is covering more people, so we have taken more people out of 
the uninsured market.
  The way the other side of the aisle would like to describe this is 
that the whole thing is falling apart because of some changes and 
shifts in the individual market, but the facts are there that the law 
is not only expanding coverage but lowering costs. Looking at what 
health care costs would have been over the last decade has always been 
a tricky issue. The rates of health care costs were going up. I like to 
say that we may want health care costs to keep pace with the rate of 
inflation--and I will give health costs a little bit of an inflationary 
bump because of technology and new innovation. It is not the same as 
the rate of inflation for everything else, but at the same time, we 
shouldn't be seeing double-digit increases in the costs of health care. 
Our goal was to change the system to the degree that we would see 
health care costs more in line or a little bit above the rate of 
inflation.
  This chart shows the national expenditures for health care on the 
dotted line on these actual and most recent projections of what the 
health care system is doing now compared to what it would have been 
before the Affordable Care Act. So again, people are debating over what 
these increases are, when in reality we were seeing double-digit 
increases, and now we are seeing the cost growth of health care go 
down.
  So going back to the chart for a second, this projection is so big 
because of many factors. This is about changing the delivery system; 
this is about making sure that there are not exorbitant amounts of 
uncompensated care; and this is about making sure that we don't 
overspend on the health care delivery system. I can imagine that for 
some States this must be the most frustrating issue, particularly if 
the reimbursement rate has led to a population that is constantly 
underserved because no one wants to see those patients. We in the 
Northwest have had that frustration because we get somewhere between 
$1,000 to $2,000 less--maybe even more--per Medicare beneficiary than 
many other States in the country. That has led to a situation where 
people don't even see Medicare beneficiaries in parts of our State. 
That is right. People have to travel a great distance to find a doctor 
because they can't find one because of the Medicare reimbursement rate.
  My solution is, if we are providing health care in my State with 
better outcomes and lower costs, I shouldn't be penalized for that; I 
should be rewarded. Every other State should try to practice medicine 
that actually helps us lower the costs.
  So why are we working on this issue? The Affordable Care Act has 
contributed to slower cost growth. Medicare spent $473 billion less in 
the 5-year period from 2009-2014 compared to the benchmark--compared to 
what would have been done if we did nothing. So, my colleagues on the 
other side of the aisle, I know you are all for repeal. Where will you 
replace this money? Where are you going to come up with those savings? 
If you come to the floor and say that you don't want to repeal the 
delivery system reform that we fought so hard for and crafted, that you 
are willing to make those changes and keep the delivery system, we will 
be listening with open arms and great receptivity because there are 
many people on this side of the aisle who have worked very, very hard 
on these reforms.
  In the private sector, we have also slowed the rate of growth in 
insurance premiums. I am talking now about the employer-based plans. We 
slowed the rate to one-third of what it was before.
  Individuals are seeing lower increases than what they would have had 
to pay before these reforms.
  So what is the debate about now? What we are trying to do in health 
care reform is improve health care by decreasing costs, having better 
patient outcomes, and helping doctors spend more time with their 
patients than with their paperwork. This is critically important 
because what we are seeing in the United States is doctors spending 
more time on the paperwork of the system than on the actual outcomes of 
their patients.
  We want everybody to have a medical home. We want everybody to have a 
delivery system that rewards outcomes, and that is what we are driving 
for, but the debate in Washington has not been over this issue of where 
Americans get their insurance coverage. As you can see from this chart, 
49 percent of Americans get insurance through work, 34 percent of them 
through Medicare and Medicaid and other public programs, and then a 
much smaller percentage are uninsured or in the individual market. The 
debate now is over the individual market. The debate is over the 7-
percent number.
  In some States, the individual market was out of whack for a variety 
of reasons. Maybe the risk pool was too small, maybe insurers went too 
low on their original estimates, maybe they made some changes that 
didn't work in that marketplace, but that doesn't mean we throw out all 
of the Affordable Care Act that is doing such great work just because 7 
percent of the population in the individual market needs further 
attention. It doesn't mean that we repeal all of this. It certainly 
doesn't mean that we give this uncertainty to the American people about 
whether they are going to have health care coverage and give the 
illusion that the other side of the aisle is doing anything but taking 
the system and capping Medicare and Medicaid, giving out a check that 
never keeps pace with inflation, and then taking the savings from the 
system and channeling it into corporate tax reform relief. No, no, no, 
no, no. We need to make the health care delivery system work for the 
American people, deliver better outcomes, and continue to make reforms.
  What are the innovations that we are talking about in the delivery 
system? Well, my colleague, the Presiding Officer, will know, because 
he understands health care, that the innovation in health care is about 
everybody having a medical home. Why do you need a medical home? You 
need a medical home because you need to be seen, not by the emergency 
room physician but by your doctor and someone who is going to 
understand your health care needs.
  We need to make investments in primary care and prevention and 
wellness. I am sure the Presiding Officer understands that we don't 
have enough primary care providers in the United States. We need to 
change our system for the GME; that is, graduate medical education, so 
we can get more primary care providers.
  We also need to focus on health and wellness. That is what the 
Affordable Care Act does. It starts to look at the system and rewards 
prevention and wellness. The Affordable Care Act says: OK, let's try to 
do this in a new way. Accountable care organizations aim for a global 
budget instead of all the paperwork that has to happen. A provision I 
authored, the Basic Health Plan, which is being used in the State of 
New York, is showing results in lowering

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the costs of premiums, giving affordability to people well beyond what 
they were able to otherwise get.
  The other idea is rebalancing nursing care to community-based care. 
Twenty-one States applied for and were approved to do rebalancing. A 
lot of these States were Republican States in the South that took the 
money from the Affordable Care Act and bought into this really smart 
notion. It says: Let's rebalance away from nursing home care into 
community-based care, and we as the Federal Government will help incent 
that. So all the Republican Governors that took that money from the 
Affordable Care Act to try to rebalance their population away from a 
very expensive delivery system to a new delivery system, are they now 
going to pay us back? Is that what repeal is going to mean, that we are 
going to ask them to pay us the money back or that we are going to 
forgo this notion that moving people out of nursing homes and keeping 
them in their community homes is more important?
  I will tell you this. We have a problem of an aging population in the 
United States of America, and the best thing we can do is help change 
the delivery system so it is more cost effective for the future. That 
is what the Affordable Care Act did.
  The Center for Medicare & Medicaid Innovation, which is also a part 
of the Affordable Care Act, drove in some incredible efficiencies. The 
Secretary just spoke today at the National Press Club, talking about 
focusing on better managing care for many people affected with diabetes 
because they are one of the biggest cost drivers. So all of this 
innovation is part of the Affordable Care Act. Are we going to repeal 
that, too? Are we going to repeal all those health care delivery 
reforms that are helping reduce the cost of health care?
  So what does repeal actually mean?
  I am taking it from two different sources here; that is, a full 
Republican repeal of the Affordable Care Act will increase the deficit 
by $350 billion over 10 years.
  Why does the Congressional Budget Office and the Committee for a 
Responsible Federal Budget say that? Why do they say that? Why would 
they make such a claim? Because they know that built into the 
Affordable Care Act are changes to the health care delivery system that 
improve access, focus on better outcomes, and change our system for the 
better. We cannot afford to repeal this as a way to try to say to our 
base: This is a better way of delivering health care.
  What does the Affordable Care Act come down to?
  The philosophy we pushed through is to put the patient at the center 
of the health care delivery system so that it works for them. The 
repeal attempt by the other side is nothing more than basically saying 
we are going to come up with a model where you are not at the center of 
this, you are going to get a check that no longer pays for your full 
health insurance costs, you are going to get capitated and so is 
Medicare and Medicaid--or at least that is all we can get out of the 
other side right now about their plans.
  It is very important to me that we do not repeal the Affordable Care 
Act and that we certainly don't repeal the Affordable Care Act without 
any idea what it is that we are going to be doing instead. We have 
millions of Americans who will not be covered, and we are going to 
throw away our whole system, which has managed to save private 
employers and individual families millions of dollars--I would say 
billions of dollars over the time period of this legislation and put us 
on the right track. If we have to make some changes and adjustments to 
the system, let's make some adjustments and changes to the system, but 
let's not throw out the entire legislation, and certainly let us not 
steal away the Affordable Care Act from the American people.
  Basically, that is what repeal is. Repeal is stealing away the 
affordability they have been granted over these last several years and 
instead taking it for some other corporate interest. I hope it is not 
to stuff it into a tax reform bill to give relief to corporate America 
because that is not what we need. We need a delivery system that works 
for everyone. We need to save those individuals by making sure there is 
a cost-effective health care option for them and the marketplace, and I 
look forward to seeing real and serious legislation--not a poster board 
but a solution.
  I love working with my colleagues who want to work on these ideas. I 
do. I will because this is a solvable problem. It is. We have shown 
that. We have enough results. We have to make some adjustments, but 
repealing is just stealing health care from hard-working Americans. I 
urge my colleagues to turn that down.
  I thank the Presiding Officer.
  I yield the floor.
  The PRESIDING OFFICER (Mrs. Capito). The Senator from Louisiana.
  Mr. CASSIDY. Madam President, I rise to address a very important 
issue in regard to the health care of our poorest Americans and discus 
my plan, the Medicaid Accountability and Care Act, or the MAC Act, 
which is also included in my ObamaCare replacement plan which would 
address the failings of our current Medicaid system. My colleague from 
Washington just extolled the virtues of ObamaCare. As she pointed out, 
Medicaid clearly is a major part of the ObamaCare kind of response so 
it is apropos I would follow.
  I wish to first tell you my perspective. I am a physician, and I had 
been working in a hospital for the uninsured for 25 to 30 years, until 
they blew it up. I saw prisoners, the uninsured, and Medicaid patients. 
You might say: Wait a second. Medicaid, it is insurance. Why would 
somebody with Medicaid insurance be seen at a hospital for the 
uninsured?
  It is because in my State, like in most others, Medicaid pays beneath 
the physician's cost of seeing a patient. To paraphrase Saint Paul, it 
is the illusion of coverage without the power of access.
  I will point out, the week ObamaCare passed, there was an article in 
the New York Times, written by a very respected journalist, Robert 
Pear, tracking a Medicaid patient in Michigan. The physician, the 
oncologist seeing her, had so many Medicaid patients, the oncologist 
was going bankrupt because she could not afford to pay her bills so she 
had to discharge the Medicaid patients from her practice.
  I followed up to find out what would happen, and 2 weeks after being 
discharged from this oncologist's practice, the patient died. This is 
Medicaid, which is so critical to the purported success of ObamaCare.
  Is it that we are not spending enough money; that maybe if we just 
spent a little bit more on Medicaid it would all be better.
  A study from MIT found that 60 percent--let me stop. The State of 
Oregon did an expansion of Medicaid so researchers from MIT and 
elsewhere went to study it. This study found that 60 percent of the 
dollars used for the Oregon Medicaid expansion went to institutions, 
not for patients--as little as, say, 20 percent to 40 percent--but as 
little as 20 percent of the money that was put toward the Medicaid 
Program actually was a benefit for the patient. Let me repeat this. As 
much as 60 percent went to benefit institutions, not patients. They 
also found that patients on Medicaid did not have improved outcomes. 
Think about this. We are giving everybody all of this coverage. It is 
supposedly wonderful. Yet when they went back 1 year later and 2 years 
and 3 years later and looked at the patients covered on Medicaid--
versus those who were not, those who continued to be uninsured--there 
were no better health outcomes among those who are on Medicaid.
  If we can't agree this is a program to reform, it is going to be hard 
to agree on anything.
  For those who are not familiar with Medicaid, let's talk a little bit 
about the program. Medicaid is a Federal-State program. The Federal 
Government provides a certain percentage--a different percentage for 
each State--but the State actually administers the program. In some 
States, the Federal Government pays 50 percent of the cost. It can go 
up as much as 75 percent of the cost. In Mississippi, they put up $25, 
they get $75. In a State such as New York, they would put up $50 and 
get back $50 so it is a 1-to-1.
  This open-ended financing structure is based solely on how much the 
State spends. I will agree with my colleague from Washington State. We 
should not reward States that spend incontinently. We should not reward 
States that just spend, but under Medicaid, the State is rewarded. The 
more it

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spends, the more it draws down from the Federal Government.
  I always smile when people speak about the economic development of 
Medicaid expansion. Medicaid expansion is not about economic 
development. It should be about taking care of patients, but I 
understand that perspective because they pull down at least $1 for 
every dollar the State spends, sometimes at the 75-percent ratio. Under 
the ObamaCare Medicaid expansion, States have been drawing down 100 
percent of what they spend. If the State is going to draw down 100 
percent of what it spends on the Medicaid expansion population--
surprise, surprise--they are actually spending at a higher rate on the 
expansion population than on those Medicaid patients for whom the State 
actually has to cover part of the cost.
  The Federal Government has very little ability to weed out the 
corruption of the inefficient programs. Again, this matching incentive 
disincentivizes States from looking for ways to be more efficient, but, 
still, States have to balance their budget every year and Medicaid is 
either the second largest or largest budget item in every State. Even 
though the Federal Government is paying 50 percent to 75 percent of the 
traditional Medicaid population and 100 percent of the expansion 
population, the State taxpayer is still on the hook for a lot. On 
average, States spend 17 cents of every State dollar on Medicaid. My 
State of Louisiana has the highest percentage. Nineteen percent of our 
budget goes to Medicaid. The percentage is steadily increasing, nearly 
doubling since 2000. Sooner or later, even though the Federal 
Government covers the majority of the cost, the budget crunch gets more 
difficult because the rate of Medicaid spending is climbing faster than 
the State tax base.
  Because of all the Federal requirements on what a State can change in 
the Medicaid Programs, in order to come up with the State match, States 
have two options. They can pay providers less or they can cut other 
programs such as education and move the money to the Medicaid Program.
  First, paying physicians less brings us back to the situation Robert 
Pear described in his New York Times article, where the oncologist was 
going bankrupt because she could not afford to see more Medicaid 
patients.
  Let's speak a little bit about education. I am just going to use my 
hands. In 1963, the State government used about that much for education 
and when Medicaid started in 1964 or 1965, about that much for 
Medicaid. In 2009, for the first time ever, on average, States spent 
more on Medicaid than on education. Now the percentage on Medicaid 
continues to climb, if you will, cannibalizing the State dollars that 
could be used to support higher education, primary and secondary 
education.
  Let's look at the effect of the ObamaCare Medicaid expansion. Let's 
look not at my own State but Kentucky, a State which has been at this 
for a little bit longer. The previous Governor, Governor Beshear, 
implemented the ObamaCare Medicaid expansion---just kind of traditional 
Medicaid--and expanded it.
  Again, my colleague from Washington State was extolling how much 
ObamaCare has lowered costs. When Kentucky originally implemented it, 
they expected the long-term cost of Medicaid expansion to be only a 4-
percent increase in their current State spending on Medicaid. After 
only 1 year of the expansion, updated projections showed the expansion 
cost the Federal Government more than half a billion dollars more than 
Governor Beshear had projected for 2014, and this will double in the 
coming years, meaning that the Medicaid expansion will cost $1 billion 
more per year than expected. Again, this was the projected cost. This 
is the actual cost.
  If this is saving money--oh, my gosh. What would happen if we 
actually lost money? By anybody's calculation, this is losing money. 
This has been the situation across the country. States that have 
expanded Medicaid have turned out to be far more expensive for the 
Federal taxpayer than originally anticipated. Again, it just isn't a 
Federal program. Like many other States across the Nation, Kentucky is 
facing serious fiscal issues. They do not have $1 billion lying around.
  On its current path, Kentucky's own projections suggest the State 
will start losing $45 million in perpetuity beginning in 2021. This is 
a 10-percent increase. The Federal Government is putting up most, but 
Kentucky itself will have to put up an extra $45 million per year.
  Also, given that the Federal taxpayer--you and me, us, the people 
watching on TV and in the Gallery--given that we, the Federal taxpayer, 
put up 90 percent of Kentucky's costs--well, every State's costs, we 
just happen to be speaking about Kentucky--but every State's costs are 
90 percent of the costs in perpetuity. As this cost grows, taxpayers 
are on the hook for 90 percent of it. Such a deal.
  It doesn't have to be this way. Let me compliment Indiana. When Vice 
President-Elect Mike Pence was Governor of Indiana, rather than 
adopting kind of ObamaCare's let's do the traditional Medicaid and 
watch the cost explosion--he took an innovative approach and created 
the Healthy Indiana Plan or HIP as an alternative to simply doling out 
the dollars. The plan gave each beneficiary a high-deductible plan in 
combination with a health savings account. It was capitated. Again, my 
colleague from Washington who just spoke kind of criticized these 
capitated plans, which means there is a set amount, and the person is, 
if you will, engaged in managing her dollars.
  The State will put up a certain amount on a sliding scale based upon 
the income of the Hoosier who enrolled. The plan empowered low-income 
enrollees to become better consumers of health care. Hoosiers who 
participated--for those not from Indiana, I have learned you don't say 
Indianans, you say Hoosiers. So Hoosiers who participated changed 
behaviors. They use 40-percent less charity care than traditional 
Medicaid patients. Seventy percent contributed to their own HSA. Once 
they started contributing, virtually all continued to do so regularly. 
That is despite 83 percent of those participants in the Healthy Indiana 
Plan earning less than the Federal poverty level. Those Healthy Indiana 
Plan patients also saw clear improvements in care over traditional 
Medicaid. They decreased their emergency room utilization by 40 percent 
relative to Medicaid's average. Thousands more physicians chose to take 
Medicaid patients. Remember, at the beginning, I discussed how 
physicians often can't see Medicaid patients. It pays them below the 
cost of their seeing patients. In Indiana, thousands more chose to take 
Medicaid patients, improving access to quality care. Clearly, the 
Healthy Indiana Plan was able to work for Indiana patients. This is the 
sort of quality innovation that States can devise if we give them the 
power.

