[Congressional Record Volume 163, Number 27 (Wednesday, February 15, 2017)]
[Senate]
[Pages S1192-S1197]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]



                   Repealing and Replacing ObamaCare

  Mr. President, I want to once again discuss the ongoing effort to 
repeal and replace the so-called Affordable Care Act. This is one of 
our most vexing issues of the day. Of course, this isn't the first time 
I have come to the floor to discuss ObamaCare, and I am fairly certain 
it won't be the last.
  I was here just last week, in fact, talking about the general 
unanimity among Republicans on these issues, despite the seemingly 
eternal focus on the supposed divisions among our ranks. While some are 
still advancing that narrative, Republicans are, overall, still united 
in our desire to repeal and replace ObamaCare. As I said last week, I 
don't know if there is a single Republican in Congress who supports 
keeping the healthcare status quo in place. All of us want to right 
what went wrong with the poorly named Affordable Care Act and provide 
patients and consumers with more healthcare choices that address 
healthcare costs.
  Most differences of opinion that do exist on these matters are more 
about timing than anything else. As I have said before, I support 
moving quickly to repeal ObamaCare and include as many replacement 
policies as possible under the rules of the reconciliation process. 
More specifically, I support repealing ObamaCare's harmful taxes, and I 
will explain why.
  Put simply, the tax provisions in ObamaCare were poorly conceived and 
recklessly enacted, and they are harmful to our economy. Those taxes 
came in a number of forms, including the employer mandate and the 
individual mandate, both of which are enforced through the Tax Code.
  In addition, there is the health insurance tax, the Cadillac tax, 
along with new taxes on healthcare savings and pharmaceuticals. 
ObamaCare also included a payroll tax hike for some high-income earners 
as well as additional taxes on investing. And, of course, we cannot 
forget the medical device tax, which, in just the first 3 years that 
ObamaCare was implemented, resulted in more than 30,000 lost jobs in 
that important industry.
  All told, the tax provisions of the Affordable Care Act represented a 
trillion-dollar hit on the U.S. economy in the first 10 years, and the 
burdens of the vast majority of these taxes are ultimately borne by 
patients and consumers in the form of higher costs, larger tax bills, 
and reduced value in existing health plans and savings accounts.
  I know some of my colleagues like to plead ignorance on the notion 
that taxes on a particular industry tend to be passed along to that 
industry's consumers, but it is a fact that can't be ignored. Taxes on 
health insurance plans increase premiums for patients. Taxes on drug 
companies make drugs more expensive. Taxes on medical device sales 
increase the costs of those devices.
  It is not a complicated concept; it is the natural byproduct of tax 
provisions negotiated with stakeholders behind closed doors under 
threat of increased government intrusion and market regulation. These 
taxes weren't drafted solely to pay the cost of ObamaCare; they were 
also part of a strategy to get the law through Congress, dividing the 
business community and pitting industries against one another to 
prevent widespread opposition. As I said, at the end of the day, it is 
patients and consumers--individuals and families--who pay most of the 
freight on these types of tax policies.
  Don't take my word for it. Let's look at one major example. 
Congress's nonpartisan scorekeeper, the Joint Committee on Taxation, 
indicated that, by and large, the tax on health insurance premiums 
would be passed along to health insurance policyholders.
  Mr. President, I ask unanimous consent to have printed in the Record 
a letter from the JCT to Senator Grassley, dated October 28, 2009.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                    Congress of the United States,


                                  Joint Committee on Taxation,

                                 Washington, DC, October 28, 2009.
     Hon. Charles E. Grassley,
     Ranking Member, Committee on