  Now, revising the current funding structure would also encourage 
States to follow Indiana's example and develop innovative Medicaid 
programs to increase the efficiency in which the program spends money. 
Again, that is Federal taxpayer money. That is our money. For those 
watching right now, it is our money. We want to encourage States to be 
efficient with how they spend it. There should be greater flexibility 
to design the Medicaid program to better meet the needs of State 
residents. States will be given the latitude and the freedom to develop 
various coverage options and specialized delivery systems for different 
Medicaid patient populations.
  This is why I developed the Medicaid Accountability and Care Act, 
which we call the MAC Act. It reforms the flawed financing of Medicaid 
by giving each State a set amount according to how many people each 
State has enrolled in the different categories that each State's 
Medicaid program treats. That is a mouthful, but it is basically 
exactly like the Federal Employees Health Benefits Program or like any 
employer who goes to an insurance company and says: I want to give you 
a set amount of money per employee who enrolls in your plan. For that 
matter, it is like Medicaid managed care, where the State will go to a 
managed care company and give the managed care company a set amount per 
enrollee in that plan.
  Now, I hear people say: Oh, my gosh, it is a set amount. That is all 
we do in health care, except in Medicaid, where we reward inefficient 
spending. So if it is good enough for the State to do it to the 
Medicaid managed care program, why isn't it good enough for the Federal 
taxpayers to do it to the State? I

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am not quite sure I understand the critics of this approach.
  But, again, under the Medicaid Accountability and Care Act, or the 
MAC Act, each State would tell the Federal Government how many 
beneficiaries it has in different categories of Medicaid and the 
Federal Government would give each State the amount of money 
appropriate for that number of enrollees in each category. The 
advantage of this is it is a set amount. It allows the Federal 
Government to do that, which it does not do now; and that is, to say to 
the State government: If you recover fraud, you can keep that money.
  Now, let's go back. Under the current situation, the Federal taxpayer 
pays 50 to 75 percent of the State's Medicaid costs. If there is 
fraud--and there is lots of fraud in Medicaid--and the State government 
recovers it, it has to give back to the Federal taxpayers whatever the 
percent was the Federal Government put up. So if the State goes out and 
recovers $1 million--spends money on the attorneys, spends money on the 
investigation, on the court case, and it recovers $1 million--it has to 
give half a million to $750 million back to the Federal taxpayers. It 
is responsible for the prosecution, the investigation, but it gives 
most of the money back to the Feds. So the States don't investigate 
because it is a disincentive to go after fraud.
  Under the MAC Act, if the State goes out and gets $1 million worth of 
fraud, the State keeps the money. That is good for the State. It 
encourages the State to root out that fraud and to keep the money and 
to make sure that fly-by-night scam artists never get to become 
Medicaid providers in the first place.
  The MAC Act's reforms will result in improved health care for 
Medicaid patients.
  I will go back to where I started.
  I am a physician who worked in a hospital for the uninsured and 
Medicaid patients. These are my patients. If this proposal was not 
about improving patient care, I would not advance it. But recall that 
Oregon, with their Medicaid program, upon review by MIT, found no 
improvement in patient outcomes. Then let's go to Indiana, which 
actually set up health savings accounts and engaged the patient in 
managing their own health, and there, we do see better outcomes. We 
should all be about patients having better outcomes.
  Along the way, we do other things, such as equalizing the amount of 
money the Federal Government gives to each State per beneficiary. 
Again, my colleague from Washington State pointed out that folks in 
Washington get less money from the Federal Government than do other 
States. I would attempt to equalize that with the MAC Act.
  So let me finish. The American people have been voting against 
ObamaCare for the last 8 years. Whatever its proponents may say, the 
American people have found it wanting. One aspect of it that has been 
wanting is Medicaid. We have a proposal before us based upon my 
experience of treating patients in the hospital for the uninsured and 
Medicaid but also taking States like Indiana and elsewhere in which we 
attempt to give States the initiative to create specialized programs 
that focus on patient-centered care. In that way, we will see better 
outcomes. The current Medicaid funding system under ObamaCare works 
against States, penalizing them for addressing fraud, abuse, and waste. 
This must change. We need to change this broken framework with a system 
that will work with States to get their Medicaid programs back on 
track, benefiting their patients as much as possible.
  With that, I yield the floor.
  Madam President, I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The bill clerk proceeded to call the roll.
  Mr. CORNYN. Madam President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.


                      Nomination of Jeff Sessions

  Mr. CORNYN. Madam President, as my colleagues know, this week we will 
take up the nominations of the men and women who President-Elect Trump 
has selected for his Cabinet. I have to say, for myself, that looking 
at the quality of the people the President-elect has nominated gives me 
quite a bit of reassurance about what his administration will be like, 
starting with the Vice President, Mike Pence. Mr. Pence is somebody 
well known to those of us here in the Congress, having served 12 years 
in the House of Representatives, and then he went on to be the Governor 
of Indiana for 4 years. He is eminently qualified to help the 
administration and the President-elect navigate the perils and pitfalls 
of the legislative process here in the Senate and in the House.

  Then we look at the other people who have been nominated, whether it 
is for Secretary of State, Secretary of Defense, or the Department of 
Homeland Security. In some cases, they are unconventional choices, but, 
in every case I can think of, they are people who have eminent 
qualifications to offer to the administration and to the country in 
this new administration.
  This is one of the most important responsibilities a Senator has--to 
make sure we conduct the advice and consent process and make sure we 
vet the nominees for these important posts. But in one case in 
particular, it is not going to be all that hard because we have served 
alongside Senator Jeff Sessions, for 15 years in my case and for 20 
years in other cases.
  We should be working together, as President Obama himself has said, 
recognizing the importance of a smooth transition from the outgoing 
administration to the new one. That should be true no matter what side 
of the aisle you are on. Unfortunately, I think some of our Democratic 
friends are still in some shock from the election on November 8.
  I remember a book written on the grieving process, describing that 
first comes denial, then comes anger, and then ultimately acceptance. I 
think what our Democratic colleagues have to work through is their 
denial and anger to get to acceptance of the fact that President-Elect 
Trump and Vice President-Elect Pence won the election.
  So what is our responsibility? It is to work in a bipartisan basis to 
make sure that they have the people around them that they need in order 
to run the government.
  We are simply trying to stick to the same standard set under 
President Obama. In 2009, our Democratic colleagues held seven 
confirmation hearings in one day. That is more than we are planning to 
do on Wednesday. So my response to our friends across the aisle is to 
listen to the junior Senator from Connecticut, who told a reporter: ``I 
can figure out how to walk across the hall and attend two hearings 
occurring simultaneously.''
  One of the most important hearings, in my mind, we will hold is the 
hearing we are going to have in the Judiciary Committee starting 
tomorrow on the President-elect's nominee as Attorney General--our 
friend Senator Jeff Sessions. As I said, the junior Senator from 
Alabama has a lengthy history serving his State and country in law 
enforcement, but his passion for public service started long before 
that.
  Before we knew him in the Senate, Jeff Sessions was an Eagle Scout 
from Hybart, AL. He later served in the Army Reserves. After college, 
he taught at Goode Street Elementary School in Montgomery, AL. I bet 
even those of us who have known him a long time did not know that he 
taught at Goode Street Elementary School in Montgomery, AL, after 
college. Then he went on to become a lawyer, receiving his law degree 
from the University of Alabama. He later worked as a Federal 
prosecutor, including 12 years as a U.S. attorney for the Southern 
District of Alabama. Then--where I got to know him--he became his 
State's attorney general.
  Senator Sessions' record is one of a person not afraid to go after 
those who are abusing power. From State judges and senators to county 
commissioners and school board members, Jeff Sessions has rooted out 
and punished corrupt officials as was his job as a U.S. attorney. As 
U.S. attorney, he fought to secure the rights of African Americans to 
vote and successfully advocated to uphold the death penalty sentence of 
Ku Klux Klan member and murderer Henry Hays.
  Here in the Senate, he served on the Senate Judiciary Committee for 
20

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years, where I have come to know him well. Working with him has shown 
me not only his sharp mind but his passion for the people of this 
country and his commitment to the rule of law. He is a hard worker and 
a person who makes his decisions based on what he thinks is the right 
thing to do and his own integrity. I know many of us can attest to 
this, including my colleagues on the other side of the aisle. While 
holding true to his principles, Jeff Sessions has found common ground 
with folks across the ideological spectrum on many issues, including 
ones he will work on as Attorney General of the United States.
  For example, in 2003, Senator Sessions worked closely with the late-
Senator Teddy Kennedy, whom I have called the liberal lion of the 
Senate. Perhaps, I am not the first one, but he certainly was that. He 
was a larger-than-life personality and somebody who personified our 
political opposition across the aisle. But Jeff Sessions and Teddy 
Kennedy worked together to help fight sexual assault in prison in a way 
that was both proactive and pragmatic. Senator Sessions crafted 
legislation to encourage State governments to take affirmative measures 
that reduced the frequency of sexual assault in jails and prisons. We 
continue to see the benefits of this legislation today, as more and 
more States get serious and crack down on this crime. Last Congress, I 
was proud to work with Senator Sessions and Senator Leahy, the ranking 
member in the 114th Congress, and others in this Chamber, to pass the 
Justice for All Reauthorization Act, which created additional tools 
that strengthened the Prison Rape Elimination Act.
  Then there is the work Senator Sessions has done with the assistant 
minority leader, the Democratic whip, and the senior Senator from 
Vermont, two of this Chamber's more liberal Members, to address 
sentencing disparities between crack cocaine and powder cocaine. It 
became obvious over time that many people living in our inner cities 
were using crack cocaine, but their fellow countrymen living in more 
affluent areas caught with powder cocaine were subject to far lesser 
sentences than those in the inner cities using crack cocaine. The work 
Senator Sessions did with Senator Durbin and Senator Leahy, called the 
Fair Sentencing Act, was signed in to law by President Obama in 2010. 
Senator Sessions saw the harsh penalties many young African-American 
men experienced for possession of crack, compared to the lighter 
punishments given to suspects found with powder cocaine, who as a group 
tended to be more White or Hispanic. To me, this is the sort of thing 
that offends the most basic sensibilities of Jeff Sessions--somebody 
who believes unequivocally in color-blind justice and equal justice 
under the law. Of course, the utmost responsibility of the U.S. 
Department of Justice is to enforce the law and ensure equality for all 
Americans under our Constitution.
  Senator Sessions has demonstrated that he is qualified and prepared 
to serve as the Nation's top law enforcement officer--not only thanks 
to a proven track record but, because at his core, he understands the 
importance of justice for all and upholding the rule of law. Now, you 
don't have to take my word for it. Here is what some of our leading 
Democratic colleagues have had to say about working with Senator 
Sessions over the years:
  The incoming Democratic leader, Senator Schumer of New York, called 
Jeff Sessions ``straightforward and fair.''
  Senator Durbin, the Democratic whip, in June 2010, working with him 
to eliminate the disparity between crack cocaine and powder cocaine 
called Jeff Sessions ``a man of his word.''
  Then, perhaps, there is an unlikely person to compliment Senator 
Sessions, because of some of the positions Attorney General Holder took 
that I think Senator Sessions found objectionable--particularly when 
injecting too much politics into the work of the Department of Justice 
and not enforcing what Senator Sessions saw to be the rule of law. 
Nevertheless, former Attorney General Eric Holder on January 2016, 
2009, called Senator Sessions ``a great U.S. attorney.''
  Senator Sessions has both the temperament and experience to restore 
the faith of all Americans in our justice system, and we have the 
responsibility to grant him a fair confirmation hearing starting 
tomorrow. I suspect our Democratic colleagues agree, because in 2015 
they penned a letter that said:

       The Attorney General plays a pivotal role in administering 
     our nation's laws and protecting our national security. This 
     is why the Senate, regardless of the party in control, has 
     historically given swift consideration to Attorney General 
     nominees.

  Those were our Democratic colleagues. The chance to do so is right 
before all of us, and I hope they will assist us in a fair and swift 
confirmation process for a truly honorable and deserving candidate for 
Attorney General.
  I know we will miss Senator Sessions in the Senate. Not that we 
always agreed with him, but he always disagreed in the most congenial 
sort of manner and in a way that we knew he had respect for people of 
widely divergent views. But the fact is that our country needs him to 
lead the Department of Justice now more than ever.
  I yield the floor.
  The PRESIDING OFFICER (Mrs. Ernst). The Senator from Wyoming.
  Mr. ENZI. Madam President, I thank the Senator from Texas for his 
comments about the Senator from Alabama. Senator Sessions has been an 
outstanding Senator. He came to the Senate at the same time I did. He 
has served for 20 years. That is a lot of votes that a person can pick 
apart, if they want to. But here is how it came out. I don't think we 
have emphasized enough that Senator Sessions didn't have a primary 
opponent in Alabama. I don't know how many Senators in the Senate 
haven't had primary opponents. Even more unusual, he didn't have a 
general election opponent. I am not sure if that has happened before. I 
know it hasn't happened for a long time. But that says something about 
the kind of respect he has in his home State, which has a wide variety 
of people. So I thank the Senator for his comments on that.
  Madam President, I ask unanimous consent that following disposition 
of the Paul amendment, there be 2 minutes of debate, divided in the 
usual form, and that the Senate then vote in relation to the Hirono 
amendment No. 20.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. ENZI. Madam President, I yield the floor.
  The PRESIDING OFFICER. If no one yields time, the time will be 
divided equally.
  The Senator from Hawaii.


                            Amendment No. 20

  Ms. HIRONO. Madam President, I rise today to ask the Senate to adopt 
the Hirono-Donnelly amendment to protect Medicare and Medicaid. During 
his campaign, President-Elect Trump made the American people a promise 
that he will protect Medicare and Medicaid.
  Today, we are giving Senate Republicans an opportunity to reaffirm 
this promise to the American people, but I am deeply skeptical that 
they will do the right thing because they are committed to repealing 
the Affordable Care Act. Senate Republicans fought for years to repeal 
the Affordable Care Act, which would drastically cut Medicaid funding 
for the States, and the President-elect's nominee for Secretary of 
Health and Human Services is the architect of the Republican plan to 
privatize Medicare. The assault on the ACA is an assault on Medicare 
and Medicaid. Both of these programs can be dismantled through the 
language in the budget that Congress is debating right now.
  The President-elect and congressional Republicans might be willing to 
break their promise to the American people. Instead, I, along with my 
like-minded colleagues, will do whatever we can, whenever we can, to 
protect these social safety net programs.
  I am fighting for seniors like Anne and Lanny Bruder from Kauai. 
Lanny is 80 years old, but he is still working three jobs to make ends 
meet after losing the family home during the 2008 mortgage crisis. Anne 
has glaucoma and pays what she calls a ridiculous amount for eye drops. 
Lanny survived a heart attack and has two artificial knees.
  Like many of our kupuna--or seniors--living on a fixed income, they 
simply could not afford the extra $6,000

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a year they would be forced to pay if Republicans succeed in their 
effort to privatize and voucherize Medicare.
  I am also fighting for young people like Anne, who walked into the 
Kokua Kalihi Valley Clinic 3 years ago. She had no health insurance, 
and she was pregnant at the age of 15. The doctors at the clinic helped 
Anne apply for Medicaid, which helped her afford prenatal care and gave 
her support to stay healthy and, very importantly, to stay in school. 
Medicaid helped Anne and her husband Dan, age 17, welcome a healthy 
baby boy named Joseph. Today Anne is a graduate of Farrington High 
School, works part time, and has plans to become a pediatric nurse 
practitioner. Anne, Dan, and Joseph now have insurance through Dan's 
employer.
  These stories--and there are thousands of similar stories in Hawaii--
demonstrate just how important Medicare and Medicaid are to millions of 
people across the country. It is why we are fighting tooth and nail to 
prevent any cuts that would jeopardize these social safety net 
programs.
  The Hirono-Donnelly amendment would prevent any partisan attempt to 
harm Medicare and Medicaid. Specifically, it would block congressional 
Republicans from using budget reconciliation to privatize Medicare or 
increase eligibility standards. It would also prevent changes to 
Medicaid that reduce State funding from current levels.
  Adopting this amendment would send a clear message to seniors and 
working families that Congress is serious about protecting their access 
to quality, affordable health care.
  I urge all of my colleagues to support the Hirono-Donnelly amendment.
  I yield the floor to Senator Donnelly.
  The PRESIDING OFFICER. The Senator from Indiana.
  Mr. DONNELLY. Madam President, I rise today in support of the 
amendment Senator Hirono and I are offering to protect Medicare and 
Medicaid for the millions of Americans who currently count on these 
programs for health coverage.
  This week, some of our colleagues are beginning the process of 
repealing the health care law. I want to be clear. I don't think it is 
a perfect law. In fact, I have long agreed with many of my colleagues 
in saying it has work to do, and for years we put forward ideas on ways 
we can work together to improve it.
  The repeal strategy we are debating this week, however, is not about 
improving the health care system. It is about taking people's health 
care away. And make no mistake, the consequences are very real. A 
repeal strategy, particularly with no alternative, would throw our 
health care system into chaos, taking away coverage from nearly 30 
million people, increasing premiums on working Hoosiers and families 
across this country, and threatening to take us back to a time where 
anyone with a preexisting condition could not get coverage.
  It doesn't have to be this way. If we are serious about improving 
health care in this country, we can do this work together. That is what 
the American people expect. Just as Hoosiers go to work every day to 
make life better for their families, they expect us to come to work and 
do the same thing. At the very least, they expect us to do no harm. 
Doctors swear by the Hippocratic Oath, where they pledge first and 
foremost to do no harm when they are treating patients. We should 
appreciate this. We should approach this debate in the same manner. Do 
no harm. That is the basis of the Hirono-Donnelly amendment.
  ``Do no harm'' means not cutting Medicare benefits or turning it into 
a voucher program. ``Do no harm'' means protecting the health care of 
those who use the Medicaid program, many of whom have health care for 
the first time.
  Here is what we know: Repealing the health care law reduces 
Medicare's insolvency by 5 years to 2021. We know that some in 
Congress, including the nominee to run the Department of Health and 
Human Services, are intent on privatizing Medicare or turning it into a 
voucher program, ending the program as we know it.
  The Hirono-Donnelly amendment makes it clear that we will not 
privatize Medicare. The amendment protects Medicare both for the 
seniors who count on the program to age in dignity and for the tens of 
millions of Americans who are contributing to the program with the 
expectation that it will be there when they retire.
  ``Do no harm'' also means we will protect insurance coverage for 
those who get their care through the Medicaid program, which, after the 
passage of the health care law, enabled millions of our friends and our 
neighbors to access affordable coverage for the first time in their 
lives. I know this is true because I worked with and supported our 
soon-to-be Vice President, Mike Pence, when he used ObamaCare to 
establish a program we call the Healthy Indiana Plan, or HIP 2.0. The 
innovative plan expanded health care coverage to over 200,000 of my 
neighbors in our beloved State and helped reduce the uninsured rate 
among Hoosiers by 30 percent. The HIP 2.0 program has been critical in 
our ongoing effort to provide treatment to those struggling with opioid 
abuse and heroin use in our State. Don't just take my word for it. In 
his farewell address as Governor to Hoosiers yesterday, Mr. Pence said:

       Our innovative Healthy Indiana Plan is a national model of 
     how to provide affordable health care coverage to our most 
     vulnerable citizens. . . . With HIP 2.0, we have also made 
     great strides expanding treatment for those who struggled in 
     the grip of drug addiction.

  I agree with the Vice President-elect that HIP 2.0 is something we 
can be very proud of because it helps Hoosier families across our State 
every single day. And it was done by working together, Republicans and 
Democrats, using the health care law to provide access to our friends 
and neighbors who wouldn't be able to obtain insurance otherwise. That 
is a great result.
  The repeal plan before us today takes all of this away, including the 
very program that Vice President-Elect Pence and I worked to put in 
place. The amendment Senator Hirono and I put forth is simple. It says 
to seniors and to people participating in HIP 2.0 and Medicaid plans 
across the country: We will do no harm.
  I am happy to work with anyone to strengthen the health care law, but 
we are not going to take away the health care people have come to rely 
on. I urge my colleagues to support the Hirono-Donnelly amendment. 
Instead of going forward with a plan that creates chaos by repealing 
the health care law with no alternative, we should work together to 
improve it. That is just common sense. Most of all, we should strive to 
do no harm. That should be our guiding principle in the Senate. My 
colleagues on both sides of the aisle can demonstrate their commitment 
to this principle by supporting our amendment.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Hawaii.
  Ms. HIRONO. Madam President, I would like to reclaim the time that 
Democrats have to talk about the Hirono-Donnelly amendment. We are 
expecting some of our colleagues to be here. I see Senator Blumenthal.
  Thank you.
  The PRESIDING OFFICER. The Senator from Connecticut.
  Mr. BLUMENTHAL. Madam President, I am proud to join my colleagues 
Senators Hirono and Donnelly. I thank them for their very impressive 
and steadfast efforts on behalf of Medicare and Medicaid, during a time 
of tremendous uncertainty in our health care system, as, unfortunately, 
our friends on the other side of the aisle work toward repeal of the 
Affordable Care Act without any replacement and any clear plan on what 
the alternative will be.
  Not only would repeal of the Affordable Care Act impact children and 
families but most particularly our seniors who have worked hard and 
have earned the benefits of Medicare. Any additional changes to the 
program that have been previously suggested by Republicans, whether 
changing the eligibility age or privatization, have no place in a 
reconciliation that has not been fully debated by the House and Senate 
and without a hearing from constituents and stakeholders about what 
those changes would mean.
  That is why we are here in support of the very important amendment 
offered by my colleagues. The Congressional Budget Office has estimated 
that full repeal of the ACA would increase Medicare spending by $802 
billion from 2016 to 2025. This increase in potential

[[Page S135]]

spending could lead to higher Medicare premiums, deductibles, and cost 
sharing for beneficiaries.
  Medicare, as it stands, as we all know, benefits our Nation's seniors 
who have worked hard and earned this program, but they would rather 
privatize or gut the program. So this action really should be decided 
not under reconciliation but by a 60-vote margin after hearings and an 
opportunity to be heard for our constituents.
  Similarly, any replacement plan must not include fundamental or 
restrictive changes to the Medicaid Program. The bottom line is, 
Medicaid continues to work to provide potential health care to our most 
vulnerable citizens. I come from a State that is truly making a 
commitment to make sure our Medicaid Program works. In fact, 
Connecticut was the first State to take advantage of the Medicaid 
expansion in the Affordable Care Act, allowing the State to cover 
72,000 more of our people in the State of Connecticut.
  In Connecticut, the State has also utilized existing flexibility in 
the Medicaid Program to improve outcomes through the patient-centered 
medical home. As a result, in 2016, Medicaid hospital admissions 
decreased by 5.4 percent, emergency department visits fell 4.3 percent, 
and people requiring intensive case management saw a reduction of 
hospital inpatient admissions of nearly 40 percent.
  These statistics are of staggering scope and scale and profoundly 
significant. We cannot make mean-spirited changes to the Medicaid 
Program, such as block granting, that would weaken the safety net, and 
we cannot allow gutting Medicare, endangering millions of seniors. We 
will not allow it without a fight. I am determined to join my 
colleagues in working and fighting for this amendment and keeping the 
pressure on our colleagues who disagree.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Oregon.
  Mr. WYDEN. Madam President, I am very pleased to be able to join 
Senator Donnelly, Senator Hirono, and Senator Blumenthal on this 
extraordinarily important issue that goes right to the heart of what we 
want health care to be in this country. I have always felt that the 
really big issues, the really important issues, need to be bipartisan. 
You need to find a path to some common ground.
  As Senator Donnelly and our colleagues have pointed out, what is 
being discussed now is an inherently partisan process for dealing with 
one of the most sensitive and most important issues of our time; that 
is, Medicare and what it represents. I had a chance to listen to 
Senator Donnelly and Senator Hirono discuss this issue. It made me 
recall my days when I was director of the Oregon Gray Panthers, the 
senior citizens group. I was director of the group for almost 7 years 
before I was elected to Congress. This was back in the days when I had 
a full head of hair and rugged good looks.
  We always talked about Medicare being a promise. It was a promise of 
guaranteed benefits. They were going to be there. They were going to be 
secure. They were going to be defined. In effect, all who supported 
Medicare said they would oppose unraveling that promise, unraveling 
that pledge of guaranteed benefits. It seems to me, without strong 
legislation, the kind of legislation my colleagues are advocating, we 
are putting that promise at risk.
  I think when you look back at the history of what was available for 
older people before Medicare, you would see why this promise and this 
pledge is so important. For so many older people, there was, 
essentially, what amounted to poor farms. We had one not far from where 
we lived at home in Oregon. When Medicare was being debated, people 
brought out those pictures. They talked about what it meant, in a 
country as strong and good and rich as ours, for older people not to 
have a life of dignity and security and decent health care.
  When Medicare was adopted in 1965, it was all about the promise. It 
was all about the guarantee. That is what Senator Donnelly and Senator 
Hirono are standing up for as part of this debate. I know that some who 
don't share our view are going to say: Well, there are tremendous 
challenges with respect to Medicare. There is no question about that--
10,000 people turning 65 every day for years and years--but there is so 
much that can be done, Democrats and Republicans, if you want to reject 
something that is partisan like reconciliation and come together. You 
can come together around updating the Medicare guarantee. I say this to 
my friends Senator Donnelly and Senator Hirono, who have done such good 
work on this.

  We are not saying there aren't any challenges. The fact is that 
Medicare today in 2017 is very different than Medicare when it began in 
1965. It is dominated by chronic illness: cancer, diabetes, heart 
disease. But we can come up with fresh, practical approaches for 
dealing with those challenges, consistent with what Senator Donnelly 
and Senator Hirono are talking about, which is keeping the Medicare 
promise, keeping the Medicare guarantee, not allowing the program to be 
privatized.
  We started on that with the Affordable Care Act. There were a number 
of us in the Senate. Senator Isakson was very involved. At the time, 
Senator Markey was a Member of the other body. We advocated for 
something called Independence at Home, which allowed the Medicare 
Program to begin to take care of those with chronic illness at home.
  So I am very appreciative of what Senator Donnelly and Senator Hirono 
are doing because what they are saying is this: Instead of gambling on 
the health of older people with a partisan reconciliation process, 
let's work in a bipartisan way to build on the promise of Medicare, the 
promise of those guaranteed benefits.
  We can do that. We can do that by creating more options for caring 
for older people at home. We can do it by expanding telemedicine and 
using new technology. We can do it by creating more opportunities for 
nonphysician providers. These are all ways that we can build on the 
Medicare promise and the Medicare guarantee and deal with the 
challenges of our time. But we are not going to be able to deal with 
those challenges through partisan approaches like reconciliation that 
would privatize the program and unravel the promise.
  So I am very pleased to be able to have a chance to be out on the 
floor with my colleagues who have been strong advocates for Medicare, 
who rightly put this issue front and center in the debate, because I 
think a lot of what is being discussed is really getting lost. A big 
part of this debate really seems to be about creating a Trojan horse to 
give tax cuts to some of the most fortunate, while, in effect, raising 
health care costs for millions of others and breaking the Medicare 
promise, which is what my colleagues are seeking to protect in their 
amendment No. 20.
  We are going to be talking more about this. Certainly, as the senior 
Democrat on the Senate Finance Committee, we will be having significant 
debates about these issues in the committee. But I am very appreciative 
that Senator Donnelly and Senator Hirono have allowed us to jump-start 
what this debate is really all about; and that is, keeping the promise 
of Medicare, keeping the promise of guaranteed benefits, working in a 
bipartisan way to update the guarantee to deal with chronic illness and 
improve options for home care. I commend them both for their good work.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Alaska.


                       Tribute to Ernestine Hayes

  Mr. SULLIVAN. Madam President, I want to talk a little bit about 
Alaska this afternoon. Alaska is a beautiful State. Anyone who has 
visited knows that. Those who have watched any of the numerous 
television shows featuring my State know that. We have the mountains 
that seem to go on forever, fish-filled rivers and streams and oceans, 
miles and miles of beautiful tundra, calving glaciers.
  People save their whole lives to take a trip to Alaska, to see the 
wildlife, to see the bears, the salmon in the wild. There is no doubt 
Alaska is physically beautiful, but for those of us who live there, the 
true beauty of our State comes from our people. From our urban areas to 
the hundreds of smaller towns and small villages that dot our State, we 
have so many great citizens doing so many great things throughout all 
of our communities.

[[Page S136]]

  What I want to do is to recognize some of our citizens and tell their 
stories. So every week I will be doing that. Every week I will be 
recognizing an Alaskan who has made a special contribution to our great 
State and great Nation. For the kickoff of the Alaskan of the Week, I 
think it is appropriate to recognize a storyteller.
  Narratives keep the people in my State connected to one another. They 
keep history and culture alive in our great State. That is what Juneau 
resident Professor Ernestine Hayes does for us in her writing. 
Professor Hayes was recognized by the Alaska Humanities Forum and the 
Alaska State Council on the Arts as the current Alaska State Writer 
Laureate.
  The recognition is well deserved. Professor Hayes teaches writing at 
the University of Alaska Southeast and is the author of two 
extraordinary award-winning memoirs, the ``Blonde Indian,'' and the 
``Tao of Raven.'' Her books chart her unique experiences of growing up 
in Juneau as a Tlingit at a time when Alaska Natives were denied basic 
rights and ``No Native'' signs were common on storefronts.
  Her career as a writer and a teacher began in her fifties. Living the 
principle that learning should be a lifetime passion, she graduated 
from the University of Alaska Southeast--magna cum laude, I might add--
when she was 55 years old. In between, she moved to California, where 
she struggled to find purpose, and, as she put it, she was determined 
to go back home to Alaska or die facing north.
  Thankfully, for us, she made it back home. In the ``Tao of Raven,'' 
she weaves in the story of Raven and the box of light. Professor Hayes 
writes about the importance of giving back to the community. ``Although 
Raven could well have decided to keep light and luster and blinding 
brilliance for only his own pleasure,'' she writes, ``he knew that to 
keep riches to oneself guarantees their decline.''
  I congratulate Professor Hayes for being chosen as our State's Writer 
Laureate and our first inaugural Alaskan of the Week. Thank you, 
Professor Hayes, for sharing your blinding brilliance.
  I yield the floor.
  Mr. WYDEN. I suggest the absence of a quorum.
  The PRESIDING OFFICER (Mr. Moran). The clerk will call the roll.
  The senior assistant legislative clerk proceeded to call the roll.
  Mr. PAUL. Mr. President, I ask unanimous consent that the order for 
the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The Senator from Kentucky.


                            Amendment No. 1

  Mr. PAUL. Mr. President, tonight we will vote on a conservative 
budget that balances within about 5 years and saves the country from 
trillions of dollars of new debt.
  This budget that will be presented as an alternative also allows us 
to repeal ObamaCare at the same time. We have taken the identical 
language from the underlying budget, put it into the replacement 
budget, but we have done something different. Instead of allowing 
spending to continue to grow unabated, instead of allowing spending to 
grow at such a rate that we will add $9.7 trillion to the debt, we do 
something novel--something that I consider to be the conservative 
vision for our country. We actually freeze spending. We just say: no 
more spending. Interestingly, the budget will balance. The country's 
budget would actually balance, and we wouldn't add $9.7 trillion if we 
simply freeze spending. I think there is something in my version of the 
budget for both Republicans and Democrats because mine calls for a 
freeze in spending but would allow the different Appropriations 
subcommittees to decide where the spending would be cut.
  So, for example, if you decided that we needed more military spending 
but you thought that maybe we could spend less on corporate welfare, 
you might cut out the Department of Commerce. You might not know it 
once we did it. You might not know that the Department of Commerce 
really could be eliminated and you really wouldn't notice that it was 
gone.
  We look at the budget and we look at the spending every year, and we 
recount all of these terrible wasteful episodes of spending. Yet they 
never get fixed. Why? Because we continue to give government more 
money. The current budget that we will vote on will increase spending 
at about 5 percent a year.
  You will hear from people this ``Washingtonese''--this language that 
says: Well, we are just holding to the baseline. All this is the 
baseline. Son, just vote for the baseline. Jump on the team and vote 
for the baseline. The problem is that the baseline is not flat. The 
baseline is inclined, and that increase in spending every year is what 
is bankrupting the country. Spending is going up 5 percent a year. That 
is what the baseline is. So when people say that we are going to cut 
trillions of dollars or this is a frugal budget, they are talking about 
cutting spending from the proposed increases in spending.
  To illustrate that, the budget I am offering isn't even a cut of any 
kind. It is a freeze. Has anybody in America ever had their income 
frozen? Has anybody in America ever had to take a cut? Why shouldn't 
government? Why shouldn't we force government to look at their finances 
and say: You know what, this spending is good, and this is not so good.
  I will give you an example. We spent $700,000 last year studying Neil 
Armstrong's statement on the moon. Neil Armstrong landed on the moon 
and said: ``That's one small step for man, one giant leap for 
mankind.'' Your government, in its infinite wisdom, spent $700,000 to 
study that to determine whether Neil Armstrong said ``one small step 
for a man'' or ``one small step for man.'' After spending $700,000, 
your government concluded that they still don't know.
  They spent $500,000 studying selfies. If you take a selfie of 
yourself and you smile, will you feel better later? They spent $2 
million studying whether or not if you are standing in a food line at a 
buffet and the guy in front of you sneezes on the food, are you more or 
less likely to eat the food.
  You can't make this stuff up. Yet the budget that we are being 
offered does nothing to fix any of that. It just puts a stamp down and 
says: We are going to keep doing things the same way we have always 
done them. Well, my friends I think we should do things differently.
  I think a $20 trillion debt is alarming. I think it is the No. 1 
problem we face as a country, and someone ought to do something about 
it. So I didn't have much luck saying: You know what, guys, we should 
produce a balanced budget.
  So what we got is $9.7 trillion, and I can't support that. So I offer 
an alternative for people who believe that debt is a problem. They can 
vote for my alternative, and it still maintains the exact same language 
that the underlying budget has for repealing ObamaCare. You can do 
both. Why should it be an either/or? Why should it be that, well, we 
have to vote for a crummy budget, but that is the only way we can get 
to ObamaCare. Why don't we vote for a budget that balances? I thought 
that was what we were for.
  I remember a time when Republicans talked about not only freezing 
spending, but some actually said we should reduce the size and scope of 
government. That is what Ronald Reagan said. Yet government grows 
inexorably. Over and over, year after year, government grows. We had 
Republicans in charge about 10 years ago. Remember? George W. Bush was 
President. We controlled, I think, both branches for at least one 
period of time, and yet the debt doubled under George W. Bush's 
administration from $5 trillion to $10 trillion. Under President Obama, 
it has gone from $10 trillion to $20 trillion. Now you have Republicans 
saying: Put us in charge. Put us in charge of the House. You did, in 
2010. Put us in charge of the Senate. You did, in 2017. Put us in 
charge of all three branches, and we will make a conservative vision 
for the country. We will balance budgets. We will reduce spending. Yet 
this is an all-Republican Congress where only Republicans will vote on 
the budget today, and yet we will be voting on a budget that will add 
$9.7 trillion.
  I am told by some: This really isn't a budget; we are going to call 
it the vehicle to repeal ObamaCare.
  That is not what it is called. It is sitting right here. It is called 
the concurrent resolution on the budget for 2017--because, whoops, we 
didn't get to it last year, but we are getting to it this year.

[[Page S137]]

  This is the budget. It does have numbers in it, and I think the 
numbers in the budget are of significance. I think, when we look at the 
numbers, we should make them mean something. But people say to me: 
Well, numbers don't mean anything. Just vote for it so we can repeal 
ObamaCare. We have to repeal ObamaCare. So just vote for the numbers, 
no matter what they are.
  I guess my response is this: If the numbers don't mean anything, why 
don't we put good numbers in there? If the budget is inconsequential 
and means absolutely nothing and only Republicans are going to vote for 
it, why don't we put numbers in it that lead to balance, because then 
we can go home to the people who voted for us and said they wanted us 
to balance the budget and wanted us to restrain ourselves and we can 
say we did what you told us to do. Instead, I have to go home and tell 
people that the Republicans introduced a budget that allows $9.7 
trillion. I am told that we are going to do a better job, and 3 or 4 
months from now we will do it again. I fear that in 3 or 4 months, when 
we come back, they will say: Well, you already voted for it once. Why 
don't you vote for it again? It is the same thing you voted for last 
time, and it is just a baseline. Well, the baseline is not flat. The 
baseline is increasing at 5 percent a year, and that is a problem.
  We have to look at spending across the board. All of the spending has 
to be looked at. The great thing about what I offered as an alternative 
is that, whether you are a liberal or conservative, it doesn't define 
exactly where you have to have the cuts come from. It says what the 
overall number will be, and it will keep us from increasing spending. 
What you could do to get to a freeze is you could cut or eliminate some 
parts of the government, like maybe the $700,000 we spent studying Neil 
Armstrong's statement, which could be eliminated completely, and maybe 
the $30 billion we spend on corporate welfare in the Department of 
Commerce. Maybe that can be eliminated and not one poor person would go 
hungry. Maybe a couple of rich CEOs will have to fly in their own jet 
instead of flying in a taxpayer jet when they are flying around the 
world. You could eliminate the Department of Commerce and you could 
keep spending for other items. If you think the military is bloated, 
you can actually cut money in the military and spend it on other items 
in the budget.
  The bottom line is, if you vote for this amendment, you will be 
voting for fiscal conservatism that says: Enough is enough. We have a 
$20 trillion debt. We are borrowing $1 million a minute, and enough is 
enough. If you are a fiscal conservative, if you are worried about the 
debt of the country, I hope you will support my amendment, which 
replaces the underlying budget with a Federal on-budget spending freeze 
and actually leads the budget into balance in the near future.
  Thank you, Mr. President.
  The PRESIDING OFFICER. The Senator from Wyoming.
  Mr. ENZI. Mr. President, it is my understanding there is 2 minutes 
equally divided between the proposer and the opposition.
  The PRESIDING OFFICER. Who yields time?
  The Senator from Kentucky.
  Mr. PAUL. Mr. President, I propose the Senate vote for this budget 
because it leads to balance, it is fiscally conservative, it allows the 
Senate and the Congress to decide where money will be spent and where 
it will not be, it will eliminate waste, and--above all--will get us on 
the right track toward eliminating or at least staying the expansion of 
a $20 trillion debt. I think this is the biggest problem we face as a 
country.
  As much as I think ObamaCare is a mistake, just ignoring the debt to 
get to ObamaCare is also a mistake.
  For those who are or claim to be fiscally conservative, I ask that 
you will consider voting for a budget that actually balances and 
continues to have the underlying language in it that would also allow 
us to repeal ObamaCare.
  The PRESIDING OFFICER. The Senator from Vermont.
  Mr. SANDERS. Mr. President, I begin by thanking Senator Paul. He has 
shown a lot of courage for standing and exposing the hypocrisy of the 
Republican budget resolution.
  Year after year, we have heard from our Republican colleagues that 
the United States is going broke, that we have huge deficits, that we 
have a $19 trillion national debt, that we have to cut Social Security, 
we have to cut Medicare, we have to cut Medicaid, we have to cut 
funding for education, we have to deal with the deficit.
  As Senator Paul has indicated, if the Republican budget resolution 
passes, the Federal deficit would more than double over the next 
decade, going from $571 billion this year to over $1.3 trillion 10 
years from now.
  I hope all of the deficit hawks on the Republican side hear what 
Senator Paul has to say and support him.
  I will not support him because I understand that the cuts that he is 
proposing are devastating to working families, to the elderly, to the 
children, to the sick, and to the poor. They would mean massive cuts in 
Medicare, Medicaid, Federal aid to education, and a variety of programs 
people desperately need, so I will oppose the amendment.
  All of my Republican friends who talk about the deficit year after 
year, here is a vote you should cast.
  Thank you.
  The PRESIDING OFFICER. The time of the Senator has expired.
  The question is on agreeing to the amendment.
  Mr. PAUL. Mr. President, I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be a sufficient second.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. CORNYN. The following Senators are necessarily absent: the 
Senator from Missouri (Mr. Blunt), the Senator from South Carolina (Mr. 
Graham), and the Senator from North Carolina (Mr. Tillis).
  The PRESIDING OFFICER (Mr. Lankford). Are there any other Senators in 
the Chamber desiring to vote?
  The result was announced--yeas 14, nays 83, as follows:

                       [Rollcall Vote No. 3 Leg.]

                                YEAS--14

     Crapo
     Cruz
     Daines
     Flake
     Kennedy
     Lankford
     Lee
     Moran
     Paul
     Risch
     Rubio
     Sasse
     Scott
     Toomey

                                NAYS--83

     Alexander
     Baldwin
     Barrasso
     Bennet
     Blumenthal
     Booker
     Boozman
     Brown
     Burr
     Cantwell
     Capito
     Cardin
     Carper
     Casey
     Cassidy
     Cochran
     Collins
     Coons
     Corker
     Cornyn
     Cortez Masto
     Cotton
     Donnelly
     Duckworth
     Durbin
     Enzi
     Ernst
     Feinstein
     Fischer
     Franken
     Gardner
     Gillibrand
     Grassley
     Harris
     Hassan
     Hatch
     Heinrich
     Heitkamp
     Heller
     Hirono
     Hoeven
     Inhofe
     Isakson
     Johnson
     Kaine
     King
     Klobuchar
     Leahy
     Manchin
     Markey
     McCain
     McCaskill
     McConnell
     Menendez
     Merkley
     Murkowski
     Murphy
     Murray
     Nelson
     Perdue
     Peters
     Portman
     Reed
     Roberts
     Rounds
     Sanders
     Schatz
     Schumer
     Sessions
     Shaheen
     Shelby
     Stabenow
     Sullivan
     Tester
     Thune
     Udall
     Van Hollen
     Warner
     Warren
     Whitehouse
     Wicker
     Wyden
     Young

                             NOT VOTING--3

     Blunt
     Graham
     Tillis
  The amendment (No. 1) was rejected.


                            Amendment No. 20

  The PRESIDING OFFICER. Under the previous order, there will now be 2 
minutes of debate equally divided prior to a vote in relation to 
amendment No. 20 offered by the Senator from Vermont, Mr. Sanders, for 
the Senator from Hawaii, Ms. Hirono.
  Who yields time?
  The Senator from Hawaii.
  Ms. HIRONO. Mr. President, I rise today to urge my colleagues to vote 
for amendment No. 20. What this amendment does is to protect Medicare 
and Medicaid in a way that will help millions of people in our country, 
and it comports with President-Elect Trump's promise to protect 
Medicare, Social Security, and Medicaid. So I urge my colleagues to 
vote for amendment No. 20.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Wyoming.
  Mr. ENZI. Mr. President, this amendment is corrosive to the privilege 
in the budget resolution, meaning that it is outside of the scope of 
what is appropriate for a budget resolution. Any inappropriate 
amendment could be fatal to the privilege of this resolution, which 
would destroy our efforts to repeal ObamaCare. In other words, a vote

[[Page S138]]

in favor of this amendment is a vote against repealing ObamaCare.
  In addition, this amendment is not germane to this budget resolution. 
This budget resolution is much more focused than a typical budget 
resolution. The Congressional Budget Act requires that amendments to a 
budget resolution be germane. Since this amendment does not meet the 
standard required by budget law, a point of order would lie against it; 
as such, I raise a point of order under section 305(b)(2) of the 
Congressional Budget Act of 1974.
  The PRESIDING OFFICER. The Senator from Hawaii.
  Ms. HIRONO. Mr. President, pursuant to section 904 of the 
Congressional Budget Act of 1974, I move to waive section 305(b) of 
that act for purposes of the pending amendment, and I ask for the yeas 
and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be a sufficient second.
  The question is on agreeing to the motion.
  The clerk will call the roll.
  The bill clerk called the roll.
  Mr. CORNYN. The following Senators are necessarily absent: the 
Senator from Missouri (Mr. Blunt), the Senator from South Carolina (Mr. 
Graham), and the Senator from North Carolina (Mr. Tillis).
  Mr. DURBIN. I announce that the Senator from Delaware (Mr. Carper) is 
necessarily absent.
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The yeas and nays resulted--yeas 49, nays 47, as follows:

                       [Rollcall Vote No. 4 Leg.]

                                YEAS--49

     Baldwin
     Bennet
     Blumenthal
     Booker
     Brown
     Cantwell
     Cardin
     Casey
     Collins
     Coons
     Cortez Masto
     Donnelly
     Duckworth
     Durbin
     Feinstein
     Franken
     Gillibrand
     Harris
     Hassan
     Heinrich
     Heitkamp
     Heller
     Hirono
     Kaine
     King
     Klobuchar
     Leahy
     Manchin
     Markey
     McCaskill
     Menendez
     Merkley
     Murphy
     Murray
     Nelson
     Peters
     Reed
     Sanders
     Schatz
     Schumer
     Shaheen
     Stabenow
     Tester
     Udall
     Van Hollen
     Warner
     Warren
     Whitehouse
     Wyden

                                NAYS--47

     Alexander
     Barrasso
     Boozman
     Burr
     Capito
     Cassidy
     Cochran
     Corker
     Cornyn
     Cotton
     Crapo
     Cruz
     Daines
     Enzi
     Ernst
     Fischer
     Flake
     Gardner
     Grassley
     Hatch
     Hoeven
     Inhofe
     Isakson
     Johnson
     Kennedy
     Lankford
     Lee
     McCain
     McConnell
     Moran
     Murkowski
     Paul
     Perdue
     Portman
     Risch
     Roberts
     Rounds
     Rubio
     Sasse
     Scott
     Sessions
     Shelby
     Sullivan
     Thune
     Toomey
     Wicker
     Young

                             NOT VOTING--4

     Blunt
     Carper
     Graham
     Tillis
  The PRESIDING OFFICER. On this vote, the yeas are 49, the nays are 
47.
  Three-fifths of the Senators duly chosen and sworn not having voted 
in the affirmative, the motion is rejected.
  The point of order is sustained and the amendment falls.
  The PRESIDING OFFICER. The Democratic whip.
  Mr. DURBIN. Mr. President, there was debate on the Senate floor that 
went on for years. It was a personal thing, a personal issue with two 
Senators--one was a Republican, the other a Democrat. The Republican 
was Senator Pete Domenici of New Mexico. The Democrat was Senator Paul 
Wellstone of Minnesota. The two of them had teamed up with a very 
simple goal in mind. They wanted to make sure every health insurance 
policy in America covered mental illness.
  When you think about the fact that so many Americans suffer from some 
form of depression and that mental illness is something that so many 
families--at some point or another--face, you wonder: Well, why didn't 
the health insurance policies cover mental illness? The reason, of 
course, was that it takes some extended, and oftentimes expensive, care 
to help those with mental illness. In other cases, there was an 
argument made that you will not find a cure.
  Things have changed a lot in the world of mental illness over the 
last few decades and changed for the better. There are new medications 
that are available and some even better ones on the way. There is new 
treatment available and more hope for people. Pete Domenici, a 
Republican from New Mexico, and Paul Wellstone, a Democrat from 
Minnesota, did not give up. They insisted on it, and they won.
  They won with the requirement that health insurance policies cover 
not just mental illness and treatment but also substance abuse 
treatment. I will be honest with you. I followed that debate closely. I 
did not pay that much attention, at the time, to the substance abuse 
treatment part of their effort. Now I have. I think many people across 
America have. There was a supplement in the Chicago Sun Times this 
morning, published by USA TODAY. It is entitled ``Obamacare repeal 
jeopardizes mental health, addiction coverage.''
  I tore it out of the paper on the airplane to bring it to the floor 
of the Senate because this a good day for us to reflect on what this 
article has to say. We are now in the midst of the budget resolution 
effort that is designed by the Republican majority to repeal ObamaCare.
  The Republicans hate ObamaCare. They hate it almost as much as the 
devil hates holy water. They have tried for 6 years to repeal it with a 
singular focus. I don't know how many times they voted in the House--
some said over 60 times--to repeal it. They have said that for so many 
years, and we have said to them: What will you do after you repeal it? 
They said: Well, we have a plan. For 6 years, they have said: We have a 
plan to replace it.
  We have never seen it. No one has ever seen it. It raises the 
question about whether they do have a plan. They certainly have a plan 
to repeal it, but when it comes to replacing it, they don't offer 
anything--but they are going to go ahead with it. They are bent on 
doing this regardless of the outcome. For a lot of people across 
America, this could be devastating. This article talks about a family 
in Kentucky, the home State of the Republican leader. Melissa 
Fleckinger of Edgewood, KY. She had to pay for heroin treatment for her 
daughter Amanda before the Affordable Care Act. Her son Brian's 
treatment for heroin addiction was covered by the ACA, but 
unfortunately he died of an overdose in 2015.
  This article goes on to talk about what it means to have children who 
are addicted to drugs and parents who are desperately trying to find 
treatment. Some of the things that are said in the course of this are 
really worrisome because this article spells out what happens to 
families without health insurance that covers substance abuse 
treatment. They become helpless, unable to take care of their kids.
  The Republicans have come back and said: Well, we will just do a 
partial repeal of the Affordable Care Act. Listen to what this articles 
says:
  Almost any route taken on Capitol Hill leads to an unraveling of 
addiction and mental health coverage for those people. Even the partial 
ACA repeal Congress is considering would eliminate the tax credits that 
reduce the premiums for about 85 percent of the people who buy 
insurance on the exchanges. Most of those who get the tax credits pay 
less than $100 a month for health insurance and have very low out-of-
pocket costs that make it possible for them to afford coverage.
  What they go on to say here is that putting a requirement in the 
health insurance policy that it cover mental health illness and 
substance abuse treatment means nothing if the people cannot afford to 
pay the premiums for the health insurance policy. So the Republican 
plan that would eliminate the tax credits families need to be able to 
afford the policy means there is no way they are going to get coverage 
for themselves and their kids.
  Who is going to be affected by that? I will tell you what I found in 
Illinois. What I found in Illinois is that the current opioid and 
heroin epidemic is everywhere. There is no town too small, and there is 
no suburb too wealthy to avoid it--story after story of teenagers and 
young people addicted who have no place to turn.
  If the Republicans have their way in the Senate and the House, they 
will close the door for many of these young people. I see my colleague 
from the State of New Hampshire. I was stunned to read--I don't know if 
it is still the case, but I was stunned to read several months ago that 
when you look at the average number of deaths from opioids

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and heroin across the Nation--and Illinois is, I am not making any 
excuses here, we are average--the rate of death for heroin-opioid 
overdoses in West Virginia is twice the national average, and the rate 
in New Hampshire is three times the national average.
  Listen to what the repeal of the Affordable Care Act would mean in 
New Hampshire. I might say to the Senator from New Hampshire that she 
is quoted in this article.

       Repealing the ACA would cause [in New Hampshire] nearly 
     120,000 people to lose coverage in the State, where federal 
     data show a nearly 200% increase in overdose deaths in the 
     past five years. More than 48,000 Medicaid claims were for 
     substance use disorder in 2015, making an ACA repeal [in the 
     words of Senator Shaheen] ``literally a matter of life and 
     death.''
       Ohio. At the Cincinnati Center for Addiction Treatment, CEO 
     Sandra Kuehn said about 30% of Kuehn's patients are covered 
     for treatment because of the expansion [under ACA]. Overdose 
     deaths in Ohio climbed from 2,531 in 2014 to 3,050 in 2015, 
     up more than 20 percent.
       Kentucky.

  The home State of the Republican Senate leader.

       Overdose deaths here totaled 1,248 in 2015, up 17% from the 
     previous year. Fentanyl--which is much stronger than heroin--
     was involved in 420 fatal overdoses in 2015, up nearly 250% 
     over the previous year.

  The lady who was quoted earlier who lost her son to the overdose was 
not surprised. She knows several other people who have overdosed and 
many others who have died, including one last week.

       Chicago.

  I am proud to represent it.

       Up to 30% of the 9,000 inmates in the Cook County Jail have 
     a diagnosed mental illness. . . . ``The ACA has been a game 
     changer for those who were in and out of Cook County Jail,'' 
     says Mark Ishaug, CEO of Thresholds, a Chicago treatment 
     provider. It costs less than $20,000 a year for Threshold's 
     highest level of community-based mental-health care with a 
     housing voucher. . . .

  So $20,000 a year or less than that. Do you know what it costs to 
incarcerate that same person? It costs $70,000 a year to incarcerate 
them. About one-third of the patients being treated by Thresholds are 
covered by the Affordable Care Act. What is the alternative, I say to 
my Republican friends. They can't wait to repeal this, but they don't 
have an alternative.
  Meanwhile, in Illinois, in New Hampshire, in Maine, and every State 
in the Nation, mental illness is still a challenge, and substance abuse 
is on the rise and people are dying from heroin and opioid overdoses. 
This is the height of irresponsibility, to repeal this measure with no 
replacement. It is sad to say we have reached this point where a 
political score has to be settled now that the Republicans are in 
control of the House and the Senate.
  Now that they have an incoming President, the Republicans finally get 
their day. Someone said to me: Why is public sentiment starting to 
change on this issue and even among Republican politicians? I said: 
They have been saying irresponsible things for a long time, but now 
people are taking them seriously. As they take them seriously, they 
realize what a devastating impact it is going to have.
  Nicholas Kristof wrote in the New York Times last week:

       If the Republicans ran a home renovation business, they 
     would start tearing down your roof this month and promise to 
     return in 2019 with some options for a new one--if you 
     survived.

  Last week, Senator Rand Paul of Kentucky wrote an op-ed arguing that 
repeal should not be done without simultaneously being replaced. 
Senator Bob Corker, Republican of Tennessee, has said that repealing 
the law without replacing it is ``a flawed concept'' and that having a 
replacement ready first would be a more ``prudent approach'' in the 
Republican Senator's words.
  Senator Susan Collins, Republican of Maine, has said she would like 
to see ``detailed framework'' accompanying any repeal.
  Senator Tom Cotton, Republican of Arkansas, said: ``I don't think we 
can just repeal ObamaCare and say we are going to get the answer 2 
years from now.''
  Over and over again, these Republican Senators are realizing how 
totally irresponsible it would be if we go forward with this proposal. 
I will tell you what troubles me as a representative of a State that 
has the great city of Chicago and a wonderful metropolitan area. I come 
from the other end of the State, the rural part of our State. I wonder 
what is going to happen to our rural hospitals if the Affordable Care 
Act is repealed. I think about Franklin Hospital in Benton, IL, 
population, 7,300. The hospital has been there 60 years. In the past 15 
years, it has been teetering on the brink of bankruptcy. It all changed 
6 years ago with the passage of the Affordable Care Act and the 
expansion of our Medicaid Program in Illinois.
  Because of those changes, Franklin Hospital found they could survive. 
Expanding Medicaid cut Franklin Hospital's uncompensated care in half. 
In Franklin's emergency room, they saw 600 fewer no-pay patients and 
428 more Medicaid patients compared to the previous year. This, 
combined with increases in Medicaid funding, allowed Franklin Hospital 
to invest in much needed improvements and to consider bringing nuclear 
medicine and a retail pharmacy to Benton, IL. What does that mean in 
that city? Well, it means all the difference in the world. There is 
something else that has to be said. If that hospital--Franklin Hospital 
in Benton--closes, it will not just mean a longer drive for critical 
health care, it is going to mean job losses. It will mean the loss of 
4,300 jobs in the 12th congressional district, where Franklin Hospital 
is located.
  So when the President-elect talks about saving 6 or 800 jobs at 
Carrier Corporation, good; I am glad. But then for his party to turn 
around and pass a measure which could kill 84,000 to 95,000 jobs in 
Illinois, that is a move in the wrong direction. I say to my Republican 
friends, go home and talk to the people you represent. Listen to what 
they have to say about what we are doing--addiction, mental illness, 
and rural hospitals that are on the brink of closing, if you have your 
way politically. This is no victory for the people of America to repeal 
the Affordable Care Act without a replacement that is as good or 
better.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Oregon.
  Mr. WYDEN. Mr. President, my colleague from Illinois has addressed 
very clearly what some of the human consequences of this are going to 
be. I am going to take a few minutes as well to describe it. I am very 
pleased our colleague Senator Murray is here because she has really led 
the effort--and I have been very pleased to join her--in terms of 
trying to promote expanded health care services for vulnerable women in 
America.
  I say to Senator Murray, I saw there was a comment made by some who 
advocate the repeal of the Affordable Care Act. They said: Nobody was 
going to get hurt--nobody in America was going to get hurt. The reality 
is, that is not true for the hundreds and hundreds of thousands of 
women who depend on Planned Parenthood for basic health care, for 
preventive health services, for essential services, for example, like 
cancer screens.
  So this notion that somehow nobody is going to get hurt by repealing 
the Affordable Care Act is simply contradicted, from rural Oregon to 
rural Maine, when you see the kind of pain and suffering this is going 
to end up generating for some of the poorest and most vulnerable women 
in our country. The fact is, what has been set in motion by Republicans 
here in the Senate is a scheme that I call repeal and run. It is about 
very large tax breaks for the most fortunate, paid for by taking health 
insurance away from millions of working people. Under it, the insurance 
companies are back in the driver's seat, health care costs skyrocket 
across the board, and that is true even for those who get their 
insurance at work.

  The replacement plan our colleagues on the other side have promised 
for years is somehow hidden away, with tens of millions of Americans in 
the dark about what is coming next for their health care.
  Whenever I hear about the replacement, the whole notion of what would 
be there for families in the future, it reminds me of what used to be 
the old movie house in town. It had a big marquee up at the top of it, 
and it would always talk about the movie ``coming soon,'' but the movie 
never actually got there. When I hear about the replacement, what I 
think about is that everybody is going to be sitting in the dark again.

[[Page S140]]

  What is essentially at stake here is whether America is going to go 
back to the days when health care was for the healthy and the wealthy. 
That is what health care used to be all about. If you were healthy, no 
problems, nothing to worry about. If you were wealthy, you could just 
write out checks when you had a whole host of preexisting conditions.
  What the Senate is going to vote on this week is whether to green-
light the first step in this scheme to go back to the days when health 
care was for the healthy and wealthy with a budget resolution.
  I think it is fair to say budget resolutions usually aren't the prime 
topic at dinner table conversations in America, but this year there are 
serious consequences--serious consequences--personal, life-and-death 
consequences because of this scheme that is being pushed through the 
Senate. That is where I believe the focus ought to be and why I am 
going to spend the remainder of my time talking about persons whose 
lives in Oregon are going to be directly affected and, in some cases, 
endangered.
  Maleta Christian is from Douglas County, OR, a beautiful rural 
community. She is a personal support worker, providing care to adults 
with intellectual and developmental disabilities. She had always 
carried health insurance until she was unexpectedly laid off from her 
job. She was without coverage for more than a year, but then she was 
able to buy a plan through the Affordable Care Act.
  For Maleta, having insurance meant cancer screenings that, very 
likely, saved her life. Doctors found tumors that had to be removed. 
Later, she was diagnosed with a degenerative hip and back problems that 
caused her pain every day, making it difficult to get through a 
physically demanding and grueling job.
  Her prescription drug coverage, which she gets through a plan under 
the Affordable Care Act, is what makes it possible for Maleta to get up 
every morning and get through that workday. Thanks to the care she has 
received, Maleta made it to her daughter's wedding, and she was proud 
that she even baked the cake.
  Another Oregonian, Rita from Salem, comes from a family who has been 
struggling with depression. It is a condition that has been stigmatized 
for far too long in this country.
  I know something about this because my late brother, Jeff, faced the 
stigma of mental health. He was a schizophrenic, and he passed at far 
too early an age. Far too many of those with mental illness have been 
denied care and shunted to the fringes of society.
  Before Rita got coverage through the Affordable Care Act, she was 
forced to pour a staggering share of her income into health-related 
expenses. It was nearly two-thirds in 2011. Even then, she didn't have 
access to the mental health treatments she needed. Her depression used 
to keep her out of work.
  With coverage from the Affordable Care Act tax credits that made it 
affordable, Rita's costs have fallen substantially. She now gets the 
prescription and therapy that help her manage her condition, and she 
can live a healthier life.
  Another of my constituents is Mary, who lives in Milwaukie, OR, with 
her husband and 7-year-old daughter. She has a hereditary disease known 
as HAE. It is a rare genetic condition that causes dangerous swelling, 
lasting days at a time, affecting various parts of the body. If Mary 
goes without treatment, attacks come on regularly, even multiple times 
a week. When they do, it is completely disabling.
  Before she got insurance through the Affordable Care Act, she rotated 
through health plans and insurers to maintain coverage and avoid 
hitting caps on treatments. She sought out clinical studies to get free 
care, typically participating in one each year.
  So on top of holding down a job, raising a daughter, battling a life-
threatening condition that affects 1 in 50,000 Americans, she was 
basically out trying to cobble some decent health care together. The 
system was so badly broken, she basically sewed her own health care 
safety net, but the ACA protected patients like Mary from 
discrimination and guaranteed access to care.
  These are three Oregonians. They come from different backgrounds, and 
they have battled different conditions, but they share a lot in common 
with each other and with people around the land.
  Not long ago, in the eyes of insurance companies, the women who I 
just mentioned would have worn their preexisting conditions like 
scarlet letters. But the insurance they have now gives them the 
opportunity for healthier, more productive lives, and that is what is 
endangered because of the scheme that is being pushed through Congress, 
pushed through the Senate by Republicans right now.
  Costs are going to shoot up if the plan goes forward. The premium 
subsidies millions of Americans count on to buy insurance could be 
eliminated. Even if Americans with preexisting conditions have access 
to health care after this repeal scheme goes through, it doesn't mean 
they can afford it.
  What my colleagues on the other side have said repeatedly for years 
is that they were going to repeal and replace--no gap, no harm done to 
anybody. The replacement would be ready on day one.
  It sure looks as though that promise is going to be broken. The 
replacement is still hidden somewhere, but the process of repeal is 
rolling forward. In the meantime, millions of Americans are left 
guessing what is going to happen to their care if this plays out.
  The bottom line for me and my colleagues is really this. If Members 
on the other side want to debate how to solve this country's health 
care challenge, we will have that debate.
  I would say to my colleagues on the other side: I have spent about as 
much time as anybody here in this body looking for bipartisan 
approaches to address health care. So let's find ways to bring down 
costs for families. Let's make prescription drugs more affordable. 
Let's uphold the promise of Medicare because that is what it is; it is 
a promise of guaranteed benefits. But we are not going to be able to do 
that on a partisan scheme called the budget resolution and 
reconciliation. That is not about bringing people together for a 
bipartisan effort. That is about tearing things down, tearing down the 
Affordable Care Act, so I want that understood.
  My colleague Senator Murray is here. She and I work together closely 
because of our committees. We feel very, very strongly about how 
uniquely important this time is because this is a time when our country 
has to decide not to go back to the dark days when health care was 
reserved for the healthy and wealthy. That is what the other side has 
on offer right now. It is a proposition that my colleagues and I are 
going to fight with all our strength.
  With that, Mr. President, I yield the floor.
  The PRESIDING OFFICER. The Senator from Washington.
  Mrs. MURRAY. Mr. President, I come to the floor of the Senate tonight 
with my colleagues to share the stories of families in our home States 
whose lives are now healthier or have even been saved because of the 
Affordable Care Act, including those who depend on Medicare and 
Medicaid, people whose voices now more than ever need to be heard here 
in Washington, DC.
  But first, I am going to make clear how the Republican plan to repeal 
the Affordable Care Act will rip apart our health care system. And 
after what came to light late last week, I also come to the Senate 
floor tonight to stand with the millions of women, men, and families 
nationwide who are rightly outraged that this reckless and harmful 
effort also includes a plan to defund Planned Parenthood.
  For 7 years now, congressional Republicans have made all kinds of 
empty promises about how undermining families' health care isn't going 
to hurt anyone; that if the Republican-controlled Congress privatizes 
Medicare, cuts Medicaid, defunds the Nation's largest provider of 
women's health care, and guts public health and prevention programs, 
somehow families are going to be magically better off.
  Well, let me be clear. Ripping apart our healthcare system with no 
plan to replace it will create chaos. This is a view shared not just by 
the Senate Democrats who are here tonight but by independent experts. 
In fact, it is a view shared increasingly by State Republican leaders 
across the country, including some Senators and Congressmen.

[[Page S141]]

  Last Friday, just to cite one example, the Republican Governor of 
Arizona urged his party in Congress not to rush to repeal the 
Affordable Care Act, saying: ``I don't want to see any Arizonan have 
the rug pulled out from underneath them in terms of changing this 
law.''
  Mr. President, if Republicans repeal the Affordable Care Act, it is 
women and kids and seniors and patients with serious illness and people 
with disabilities who will bear the burden. Premiums will skyrocket. 
Out-of-pocket prescription drug costs will rise, and overall health 
care costs will increase. It is a perfect storm to make America sick 
again and is absolutely the wrong direction for our families and our 
economy.
  Mr. President, I have to say, I have never seen a start like this to 
a Congress, where the majority is jamming legislation through on a 
fast-tracked basis with no hearings for public debate or actual 
legislative text. As a former chairman of the Budget Committee, I have 
to say I have never seen such an abuse of the budget process.
  What many of my Republican colleagues are doing right now is 
unprecedented, but it gets worse. As if all of their harmful plans 
weren't enough, House Republicans announced last week after meeting 
with Vice President-Elect Pence that they plan to defund Planned 
Parenthood in this budget. In other words, congressional Republicans 
are not only trying to undo a law that protects women from being 
charged more than men for their health care and ensures birth control 
is covered without a copay, they are also going after the Nation's 
largest provider of women's health care as well. They are doubling down 
on their shameful and tired obsession with undermining women's access 
to health care, and it will have devastating consequences for women's 
health and rights and economic security.
  So I am here with a very clear message: not on my watch. I, along 
with my colleagues and women and men across the country, have fought 
this fight before in 2011, in 2013, in 2016, and we will fight it in 
2017. We know what Planned Parenthood means to millions of patients--
men and women--who have trusted it for over 100 years for cancer, STD 
screenings, for HIV tests, birth control, and so much more. We are not 
going to let extreme politics get in the way of their health care. So 
if Republicans think causing chaos in our health care system, 
heightening economic uncertainty, attacking women's health and rights, 
and burdening our seniors and their families with higher health care 
costs somehow makes our country ``greater,'' they are obviously not 
listening to millions of families who did not vote in November for 
higher premiums or a health care system thrown into chaos.

  I have gone back to my home State of Washington, and I have heard 
from moms and dads and grandparents who are finally experiencing some 
stability and are able to cover their families with quality, affordable 
health insurance--many for the very first time. There was a mom from 
Bellingham, WA, who sent me a story about how the Affordable Care Act 
helped save her son's life when doctors found a life-threatening blood 
clot during a routine physical. She was not only able to afford the 
preventive check-up that found the clot because of her new coverage, 
but her son's treatment was then covered by the Affordable Care Act 
through the Medicaid expansion.
  I heard from a small business owner from Spokane, WA, who told my 
office about his wife, a retired nurse of 62, and how she was able to 
get a better plan thanks to the Affordable Care Act. He told us what 
this meant for his wife and his family. You bet he gets upset when he 
hears Republicans say the law hasn't worked for anyone or that they 
want to privatize Medicare by turning it into a voucher program.
  Finally, I want to share the story of Kalon, who is a software 
engineer from Seattle, and his son Bryce. Kalon reached out to my 
office right after the November election. Two years ago, his son Bryce 
was kayaking in West Virginia and he injured his back. The pain in 
Bryce's back didn't go away for months. What doctors first suspected as 
a stubborn muscle strain ended up to be a rare type of bone cancer 
called Ewing's sarcoma, a horrible illness. Thankfully, his family had 
health insurance.
  Today Bryce is getting excellent treatment at Seattle Children's 
Hospital, where doctors have been able to ease some of his pain, and he 
is responding well now to chemotherapy. Bryce, who is now almost 18, 
will need care--expensive care--for many years to come, and Bryce's 
dad, Kalon, is greatly concerned that, if the Affordable Care Act goes 
away, the preexisting condition protection that we fought so hard for 
in this law will go away, and his son will not be able to afford health 
care or get the benefits or treatments he is going to need in the 
future.
  Those are just three stories, but they represent many of the more 
than 600,000 people in my State who are part of the 30 million 
Americans across the country who are benefitting from this law today. 
Of course, there is more we need to do. I said it before. The work 
didn't end when the Affordable Care Act was passed--far from it. 
Democrats are ready. We have always been ready to work together to make 
health care more affordable and more successful and better for our 
families.
  I hope Republicans reverse course right now and agree to work with us 
on improvements to the health care system. That is the path to take if 
they are truly serious about helping families. If they don't, and if 
they continue rushing to take away families' health care with no 
alternative plan, they will be fully responsible, and they certainly 
will be held accountable. The real impact will be on millions of 
families across our country, families like the ones I just talked about 
and those you are going to hear about throughout tonight--Democrats, 
Republicans, and Independents who do not want to see this law repealed 
and want us to work together to improve it instead.
  I hope Republicans are listening. I urge them to make the right 
choice.
  Thank you. I yield the floor.
  The PRESIDING OFFICER. The Senator from Rhode Island.
  Mr. REED. Mr. President, I rise in opposition to the budget 
resolution that the Senate will vote on this week. We are nearly half 
way through the fiscal year, and the Republicans have offered this 
budget resolution not to set a path forward for spending for the year 
but to give them the ability to repeal the Affordable Care Act through 
the budget process, requiring less support than is needed under regular 
order. This budget is nothing more than a sham, being used to take away 
health insurance from more than 20 million Americans. What is worse is 
that my Republican colleagues intend to do so without any plan in place 
to mitigate the impact and protect the people who will be harmed.
  The uninsured rate is at its lowest point in recent history. Since 
the implementation of the ACA in my State of Rhode Island, the 
uninsured rate has fallen from 12 percent to under 4.5 percent. In real 
terms, that means that over 100,000 people in Rhode Island have gained 
coverage because of the ACA. That is about 10 percent of my State's 
population. Over 30,000 middle-income Rhode Islanders get tax credits 
averaging $250 a month to help them afford coverage on the State's 
health insurance marketplace.
  We cannot go back to a system that allows private insurers to deny 
coverage for preexisting conditions or charge more to those who need 
insurance the most. In fact, the Republican plan for repealing the ACA 
means that nearly half a million Rhode Islanders with preexisting 
conditions, about half the State's population, will be denied coverage 
or will be charged more. Again, as Senator Murray described so 
eloquently in the case of a young man who needs years of expensive 
treatment, if preexisting conditions are once again possible and if 
that young man is dropped from his parents' plan at 21, both of those 
factors will probably deny him the coverage that he enjoys today, and 
that is not what we want to do. I hope that is not what we want to do.
  In my State, there are over 106,000 Rhode Islanders with diabetes, 
over 112,000 with asthma, and nearly 63,000 cancer survivors who will 
be forced to pay more for coverage. These are huge numbers in my 
State--roughly 1 million people in population. They have these 
conditions, and insurance companies said in the past: We won't cover

[[Page S142]]

you, or, by the way, you will be spending 2, 3, 5, 10 times as much for 
the coverage we extend to someone else.
  We have also been able to improve coverage through the ACA for those 
who are getting their care through their employer. Before the ACA, 
insurance plans, including employer-sponsored health coverage, could 
impose annual or lifetime limits on coverage, meaning that coverage 
could end when it was most needed. You could have a job, and you could 
have insurance at a job, but if you have a serious condition, when you 
reach that limit, that is it--no more responsibility by the company. 
That is exactly the time you need the help because you have already 
either exhausted some of your own resources or you are in a position 
where you have been sick for so long that your ability to go back into 
the workplace is practically nonexistent. The ACA prohibits these 
limits, along with ensuring free preventive care and coverage of 
dependents up to age 26, ensuring real coverage for nearly 600,000 
workers in Rhode Island with employer coverage.
  There is a perception out there that the ACA doesn't apply to 
employer coverage and that it has no effect--that if it is repealed, it 
is fine because I get my health insurance from my employer. That is not 
the case. The impact will be there, and it could leave many people 
devastated.
  Additionally, the ACA strengthened the rate review processes to help 
control premiums. Prior to the ACA, double-digit increases were always 
the norm. When I served in the House and in my first years in the 
Senate, invariably, when trade associations came to visit me, the first 
or second issue on the list was this: Our insurance coverage just went 
up 20 percent. We can't afford it anymore. We are dropping coverage or 
telling our workers: Do you want a raise, or do you want coverage? You 
can't get both.
  Well, we have to do more to keep premiums under control and bring 
down costs, but there has been an improvement under the ACA in my State 
and in many other States. In 2 of the last 3 years, premiums actually 
went down from the previous year in Rhode Island. During open 
enrollment for 2017, Rhode Islanders saw decreases of as much as 5 
percent in their premiums. In fact, due to the ACA, consumers in Rhode 
Island have saved nearly $220 million since 2012, according to the 
State resource.
  This program has done something that we were feverishly trying to do, 
which was to somehow bring costs under control and reduce them if we 
could but certainly eliminate the double-digit growth, when every year 
every employer group was coming in and saying: We can't afford this. We 
want to cover our workers, but we can't. We are giving them that 
choice, or we will have to sadly say we can't give you insurance 
anymore. Repealing the ACA would end all of these consumer protections 
and put insurance companies back in charge.
  One other thing that it has done is that we actually required that a 
significant amount of the premium be used for health care, not 
overhead. We actually built into the law that, if you are going to 
charge a premium, it better go to help people get health care, not just 
to boost your profits, dividends, or anything else. That is another 
factor that has helped positively this rate and premium structure.
  Then, of course, there is a huge economic impact of ACA repeal. For 
years I have heard my Republican colleagues very sincerely and 
adamantly declare that the ACA is a job killer, that it was going to 
destroy millions of jobs. That was one of the refrains that echoed 
throughout this Chamber as we were debating the ACA for months and 
years afterwards. But what has happened? We have had an unprecedented 
75 consecutive months of job growth--something we haven't seen since 
1939. Repealing the ACA would wreak havoc on this progress. Premiums 
for everyone, not just those in the individual market, will skyrocket. 
Large businesses will see their health care costs go up, which means 
workers will forgo pay increases as their employers struggle to simply 
maintain health care coverage or they will drop the coverage entirely.
  We have come a long way since the economic downturn in 2008, and we 
have much more work to do to keep things moving in the right direction, 
but one of the worst things we can do for the economy is to repeal the 
ACA.
  Rhode Island stands to lose over $7 billion in Federal funding over 
the next 10 years with repeal. Again, that is a staggering number in my 
State--$7 billion. That would be devastating for the State because they 
would have to step up as best they could, and frankly, they don't have 
the kind of resources to replace that loss. It would have an effect on 
hospitals and other health care providers. Hospitals in Rhode Island 
stand to lose nearly $2 billion in funding on top of the added expenses 
of emergency room care for the newly uninsured. We remember the old 
model of health care. The old model was that, if you didn't have 
insurance, you went to the emergency room. Those emergency rooms were 
crowded with people. They were much more expensive to treat because 
they were there without any previous experience with the physicians and 
without health records, in many cases. They had to do diagnostic tests 
that were not available and that are now available at the health care 
facilities because they have insurance. All of that would come undone. 
It will be a huge impact on the economy.
  One of the largest employers in the State of Rhode Island is the 
hospital system. I don't think we are alone. If you go out into the 
rural parts of the United States, in many cases, the biggest employer 
in many counties is the health care system, the hospital system. When 
they can no longer make their books balance, they are going to have to 
start closing down operations, laying people off. That is what is going 
to happen. This is not farfetched. We have seen it before. We have seen 
struggling hospitals struggling under emergency room uncompensated 
care. We have seen all these things happen before. Repealing the ACA 
would lead to a combination of all these factors--skyrocketing premiums 
and the loss of Federal funding in health care for States, which would 
have a ripple effect throughout the country.
  If Rhode Island or any other State has to step in and partially make 
up for the loss of Medicaid funds or any other aspect of this program, 
where are they taking it from? Where are they taking it from? 
Education, infrastructure, public safety. They will suffer. Ultimately, 
it is the jobs--the jobs of the people in my State and the jobs of 
people across the Nation.

  So there are things we can do to strengthen the bill. Senator Murray 
was very clear about attempts we have made. She has been one of the 
great leaders in this effort to make improvements. We have been working 
on and improving Medicare since 1965, and we still have some work to 
do, but that was a different program. That was a program that was a 
bipartisan program, one that was embraced and developed and supported. 
In fact, one of the ironies today is some of the staunchest supporters 
and protectors of Medicare are Republicans, as well as Democrats, but 
that was a program that took several decades to work through, and we 
are still working through issues with respect to Medicare. We are 
prepared to do that with the Affordable Care Act in a principled, 
thoughtful, practical, pragmatic way, not to score political points, 
but to make it a system that is more affordable, more effective, and 
that gives more American families a chance. Frankly, you don't have 
much of a chance for a good education, a good job, or a secure 
retirement when your health is in jeopardy and your finances are 
equally in jeopardy.
  At this point, the Republicans have offered no plan to replace the 
ACA, and it is a tough task. I served on the HELP Committee as we were 
drafting this, and we spent over a year on this law. We spent countless 
moments reaching out to our colleagues on the Republican side asking: 
Can we make this better? What improvements can we make? We had numerous 
folks in the mix. It is tough work. To suggest that we can just repeal 
this and something will magically appear, I don't think that is 
particularly logical, obvious, or will happen.
  Roughly, 7 years have gone by since the passage of this bill, where 
the Republicans have had a chance to prepare a detailed plan to replace 
aspects of the ACA or replace it. I don't think that plan is out there. 
It is certainly not being communicated.
  We have to ensure--and Senator Murray was very effective in making 
this point--that we can improve ACA,

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not demolish it, that, if we get into a legislative process, we produce 
a better outcome for the American people, not an outcome of denial of 
health care and financial uncertainty and perhaps even financial ruin.
  So we have to get to work. I think we are prepared to do this but in 
the context of something pragmatic and productive for the benefit of 
the American people.
  Let me switch gears, just for a moment, and talk about Medicare and 
Medicaid because, when people talk about Medicare and Medicaid, they 
usually don't make an association with the ACA. They think that is 
something else. I can recall being in a public discussion in August of 
2009, when we were discussing ACA before it became law, and something 
came up that was very critical about the program because they didn't 
want publicly funded insurance in any way, shape, or form, and I asked: 
Where do you get your health care?
  Well, I have a private provider.
  Again, I asked: Where do you get your health care?
  I am on Medicare.
  Medicare is, as I recall, a single-payer national system of health 
care, a funded entitlement by the government, with some copayments by 
participants.
  Medicare and Medicaid are effective in a significant way. We made 
historic improvements to these programs, enhancing benefits. Indeed, we 
added 9 years of solvency to the Medicare trust fund. One of the great 
issues that reverberates throughout this Chamber is we have to control 
entitlements. We have to prepare for the future. We have to make sure 
these social programs like Medicare, Social Security, Medicaid, and 
others are solvent. We added years of solvency to the program in the 
ACA. If it is repealed, subtract 9 years of solvency from the Medicare 
trust fund. Tell seniors and people in their fifties who are getting 
ready to enjoy the benefits: Just take 9 years off your expected 
benefits, or at least a portion of the benefits.
  The ACA made a number of other improvements. They closed and are 
closing the doughnut hole for prescriptions, they eliminated cost 
sharing for cancer screenings, for example, for Medicare recipients. 
Over 15,000 Rhode Islanders saved $14 million on drugs in 2015. That is 
an average of $912 per Medicare beneficiary because of what we did with 
respect to the doughnut hole. In the same year, over 92,000 Rhode 
Islanders--huge numbers in my State--took advantage of free preventive 
services, representing over 76 percent of the beneficiaries. Seventy-
six percent of the Medicare beneficiaries in my State took advantage of 
free services. Otherwise, they would have paid out of their pocket, 
and, frankly, many seniors don't have the resources to do that. 
Repealing the ACA means these benefits go away, and it shortens the 
trust fund by about a decade.
  Repeal would also mean cutting $270 million in Federal funds to help 
pay for health coverage for low-income adults, children, seniors, and 
people with disabilities through Medicaid. The ACA expanded eligibility 
and streamlined enrollment and made it easier for the most vulnerable 
to access quality health care coverage. As a result, approximately 
70,000 Rhode Islanders were able to access coverage for the first time 
through Medicaid--their previous source of health care: most times, the 
emergency room, if they could get there.
  I want to point out a couple of things about Medicaid. Medicaid has 
become a program for our senior citizens that happens to also help 
struggling Americans. Seniors make up a small percentage of the 
Medicaid population but account for approximately half of Medicaid 
spending nationwide. Nearly 60 percent of nursing home residents are 
covered by Medicaid. Think about that. Sixty percent of all nursing 
home residents need Medicaid. The next time you hear someone casually 
suggest drastic cuts and changes to Medicaid, think about that. Those 
cuts will work their way back to nursing homes throughout your State. 
Those families of those seniors are not all people who have been poor 
and on the margins all of their lives; they are our neighbors, and they 
will feel it.
  In Rhode Island, over 30,000 seniors access health care coverage 
through Medicaid. My colleagues across the aisle want to make drastic 
cuts to Medicaid. Make no mistake, cuts to Medicaid mean cuts to 
nursing home services for seniors and a return to pre-Medicaid times 
when the elderly had few options. In the 1950s and 1960s, before 
Medicare and Medicaid, your grandmother or grandfather was in your 
living room in a hospital bed being taken care of by typically your 
mother. That is the way you grew up back in the 1950s and 1960s in most 
middle-income neighborhoods. That was at least my experience. If you 
want to go back, that is what would happen, in some respects, if we 
repeal this law.
  If Republicans want to come and work with us, we are ready--more than 
ready--but we can't stand by and allow them to do the damage they 
propose: to take away coverage from 20 million Americans and cut 
benefits to seniors. That is not the right direction for America and 
for our country.
  With that, I yield the floor.
  The PRESIDING OFFICER. The Senator from New Hampshire.
  Mrs. SHAHEEN. Mr. President, I am here to join so many of my 
colleagues to oppose efforts to repeal the Affordable Care Act. 
Outright repeal without a replacement plan will hurt hundreds of 
thousands of people in New Hampshire as well as millions across this 
country. The estimate is anywhere from 20 million to 30 million people 
who will lose their health insurance coverage.
  There are all kinds of reasons why this is a bad idea. Many of those 
have been addressed by my colleagues very eloquently. I wish to speak 
about a couple of those reasons.
  The first is one Senator Durbin alluded to earlier; that is, what 
repeal of this law will mean for the heroin and opioid epidemic that is 
facing New Hampshire and so many States across this country. Repeal 
will dramatically worsen that epidemic because it will deny treatment 
for people who are abusing substances, and it will also deny them 
access to mental health services. That will mean a surge in overdose 
deaths, and it will reverse so much of the progress we are beginning to 
make.
  I understand that sweeping health care reform is not easy. We all 
know the Affordable Care Act is not perfect. It needs work. The way to 
address it is not to repeal it, it is to work together to make it 
better. Rather than rush to destroy the Affordable Care Act with no 
replacement in sight, we should be working together, on a bipartisan 
basis, to make commonsense improvements to the law. It can be done. I 
know, because Tim Scott and I worked together to pass the PACE Act last 
year to make it easier for us to control health care insurance 
increases and to allow States to make the determination about group 
size for health insurance plans.
  One of the things I am hopeful about is that President-Elect Trump, 
in the course of many visits to New Hampshire over the last year, again 
and again pledged to take robust action to combat the opioid epidemic 
in New Hampshire and across America. Yet, by repealing the Affordable 
Care Act, President-Elect Trump and the Republican leadership in 
Congress will make the opioid crisis so much worse. This would be a 
broken promise to communities all across this country that are 
struggling with addiction.
  The Affordable Care Act has given millions of Americans access to 
treatment and recovery and saved countless lives, and repealing it 
would deny treatment to people suffering from substance use disorders. 
It will cost lives. It will take a terrible toll on communities across 
America.
  In New Hampshire alone, health care reform has helped over 100,000 
people gain access to health care coverage--people like Keith from 
Rindge, NH. Keith was one of the thousands of Granite Staters able to 
access quality, affordable health insurance through our State's 
Medicaid expansion program.
  Keith told my office that the Medicaid expansion literally saved his 
life. Keith was suffering from several health issues when he went to 
see his doctor after he signed up for the New Hampshire Health 
Protection Plan, which is what we call our expansion of Medicaid. He 
told us that had he not had insurance, doctors likely would not have 
caught his kidney cancer early like they did, but because he had that 
health insurance, Keith was able to afford and quickly access treatment 
for

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his cancer. He is thankfully now cancer-free, and he credits having 
insurance through Medicaid expansion with saving his life.
  As I said, New Hampshire is in the midst of a heroin and opioid 
epidemic. We have talked about the grim statistics frequently in the 
last year as we have come to the floor. In 2014, we lost 47,000 
Americans due to heroin and opioid overdoses. In New Hampshire, when 
all of the analysis is in for 2016, we are expecting to have lost 
almost 500 people due to overdose deaths. As Senator Durbin pointed 
out, we have one of the highest percentages of overdose deaths in the 
country.
  It doesn't have to be that way because addiction is an illness. It is 
an illness that doesn't have a cure, but we have made progress in 
treating it. The Affordable Care Act ensures that substance misuse 
services are covered by insurance. As a direct result of the Affordable 
Care Act, many of those suffering finally have access to counseling and 
therapy like medication-assisted treatment.
  In addition to covering substance misuse counseling, the Affordable 
Care Act is also built on mental health parity provisions that require 
group health plans and insurers offering coverage of mental health 
services to provide comparable coverage to what they provide for other 
medical care when it comes to substance misuse.
  The Affordable Care Act extended these parity goals by requiring 
mental health services to be covered as essential health benefits, and 
it also helped expand access to these services by insuring more 
patients.
  We worked very hard, in a bipartisan way, over the last year in this 
Chamber to pass the Comprehensive Addiction and Recovery Act and to 
pass the 21st Century Cures Act that provided $1 billion to address 
heroin and opioid problems in this country. Both of those bills provide 
significant benefits to people who are suffering from substance 
misuse. If we repeal the Affordable Care Act, we are going to undo all 
of the progress we have made through these supplemental pieces of law 
because it would reverse the treatment access so many people in New 
Hampshire and across this country have. Why would we deliberately take 
away access to this lifesaving treatment from so many people who are 
struggling to overcome addiction?

  Repealing the Affordable Care Act will affect people like Ashley 
Hurteau of Dover, who said her access to health care as a new Medicaid 
enrollee was critical to her addiction recovery. She told our 
newspaper, the Union Leader: ``I am living proof that, by giving 
individuals suffering with substance use disorders access to health 
insurance, we, as a society, are giving people like me the chance to be 
who we really are again.''
  I had the opportunity last Friday to visit a program called Hope on 
Haven Hill in Rochester, NH. It provides help for women with substance 
misuse issues who are pregnant or who have just delivered babies. It 
works because these young women are enrolled in our Medicaid expansion 
program. Without that, they would lose any opportunity for treatment 
for their substance misuse. When I visited them, they talked about what 
it was like to be in a place where it was like a home, where people 
wanted to help them so that they could provide a better life for 
themselves and their children.
  Without access to lifesaving addiction treatment, many people like 
Ashley and like those young women at Hope on Haven Hill would succumb 
to their addiction. Again, what is so frustrating about this situation 
is that it is completely preventable. It is not only the right thing to 
do, but it is the economic thing to do because the cost of failing to 
provide treatment for people who have substance misuse disorders is to 
make sure that they cannot become profitable, taxpaying members of our 
society.
  One other benefit of the Affordable Care Act that, as Senator Murray 
said, is so critical to 50 percent of our population is access to 
health care for women. Before the Affordable Care Act, women paid more 
for health insurance, and contraceptives were something that made 
insurance cost more. Particularly for women who don't have the economic 
means, the Affordable Care Act has, for the first time, made 
contraceptives available to women without cost-sharing requirements 
like copays, deductibles, and coinsurance. Study after study has shown 
that access to contraceptives is one of the greatest indicators of 
success for women. When women are able to plan their pregnancies, they 
are more likely to graduate from high school, to enroll in college, to 
have stable and higher paying jobs, and to make sure that their health 
outcomes are better for themselves, their children, and their families.
  It is especially frustrating that last week our Republican colleagues 
in the House leadership announced that they are going to use the budget 
processes not only to repeal the Affordable Care Act and the help that 
it provides to women for contraceptive coverage, but they are also 
going to use this vehicle to defund Planned Parenthood. This is not 
only irresponsible, it is dangerous.
  Just this morning, Senator Hassan and I visited a Planned Parenthood 
clinic in Exeter, NH. We talked with women who have benefited from the 
vital services this center provides to thousands of Granite Staters. 
They talked about how 94 percent of the services provided in New 
Hampshire Planned Parenthood clinics are related to prevention. This is 
what one of the volunteers said in talking about the women with whom 
she had met who had come to Planned Parenthood clinics: What they tell 
me is that Planned Parenthood saved me.
  For so many women who have economic challenges, for low-income women 
who need access to services in New Hampshire and across the country, 
they don't have any other place where they can get services if we close 
down Planned Parenthood clinics. Two counties in New Hampshire don't 
have community health centers and a place where women can readily go. 
So defunding Planned Parenthood, closing the doors to Planned 
Parenthood health centers--in New Hampshire and across this country--
would put millions of women in a situation where they have nowhere to 
go to access basic health care services. This will cost women and their 
families access to preventive care, and, ultimately, it is going to 
cost the lives of women.
  Repealing the Affordable Care Act is going to actively worsen health 
outcomes. It will provide less access to care for our most vulnerable 
populations. It will increase unplanned pregnancies. It will mean that 
people who have preexisting conditions will not be able to access 
health insurance in the future. The list goes on and on. The repeal of 
the Affordable Care Act will not only throw millions of people off 
their health care, but it will also impact the coverage of millions of 
others because millions of Americans will see their premiums rise. They 
will see reinstatement of lifetime limits. They will see reinstatement 
of expensive cost-sharing requirements, higher deductibles, a 
reinstatement by health insurance companies of coverage denials, or 
sky-high premiums because of preexisting conditions. Why would we go 
back to those exclusionary and detrimental practices? Why would we go 
back to a time when we had over 20 million fewer people in this country 
who had access to health insurance?
  Now is the time for us to come together. Instead of scrapping this 
law, we should be working together to improve it, to make it work for 
all Americans.
  Make no mistake, repealing the Affordable Care Act without a 
replacement plan, stripping away health insurance for tens of thousands 
of Granite Staters and over 20 million Americans is not only 
counterintuitive but it is dangerous. We can do better in America.
  I yield the floor.
  The PRESIDING OFFICER (Mr. Daines). The Senator from Massachusetts.
  Ms. WARREN. Mr. President, for 8 years Republicans have complained 
about health care in America. They have blamed everything in the world 
on President Obama. They have hung out on the sidelines, name-calling, 
making doomsday predictions, and cheering every stumble that they could 
blame on someone else. They spent a lot of energy rooting against 
families who needed help paying for health insurance or who wanted 
coverage but were frozen out because of preexisting conditions. They 
jeered and carried on. But what they didn't do--ever--was lift a finger 
to try to improve health care

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in America. But they are in charge now. They get to call the shots.
  So what is the first thing on the Republican agenda now that they are 
in control? Is it working to help improve health care in America, 
working to bring down premiums and deductibles, making fixes to expand 
the network of doctors and the number of plans that people can choose 
from--any of those? No, the very first thing on the Republican agenda 
in the 115th Congress is to shatter health care in America. The first 
thing is to rip health insurance out of the hands of millions of 
Americans who need it. The first thing is to massively raise the cost 
of health insurance for everyone who has it. The first thing is to 
create chaos for hospitals, clinics, and insurance companies, and send 
their costs spiraling out of control. The first thing is to abandon the 
people they were elected to represent. The first thing is to repeal and 
run away.
  Republicans have been rushing around Capitol Hill for the past couple 
of weeks, huddling in meetings and trying to come up with a plan to 
replace the Affordable Care Act. They are shocked--shocked--to discover 
that guaranteeing Americans access to health care is a complex 
business, and they don't have any good ideas.
  Now, after 8 years of complaining, they are trying to convince each 
other that it will all be OK if they just repeal health care access, 
with nothing to replace it. They are trying to reassure each other that 
they know what they are doing.
  Get real. They don't have a clue what to do next. For 8 years they 
have had no plan, and they don't have a plan now.
  Let's be very clear about what is going on here. Republicans want to 
tear apart our Nation's health care system--a health care system that 
protects kids with cancer, protects women getting mammograms, protects 
independent contractors, protects new moms, protects college kids, 
protects grandparents, protects disease survivors, and protects so many 
of America's families. They want to tear it apart, and they don't have 
the first clue what to do with it afterwards. Repeal and run, that's 
the Republican plan.
  In Massachusetts, we know how important health reform is because we 
have been working on it now for years--long before the Affordable Care 
Act was even a spark on the horizon in Washington.
  My Republican colleagues could learn a lot from our work in 
Massachusetts. In Massachusetts, the belief that everyone should have 
access to affordable health insurance coverage is a shared value that 
Democrats, Republicans, business leaders, hospitals, insurers, doctors, 
consumers, and advocates have all worked to implement over the past 
decade. It is not just the lip service we are hearing right now here in 
Washington. It is real commitment, and, because of it, in Massachusetts 
we got real results.
  Just because we are all behind this effort together in Massachusetts 
doesn't mean that health care reform has been a cake walk. Finding ways 
to cover more people and bring down costs, all while improving the 
quality of care, is a tough job. You have to be in it for the long 
haul. That is why, in Massachusetts, we didn't just pass one health 
care law in 2006 and then just run away. We came back a couple of years 
later with additional legislation to make fixes and adjustments. We 
formed commissions to study how things were working and to make 
recommendations for more changes. We passed amendments. We revised our 
regulations where they needed to be changed to support implementation. 
We worked to make coverage more affordable. We set standards to make 
sure insurance is a good value. We invested in prevention programs to 
keep people healthy in the first place. We got more coverage for more 
people, and we lowered health care costs.
  We kept working month after month, year after year because we knew 
what it meant for a family to have the peace of mind that comes with 
affordable, high-quality health insurance coverage. We kept working 
because we knew it was the right thing to do. We kept working because 
we knew that is what Massachusetts residents expected us to do. Once we 
started something, we had to see it through. When it got tough, we 
worked harder. We didn't repeal and run.
  When the Affordable Care Act was signed into law in 2010, 
Massachusetts went all in. We expanded our Medicaid program. We used 
Federal funds to cover people who still lacked insurance even after our 
State reforms. We set up a State health insurance exchange, the Health 
Connector, and we combined Federal and State dollars to make sure that 
insurance was truly affordable.
  Just 2 months ago, we signed an ambitious new Medicaid agreement with 
the Federal Government that will allow us to set up innovative 
partnerships among health providers, insurers, and community 
organizations so we can better serve Medicaid patients in our State.
  We have a great deal to be proud of in Massachusetts. More than 97 
percent of our citizens are insured. People have coverage. They have 
good coverage--coverage they can afford. This wasn't something we got 
done overnight, but it is something we worked at, and it is something 
we can achieve in every State if we are willing to do the work.
  Democrats and nonpartisan government officials have worked for years 
here in Washington to try to make this health system work, and we have 
made real progress. Now Republicans in Congress are ready to throw away 
these years and years of progress. They are ready to threaten the 
collapse of our insurance markets. They are ready to threaten the 
health and the safety of millions of Americans simply to make a 
political point. They are ready to repeal and run.
  In Massachusetts, right now, families are watching this debate, and 
they are worried about what happens to them. Kids with diabetes and 
moms with cancer are worried. Hospitals and insurers are watching, too, 
and they are worried--worried about an irresponsible Republican Party 
that is more interested in political stunts than in helping Americans 
get access to health care.
  I don't blame them for being worried because this isn't a game. There 
is no magic replacement plan that will suddenly make everything all 
better. In Massachusetts, we can't just snap back to our old health 
insurance system if Republicans decide to rip up the Affordable Care 
Act. Other States across the country are also facing the terrifying 
prospect that they will be left high and dry as a result of the 
Republicans' reckless actions.
  Every Senator here has ideas about how to improve health care in 
America, but no Democratic Senator will vote to destroy it today based 
on the vague assurance that maybe at some point Republicans might think 
up some kind of replacement plan later on. The Republicans' strategy is 
repeal and run. Repeal and run. That is not governing. That is not 
leadership. It is one of the most reckless and irresponsible things 
that has ever been proposed in this Congress. I know some Republican 
Senators agree with that. I know they are worried about whether this is 
the right move forward, given all that hangs in the balance. I hope 
their consciences get the better of them and they scuttle this plan 
before it is too late. I hope they remember that every single Senator 
who votes to destroy health care in America will be responsible for the 
disastrous consequences that come next.
  If Republicans actually want to improve health care in America, let's 
talk about how to do that. That is what we were sent here to do. That 
is what voters--conservative and liberal, Republican and Democratic--
expect us to do. If Republicans want to destroy health care in America, 
I will fight them every step of the way. The stakes are too high for 
the millions of Americans whose futures are about to be sacrificed so 
one party can make a political point.
  Let's stay and do the work that needs to be done to make sure every 
American gets access to high-quality, affordable health care. Repeal 
and run is for cowards.
  Mr. President, I yield.
  The PRESIDING OFFICER. The Senator from New Mexico.
  Mr. UDALL. Mr. President, I rise, along with Senator Warren and my 
other colleagues this evening, to oppose this action by President-Elect 
Trump and congressional Republicans to take health care away from tens 
of thousands of New Mexicans.

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  Let me be clear. What President-Elect Trump and Republicans are doing 
now will throw health care into chaos. It is reckless. It will hurt 
thousands of New Mexicans and millions of Americans. The worst part is, 
the Republicans have no plan to replace care they will take away.
  The Affordable Care Act is not a perfect law. I have always said we 
should work to improve it. It has helped thousands of people in my home 
State of New Mexico. Before we passed the Affordable Care Act, New 
Mexico had a high rate of people without health insurance. It was one 
of the highest in our region and in the country. Since 2010, that 
number has gone down 44 percent--pretty incredible.
  Countless people have written me, called my office, and stopped me on 
the street to tell me how relieved they are to have health care. Others 
tell me we can't afford to go back to having insurance companies in 
charge, we can't go back to caps on coverage, back to allowing 
corporations to deny care because of a preexisting condition, and back 
to lifetime limits.
  Tonight I want to share what just a few of my constituents have told 
me.
  ``Save my daughter.'' That was the heartbreaking plea that came to me 
from one of my constituents, Kevin from Albuquerque. Kevin's 33-year-
old daughter Amber has multiple sclerosis. It is a tough disease, as we 
all know.
  To treat her MS, Amber must follow an exact and rigorous drug 
regimen, coupled with regular visits to her neurologist and annual 
MRIs. The retail cost of her drugs is $60,000 per year. Her doctor 
visits and MRIs would run into the thousands of dollars.
  Amber works. In fact, she has a good-paying job, but her employer 
does not provide health insurance. Amber purchases health insurance 
through the individual open market without Affordable Care Act 
subsidies. Amber is able to work because she gets the medical care she 
needs through insurance. Kevin fears his daughter will lose the right 
to health insurance if the Affordable Care Act is repealed. The ACA 
makes it illegal for an insurance company to deny you coverage if you 
have a preexisting condition such as MS.
  The Affordable Care Act provides assurance that Amber will get the 
coverage she needs to remain healthy, to lead a normal life, to work, 
to contribute to society, and to stay off public assistance, and to 
survive. This one provision protects an estimated 861,000 New Mexicans 
and an estimated 134 million Americans. It is a safe bet that all of us 
here know at least one person like Amber. It isn't surprising that the 
vast majority of Americans--close to 70 percent--want to keep this 
protection.
  The Kaiser Family Foundation estimates more than one-quarter of all 
adults under age 65 have health problems and that could make them 
uninsurable without the Affordable Care Act. If President-Elect Trump 
and the Republicans get their way, all of this will be at risk. Kevin 
is also scared because the cost of treating Amber's disease is so high. 
Without the ACA, any insurance company could cut off her health 
coverage if her medical expenses exceeded the company's lifetime limit. 
This provision protects an estimated 550,000 New Mexicans and an 
estimated 105 million Americans.
  People who need medical care the most, people with serious medical 
problems, have some of the highest medical costs. If President-Elect 
Trump and Republicans have their way, care for people like Amber would 
be wiped away. I am the father of a daughter, and I am angry this 
father has to worry about whether his daughter will get the medical 
care she needs to live a healthy and productive life.
  Let me tell you about Pam and Mike. They are a husband and wife from 
Placitas. They own a small business. They signed up for an insurance 
plan under the Affordable Care Act as soon as they could because 
premiums before the ACA were too expensive and Pam had a preexisting 
condition. Using their new preventive care, they found out that Mike 
had an aggressive form of cancer. Thankfully, doctors caught the cancer 
at an early stage. Mike was treated at the New Mexico Cancer Center and 
is now cured. Pam says there is no question that the ACA saved her 
husband's life.
  Because of the ACA, private health plans must cover a range of free 
preventive services--everything from cancer screening to flu shots. 
Over 730,000 New Mexicans now benefit. Discovering a disease early 
saves lives and reduces health care costs, but preventive care is 
expensive if you are uninsured or poor.
  An overwhelming majority of Americans--83 percent, in fact--support 
making preventive health care free. What would President-Elect Trump 
and Republicans do to make sure Pam and Mike and millions of others can 
keep getting cancer screenings? Nothing. They have no plan. They talk 
but no plan.
  Next, I want to tell you about Karen from Albuquerque, the mother of 
two college-aged children. Karen's son graduates next May and turns 23. 
She is worried he will not get health insurance for an entry-level job. 
Her concern is well-founded since young adults have the lowest rate of 
access to employer-based insurance. Young adults do get sick, and one 
in six has a chronic illness such as cancer, diabetes, or asthma. Karen 
wants her son to have medical care if he needs it.
  Today, the ACA allows him to stay on her insurance policy until he 
turns 26. This is one of the ACA's most popular provisions. The vast 
majority of Americans--85 percent--want young adults to be able to get 
insurance, but President-Elect Trump and congressional Republicans 
would leave an estimated 15,000 New Mexicans, like Karen's kids, and an 
estimated 2.3 million Americans without coverage because they have no 
plan to replace the Affordable Care Act.
  New Mexico is not a wealthy State. A lot of working people qualify 
for Medicaid. New Mexico wisely adopted the Medicaid expansion under 
the ACA, allowing 82,000 more people to get health care. Before the 
ACA, the only place many New Mexicans could get health care was in the 
emergency room. Now many are scared that President-Elect Trump and 
Republicans will take their health care away.
  Take Amy, her husband, and her four boys--ages 13 to 19. Amy and her 
husband own a family business in Sante Fe. Before the ACA, they went 
without health insurance because they couldn't afford it. They just 
hoped nothing catastrophic happened to them. As soon as she could, Amy 
applied for health insurance under the Medicaid expansion. It covers 
her, her husband, her oldest son. Amy says she is grateful that because 
of the ACA, medical bills will not ``drain us financially.''
  There are 8.4 million people across this country like Amy. Like Amy, 
many are low-income workers. They have jobs but no health insurance. 
They couldn't afford health insurance before the ACA, and they will not 
be able to afford it if President-Elect Trump and congressional 
Republicans have their way and repeal it with no plan to replace it.
  These hard-working Americans deserve good medical care. Americans 
agree. Eighty percent favor the Medicaid expansion for low-income, 
uninsured adults.
  Finally, we have 19 pueblos--Indian pueblos--and 4 tribes in New 
Mexico. Native Americans make up more than one-tenth of our population. 
As vice chair of this body's Indian Affairs Committee, I represent all 
of Indian Country. Native Americans are eligible to receive care 
through the Indian Health Service, but it is severely underfunded.
  Long delays are common. As a result, many tribal members rely heavily 
on Medicare, Medicaid, and the ACA health exchanges. More than 132,000 
tribal members are enrolled in Medicaid in New Mexico alone. The All 
Pueblo Council of Governors, which represents all 19 pueblos, tells me, 
without the ACA, more tribal members will go back to the days of long 
delays, many will see their coverage cut.
  This is also the subject of an amendment I will be offering. Indian 
Health Services' hospitals are heavily dependent on third-party 
collections for clinical services. In fact, current Federal funding 
covers less than half of their operational costs. Fortunately, 
increases in revenue from the Medicaid expansion have offset those 
annual costs. But without that revenue, necessary services may no 
longer be available throughout Indian country. This is unconscionable. 
My amendment would protect the Indian Health Service from any cuts in 
Federal funding if the Affordable Care Act is repealed.

  There are tens of thousands of stories in New Mexico like those of 
Kevin,

[[Page S147]]

Pam, Mike, Karen, and Amy. Over 360,000 New Mexicans have gained health 
care since the Affordable Care Act was passed, and over 21 million 
Americans have health insurance because of ObamaCare. I have heard from 
New Mexicans who are terrified because there is no plan to replace the 
Affordable Care Act's protections, benefits, and rights.
  Republicans have called to repeal and replace the Affordable Care Act 
for years. They have had years to figure out how to replace it, and 
they have not. They have no plan. Repeal and replace is not a sound 
public policy. It is only a sound bite.
  Health care is a basic human right. Providing adequate medical care 
for everyone should be our guiding principle for health care policy. 
What is the guiding principle of repeal and replace? Act now; figure it 
out later.
  I have said it before: The Affordable Care Act is not perfect, but it 
was historic--the biggest expansion of health care since the 1960s. It 
has helped millions of Americans get care. Many of them now can see a 
doctor regularly for the first time ever.
  We need to work to improve, not repeal the Affordable Care Act.
  Thank you, Mr. President.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from New Mexico.
  Mr. HEINRICH. Mr. President, I am here tonight to join my colleague 
the senior Senator from New Mexico and all my other colleagues on the 
Senate floor to stand up for hundreds of thousands of my constituents 
in New Mexico who will lose their health care coverage if Republicans 
repeal the Affordable Care Act and throw our Nation's health care 
system into chaos.
  It is absolutely criminal for Republicans to strip millions of their 
health care without even a conceptual replacement plan in place. To my 
colleagues on the other side of the aisle, I want to make it clear that 
``we will fix it later'' simply doesn't cut it.
  They promised repeal and replace, and now they are giving us repeal 
and run, and that will cause chaos in our health care system. In my 
home State of New Mexico, according to the Urban Institute, an 
estimated 266,000 people will lose their health care coverage. This is 
not a change to their plan or a different premium. They will lose their 
coverage in its entirety. Thousands more of our State's 2 million 
residents will lose access to birth control and other preventive 
services and Medicare prescription drug coverage. Nearly everyone will 
be subjected to higher costs for lower quality insurance, especially 
those with preexisting conditions. Dismantling our health care system 
would also put at risk many of the gains we made in protecting the 
860,000 New Mexicans who have preexisting conditions like cancer, 
diabetes, and heart disease. These individuals will be forced to pay 
more for their health care coverage and possibly lose access 
altogether.
  This is not a game; this is a matter of life and death. Without any 
plan in place, this repeal and run maneuver will cause health care 
costs for all Americans to skyrocket. Dismantling our health care 
system literally means taking hundreds of dollars each month away from 
hard-working families. In my book, that is highway robbery. How? It is 
simple. This reckless Republican repeal and run will strip away the tax 
credits that help many working Americans afford their premiums. More 
than 32,000 New Mexicans rely on those tax credits, which average about 
$200 a month--well over half of their monthly premium for health care 
coverage. Many of the sickest, oldest, and the poorest of our neighbors 
and family members will lose their health care coverage altogether.
  Over 20,000 New Mexican seniors will be forced to pay $1,000 more per 
year for their prescription drugs. Fixed income seniors can't afford to 
pay more for prescription drugs.
  Dismantling our health care system is particularly problematic in our 
Nation's rural areas, including much of the State of New Mexico. Last 
fall I went on a multiday rural health care listening tour across 
communities throughout Northeastern New Mexico. Rural hospitals like 
those in Raton, Clayton, and Santa Rosa are often the only health care 
providers for hundreds of miles in any direction. Under the Affordable 
Care Act, rural hospitals agree to exchange higher rates of insurance 
coverage for their patients for a reduction in reimbursement rates. In 
other words, they aren't being paid as much per patient as they once 
were, but the number of patients who come in without any insurance is 
dramatically lower. Now Republicans are going to take away coverage 
from a quarter million New Mexicans, but they aren't going to give 
rural hospitals their higher reimbursement premiums back. This repeal 
and run maneuver will cause many rural hospitals that already are 
operating on the margins to shut their doors or to simply turn away 
sick patients.
  Nationwide, nearly 700 local hospitals in rural communities face the 
risk of imminent closure. Think about that. That is nearly one-third of 
the Nation's hospitals. Almost all of them would be forced to turn away 
patients if the Republicans move forward in dismantling our Nation's 
health care system. In New Mexico, that would mean forcing many of my 
constituents to drive for hours to access critical lifesaving care. It 
would also shake our State's economy to its core.
  Health care jobs were one of the few economic bright spots in New 
Mexico over the past 6 years, particularly in rural communities, but 
this reckless plan--or I should say lack of one, to be accurate--throws 
our Nation's health care system into chaos and scars New Mexico's rural 
communities for years to come. A community whose hospital shuts down 
may never recover. That is what is at stake here. Denying a family 
health care, denying a whole community health care is reckless and 
immoral.
  You might hear Republicans say they want to tear everything apart 
now, but we shouldn't worry because they will fix it later. Let me be 
clear: We have the capacity to fix and improve our current health care 
system in a bipartisan way without throwing it all into chaos, but 
Republicans have to make that choice before it is too late. I would 
welcome honest attempts to find ways to improve our Nation's health 
care laws, to make them work better for all Americans.
  In the past, I have taken the lead on commonsense fixes to our 
Nation's health care policies. In 2010, in the House of 
Representatives, I led the fight to extend coverage to the children of 
military families covered by TRICARE up until the time they are 26 
years old. After hearing from many small businesses in New Mexico, I 
fought to repeal unnecessary 1099 tax reporting requirements for small 
businesses. To this day, I continue to work with Republicans like Dean 
Heller of Nevada to eliminate the so-called Cadillac tax that would 
place an incredibly unfair tax burden on employer-provided health 
insurance that many working families rely on.
  Republicans need to put partisan politics aside and remember why 
Congress passed the ACA in the first place: To expand access to quality 
health care for all Americans. Before we passed health care reform, New 
Mexico had the second highest rate of uninsured citizens in the entire 
Nation.
  I have heard from a lot of New Mexicans who have told me how access 
to health care coverage has impacted their lives, even saved their 
lives. I would like to tell you just one story of one of those New 
Mexicans.
  Karen from Santa Fe is a registered nurse, and she is a breast cancer 
survivor. As a nurse, Karen has seen how health care reform and the 
reduction of uninsured and uncompensated care has helped community 
hospitals better serve their patients. But the real impact of health 
care reform for Karen has been personal. When she was diagnosed with 
breast cancer in 2002, Karen's insurance company dropped her coverage. 
When she had to pay out of pocket for her coverage, her costs doubled. 
As she went through several more recurrences of cancer, Karen went 
bankrupt. She lost her home.
  In a letter to me, she said: ``Cancer is hard enough, but not to be 
able to afford my co-pays and appointments caused me so much stress it 
made me more vulnerable for complications.''
  Today, Karen is able to afford health care coverage even with her 
preexisting condition. But Republicans are threatening to take that all 
away from her and from hundreds of millions of other Americans.
  Karen went on to say in her letter:

       No one should go without health care because of income. 
     Good health is not a privilege for a wealthy few, but a human 
     right.


[[Page S148]]


  It is hard to say it any better than that. No American has sent their 
elected representative to Washington to score political points and 
threaten the health and finances of hard-working Americans. Republicans 
need to realize that is exactly what they are doing. What they are 
doing means chaos. It means less health care. It is that simple.
  I wish we could be here today talking about pragmatic policy 
solutions to reduce health care costs and improve how providers 
actually deliver that care. Instead, and unfortunately, we are here 
trying to stop Republicans from turning bumper sticker governance into 
a very real disaster for thousands of my constituents and millions of 
Americans. This reckless effort threatens the very lives and the 
livelihoods of the people of New Mexico.
  I will not stand for that, and I know my constituents will not 
either.
  The PRESIDING OFFICER. The Senator from Minnesota.
  Mr. FRANKEN. Mr. President, like my colleagues here today, I rise to 
talk about the Republican effort to repeal and replace the Affordable 
Care Act. I have been talking to a lot of people in Minnesota who have 
health insurance, thanks to the Affordable Care Act, or whose lives are 
changed by the protections in the ACA that benefit every American. 
Frankly, they are scared, hard-working people for whom this is 
literally life or death. If their health insurance is taken away, they 
do not know what they are going to do.
  Today, on their behalf, I have one request for my Republican 
colleagues: Show us your health care plan. You must have one. We would 
like to hear it. We would like to see it now. You can understand the 
question, right? If your child had cancer and the Affordable Care Act 
was the reason you could get health insurance, you wouldn't want to rip 
up the ACA before knowing what would replace it. I am not the only 
Senator with constituents whose lives are on the line here, so I know 
that you don't intend to rip up the Affordable Care Act and leave them 
with nothing. You have to have a plan, right? So let's just see it.
  Last week, President Obama said that if Republicans produce a plan 
that is ``demonstrably better than ObamaCare,'' he would support it, 
and so will I. Just show it to me. President-Elect Trump clearly has a 
plan. He laid it out, laid it all out during his campaign. His plan 
was, he said, to ``repeal ObamaCare and replace it with something 
terrific.'' That is what he said. Then he went into a little more 
detail and explained that ``something terrific'' would be ``so much 
better, so much better, so much better.''

  Terrific. So much better. That sounds great. Let's see it. One of 
Trump's top advisers said on MSNBC: ``We don't want anyone who 
currently has insurance to not have insurance.'' Great. Neither do we. 
Speaker Ryan said that there will ``be a bridge so that no one is left 
out in the cold, so that no one is worse off.'' That is wonderful. No 
one being worse off is exactly what we want to see.
  I am sure Speaker Ryan's staff was mistaken when they later told a 
reporter that the ``no one worse off'' applied only to the transition 
period, not to the replacement period. Show me the plan, please. Please 
show me the plan that keeps coverage for the 20 million people who have 
gained coverage that would continue to bend the cost curve so the cost 
of the entire health care system continues to grow less quickly than it 
did before ACA was adopted, the plan that would ensure that nobody gets 
denied coverage when they need it or has to unfairly pay more than 
someone else because of their gender or a preexisting condition. Show 
me that plan.
  I know Republicans have put forward some different plans, a lot of 
different plans, but a lot of plans is not a plan. A lot of plans is 
not a plan. We want to see the plan, you know, the one you have been 
working on for 6 years. I was here in 2009 when we passed the ACA. I 
know how hard it was. If I could, let me offer you something. Some of 
your Republican friends actually did come up with a health care plan a 
while ago. It all started at the Heritage Foundation, which is a bona 
fide conservative think tank.
  Over at Heritage, they did not like the idea of single-payer health 
care insurance, where the government is everyone's insurer. So what 
they wanted to come up with was a way to use the magic of the 
marketplace to solve the problem of providing everyone access to 
insurance.
  Here is what they came up with, a three-legged stool. The first leg 
is, insurance companies can't deny coverage to people with a 
preexisting condition. They can't charge them more. We can all agree on 
that, right? President-Elect Trump and I agree on that, for sure. It is 
a great idea--great idea--but there is a catch. If you can not turn 
people down because of preexisting conditions, you cannot charge them 
more, well then everyone would just wait to buy health insurance until 
they get sick and need care. But the whole idea of health insurance is 
that at any given moment, most of the people paying premiums are 
healthy. So their premiums cover the cost of the people who are sick.
  If the only people with insurance are sick, the premiums will 
skyrocket. So you need a way to get healthy people into the system to 
bring the cost of insurance down, which brings us to leg No. 2. 
Everyone has to be insured, otherwise known as the individual mandate. 
Everyone has to be insured. The Heritage Foundation said that. They 
called it the free rider syndrome. They said, no, everyone has to be 
insured.
  This is what conservatives now say they hate; that the government 
says everyone has to buy insurance. But if you have to sell everyone 
insurance, then everyone has to buy it or the cost explodes. Now, look, 
if you have a better way to keep people covered and keep costs down, 
show me the plan. Show me the plan. But this is the best one the 
Heritage Foundation could come up with.
  But wait, what if someone can't afford that health insurance? That 
brings us to the third leg. The government will subsidize insurance for 
people who can't afford it. Voila. There you have it, the Heritage 
Foundation plan, which a Republican Governor then implemented in a 
State to huge success.
  Let me ask you, my Republican friends, is that your plan? Because if 
it is, it works for me. Guess what. Then we don't even have to repeal 
the Affordable Care Act in order to replace it with this plan because 
this plan was the model for the Affordable Care Act. The Affordable 
Care Act is not perfect. Premiums went up a lot this fall for people 
buying insurance through the marketplace.
  It is often ignored that subsidies cover the cost increases for about 
70 percent of those folks, but for many those increases genuinely hurt. 
That is a real problem. Then the solution to it is to recognize that 
subsidies don't provide enough help and don't go to enough people. 
Let's fix that. There are places where there is not enough competition. 
The best and most direct solution that I know of is to introduce a 
public option.
  If my Republican colleagues have another idea about how to address 
these costs and competition issues that would ensure that people don't 
lose their coverage, I am ready to roll up my sleeves and go to work. 
While we are honest about the shortcomings, let's not forget the bottom 
line. As a primary care doctor for Indiana University's Health 
Physicians said, ``I've been a registered Republican my whole life, but 
I support the Affordable Care Act because it allows patients to be 
taken care of.''
  For 6 years, you have been blasting the ACA, promising to replace it 
with something better. Let's see what you have, but don't just tell me 
your plan. I want you to join me on a trip to Minnesota to see Dolly. 
Dolly is one of my constituents who wrote to me about her husband's 
pulmonary embolism. Before the ACA, she and her husband both had jobs 
that did not offer health insurance, but once the ACA passed, they were 
able to buy insurance and go to the doctor.
  The doctor discovered her husband's embolism and saved his life. I 
would like you to look Dolly in the eye and explain how your plan--your 
plan--will ensure that her husband's life will not be endangered.
  I would like you to join me in talking to Gina. Before the ACA became 
law, Gina's father was undergoing treatment for leukemia. Then one day 
he was told he had hit the lifetime maximum on his insurance coverage. 
From that point on, the family would have to

[[Page S149]]

pay for his treatment out of pocket, but they did not have the money so 
they stopped treatment. Gina's father died 3 days later.
  Since then, Gina's fiance was diagnosed with Crohn's disease. So I 
want you to explain to Gina how exactly under your plan Gina will not 
face the same kind of impossible financial situation with her future 
husband's condition that she did with her dad. Sit down with Gina and 
tell her that.
  Now, once you are done calming Gina's concerns about what your plan 
might do to her family, we will go over and talk to Leanna. Leanna's 3-
year-old son Henry has been diagnosed with acute lymphoblastic 
leukemia. His treatment will last until at least April of 2018. He 
often needs around-the-clock care to manage his nausea, vomiting, pain, 
and sleepless nights. Little Henry's immune system is so compromised 
that he is not supposed to go to daycare. So Leanna has left her job to 
take care of him. They are supported by her spouse, but they could not 
pay for his treatment on one salary.
  Leanna says:

       It is because of the ACA that Henry gets proper health 
     care. Henry can get therapy and the things he needs to 
     maintain his health and work towards beating cancer. Henry is 
     still with us because of the ACA.

  Let me say that again. ``Henry is still with us because of the ACA.'' 
I want you to sit down with Leanna, as she holds her precious 3-year-
old son, and explain how Henry will still be with us under your plan. 
Show us your plan. Show us your plan.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Connecticut.
  Mr. BLUMENTHAL. Mr. President, I am honored to be here tonight with 
my very eloquent colleague Senator Franken from Minnesota and also with 
two colleagues who will follow me shortly, Senator Schatz and Senator 
Markey, all of them great champions of better, more affordable health 
care for all the people who live in this great country.
  This is the greatest country in the history of the world because we 
care about each other and we care about the common good. That is what 
the Affordable Care Act represents. It is not perfect. No great social 
reform ever is the first time around, including Social Security, but it 
can be repaired and improved without completely repealing it.
  So repeal without a replacement is the height of irresponsibility. 
The first order of business for the Republican leadership during this 
session of Congress is to tear down and rip apart the Affordable Care 
Act, not to deal with job creation or economic growth. In fact, the 
Affordable Care Act provides 3 million jobs in our country, and 
repealing it would eliminate those jobs. No, it is to destroy and 
decimate a program that has literally saved lives, opened new futures, 
transformed the existences of millions and millions of Americans who 
would lose health care coverage if this measure is just repealed.

  In fact, 22 million people across the country and more than 100,000 
in Connecticut would lose that critical insurance. Preexisting 
conditions would become, again, an excuse for the health care industry 
and insurance companies to deny coverage. Women would be charged more 
simply because they are women. And young people would be denied access 
to their parents' health care coverage up to the age of 26.
  Those kinds of losses just begin the list, but among the most 
egregious of the profound defects to this approach is the effect on the 
Prevention and Public Health Fund. I know it isn't a household term: 
Prevention and Public Health Fund. It is not exactly on everyone's 
tongue, but it is a measure that is profoundly important to the future 
of this Nation if you care about lives and dollars. And if you care 
about dollars, the $931 million from the Prevention and Public Health 
Fund is allocated to provide funding for things like diabetes 
prevention, preventing healthcare-associated infections, chronic 
disease management, smoking prevention, lead poisoning, suicide 
prevention, and Alzheimer's disease prevention.
  You may not consider these kinds of challenges--smoking prevention, 
lead poisoning, Alzheimer's disease, hospital-acquired infections--as 
the most glamorous, but treating them costs millions and millions and 
millions of dollars--in fact, billions of dollars.
  Just to give you one example, the Tips From Former Smokers campaign, 
which the Prevention and Public Health Fund supports, has led to an 
estimated 1.6 million smokers attempting to quit smoking and has helped 
100,000 Americans quit smoking. Tobacco use is the single largest 
preventable cause of disease and premature death in the United States. 
The country spent $133 million on tobacco-related healthcare costs 
between 2000 and 2012.
  I just made I think an error. I said $133 million. In fact, it is 
$133 billion. How easy it seems to confuse billions with millions--$133 
billion by investing this kind of money from the Prevention and Public 
Health Fund. We can literally save tens of billions of dollars on 
smoking-related diseases and premature deaths.
  Improving public health outcomes and preventing the public from 
getting sick and dying are important goals in and of themselves because 
the human suffering and the premature deaths they cause are important, 
humane causes to our Nation, a nation that cares about people. But the 
$1.3 trillion in treatment costs and lost productivity every year--let 
me repeat that--$1.3 trillion in treatment costs and lost productivity 
every year on chronic diseases like cancer, diabetes, heart disease, 
and stroke can be reduced and, dare I say at some point, reduced by so 
much that we may look back, and we will say: That Prevention and Public 
Health Fund was one good investment, but not if it is decimated and 
destroyed by the repeal of the Affordable Care Act, which costs us 
money as well as lives.
  In Connecticut, the fund has invested over $27 million in our 
communities since 2010, improving the lives and well-being of the 
people of Connecticut literally every day.
  This strong investment has provided more Connecticut women with 
screenings for cancer, mammograms, other critical, preventive care, and 
it has given our State health department the ability to prevent 
diabetes, heart disease, and stroke and to fight obesity through 
improved physical activity.
  It has allowed our State to address school health much more 
effectively, and we are talking about the Nation's children--preventing 
obesity, smoking, diabetes, which, as we know, more and more affects 
our children.
  It has staved off disease outbreaks by providing Connecticut with 
millions of dollars to provide vaccinations for young people who 
otherwise would go without, children who would be denied this essential 
means of preventing emotionally crippling, if not physically 
debilitating, diseases that can transform their lives forever.
  Perhaps most importantly, the Prevention Fund has relied on the 
communities impacted by the money for solutions. That means stronger 
collaboration between community organizations and the health system to 
prevent suicides, for example, in the Community Transformation Grants 
Program that encourages healthier lifestyles across our State.
  The ACA, in short, has reflected a historic shift. We are trying to 
prevent, not just treat the disease, and that kind of investment from 
the Prevention and Public Health Fund in my State and many others has 
already produced a return on that investment which is of invaluable 
importance.
  I have authored an amendment, which currently has 12 cosponsors, to 
create a budget point of order against any piece of legislation that 
would take away funding for preventive care. It is very simple. If we 
are going to work toward reducing the cost of health care in this great 
country, we should not be talking about getting rid of effective and 
efficient ways of preventing disease. We ought to be talking about 
reducing drug prices, stopping costly addictions, preventing disease, 
and improving the quality and efficiency of care.
  I want to stress, again, the importance of reducing pharmaceutical 
drug prices, which has been a concern to me for years in this job and 
for many more years when I served as our State's attorney general.
  But reducing health care costs and improving quality is not what our 
Republican colleagues are trying to do.

[[Page S150]]

They are trying to make good on campaign rhetoric and political 
promises to completely repeal the Affordable Care Act without any 
replacement, without following through on their commitment to provide 
health insurance to our Nation's people. We are expected to just wait 
and see what they have in the plan. Meanwhile, millions of people will 
be left without health care, and the health care industry will be in 
confusion and chaos as insurance companies wonder what comes next.
  The simple fact is that our Republican colleagues have no idea, no 
clue, no plan. In their view, the Earth is flat. They can abolish 
something and promise to replace it because they know something will 
come. That is unacceptable, and I will fight to ensure that the 
Affordable Care Act continues to mean access to affordable health care 
for millions of Americans. Most importantly, fairness and effectiveness 
in health care means prevention. The Prevention and Public Health Fund 
is critical to that effort.
  I hope my colleagues will recognize the importance of prevention, 
safeguarding our health, and heed the voices and faces that have been 
so dramatic and powerful to me, so inspiring in their courage and 
strength, as they were just this morning when I met with and presented 
to the people of Connecticut at an event we did there. Three brave 
women came forward to talk about what the Affordable Care Act had meant 
to them and what its loss would mean as well. These perhaps not 
immediately visible voices and faces should be a stirring reminder to 
our colleagues that we need to do better, improve the Affordable Care 
Act, make it better--but not simply trash it, decimate it, destroy it, 
and abandon the great hope and ideal of assuring affordable care for 
all.
  I yield now to my colleague from Hawaii, Senator Schatz, who has been 
a champion of affordable care in this Nation and is a great credit to 
his State of Hawaii.
  The PRESIDING OFFICER. The Senator from Hawaii.
  Mr. SCHATZ. Mr. President, I thank the senior Senator from 
Connecticut for his leadership on this and so many other issues on 
behalf of the people of his home State.
  Before I get into prevention as a policy issue, I just want to 
reiterate a process point.
  Here we are in the world's greatest deliberative body--the world's 
greatest deliberative body--and there really are so many talented 
individuals who come from county counsels, who come from State 
assemblies, who come from State senates, who come from the U.S. House, 
and find themselves in the U.S. Senate, the world's greatest 
deliberative body. And here we are debating one of the biggest public 
policy issues over the last decade, arguably over the last generation. 
Here we are.
  I am thinking about my early days in the Hawaii legislature and what 
we would do. If we wanted to move a bill along but we weren't sure 
exactly what to do, we would flaw the effective date because we knew 
the language didn't work yet, but we wanted to take it to conference 
committee. We didn't want it to be enacted into law, but we wanted it 
to move through the process. So what we would do is we would flaw the 
effective date. We would say ``Effective year 2100,'' so that even if 
it were accidentally enacted into law, it wouldn't have the force of 
law.
  Yet once in a while, a staffer or a member would make a clerical 
error and actually enact something with a delayed effective date into 
law, and they were humiliated. This was a mistake. This was a clerical 
error, and this showed that it was amateur hour. This showed that 
somebody didn't know what they were doing. This showed that somebody 
wasn't a very serious legislator.
  Yet here we are in the Nation's legislature, here we are in the 
world's greatest deliberative body, and we are doing that on purpose. 
We are doing that right away. We are doing this with the Affordable 
Care Act after 7 years of blasting this law because they know they 
can't repeal the parts that are popular. So what they are going to do 
is eviscerate the revenue attached to the bill and leave themselves, as 
one of my colleagues said, in a ``box canyon'' so the only thing they 
can do is shovel money to insurance companies--borrowed money--to 
maintain the benefit because they don't want to deal with the political 
ramifications of what they had done to their constituents on 
preexisting conditions, on coverage for people up to the age of 26, on 
prevention.
  This is the most unserious effort I have seen in this legislative 
body. This is absolutely unserious. And whatever your political 
persuasion is, you should ask every Member of the Senate to stand up 
and be counted and say what they want to do about health care in the 
United States.
  The answer can no longer be because it is an article of faith that 
because the Affordable Care Act has ``Obama'' in its name--it is 
ObamaCare--it must be bad, and it must be repealed root and branch. 
That is no longer acceptable.
  This President is only President for another 10 days, and we have an 
obligation to our constituents to say what we are going to do about 
this law. We all know that we should get a regular check-up from our 
doctor, eat fruits and vegetables, and exercise as much as possible, as 
difficult as it is for all of us at times. Why do we do this? Any 
doctor will tell you that it is better to stay healthy and prevent 
disease than to get sick. It is not just common sense. It is not only 
less painful for people, but it is less costly to prevent illness than 
to treat it.

  The same is true for public health. If we can prevent drunk driving 
or the spread of diseases such as Zika, we could save lives and save 
the public money. That is why Senator Cassidy and I introduced the 
Public Health Emergency Response and Accountability Act last Congress. 
Our bill, on a bipartisan basis, recognized, basically, that we should 
be able to respond quickly to public health threats before they spread 
and harm more Americans and cost more money.
  That is what the ACA does through its Prevention and Public Health 
Fund. The fund serves a very important dual purpose, investing Federal 
dollars in effective programs that prevent disease and also it saves 
money.
  It is a simple concept. We should stop diseases from developing or 
spreading before they start. This sounds like common sense to almost 
everybody, but here is the problem. In the partisan battle around the 
ACA, even a really good idea within the Affordable Care Act must be bad 
because it is part of ObamaCare. This is insane.
  This is the Prevention and Public Health Fund that provides money to 
the Centers for Disease Control. The CDC did an incredible job with the 
U.S. Public Health Service, with the U.S. military in addressing the 
Ebola crisis. The CDC did an incredible job, again, with the National 
Institutes of Health and others in addressing the potential Zika 
crisis, which looks to have abated. The CDC does incredibly important 
work in tobacco prevention and cessation, and this Prevention and 
Public Health Fund has gotten 1.8 million individual smokers to call 
and try to quit smoking. That is hundreds of thousands of lives saved, 
not just in blue or purple States but all across the country. This 
Prevention and Public Health Fund helps our elderly to avoid falls. It 
helps our elderly to avoid falls. I know there are people of goodwill 
on both sides of the aisle. I know that we are all responsive to our 
senior citizens in our individual communities, and I know that this is 
a smart and humane use of public health money. If we can prevent an 
elderly citizen from falling in their own home or falling on the way to 
a bus stop or to church or to a family member's home, that is money 
well spent, not just morally but fiscally.
  This is my great regret when it comes to the Affordable Care Act and 
the debate that is happening. The only time I hear a serious-minded, 
good-faith debate between a Republican and a Democrat in the Senate 
when it comes to the Affordable Care Act is in private, because if you 
look at this side of the Chamber, there is only one Member of the 
Republican caucus who is here. We are not having the world's greatest 
deliberative body deliberate over the Affordable Care Act. We have an 
empty Chamber, full of Republicans who are absolutely bound and 
determined to walk off this cliff and take 22 million Americans with 
them.
  Public health prevention works. Public health prevention is fiscally 
prudent, and it is the humane thing to do. That is just one of the many 
attributes

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of the Affordable Care Act that ought to be preserved.
  If there is to be a good faith conversation about how to improve upon 
the Affordable Care Act, we are all ears. I can guarantee you that 
there are 48 of us who want to have that conversation, but do not put 
the whole country into this box canyon. Excuse me for mixing my 
metaphors. Do not take the whole country off this cliff because it is 
going to be very, very difficult for us to make good policy after that.
  With that, I yield the floor to the senior Senator from 
Massachusetts.
  Mr. MARKEY. Thank you. I yield to Senator Daines.
  The PRESIDING OFFICER (Mr. Young). The Senator from Montana.
  Mr. DAINES. Mr. President, I ask unanimous consent that it be in 
order to call up the Flake amendment No. 52, and that at 2:30 p.m. 
tomorrow, the Senate vote in relation to Flake amendment; further, that 
following the disposition of the Flake amendment, there be 2 minutes of 
debate, equally divided in the usual form, prior to the vote in 
relation to the Sanders amendment No. 19.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.

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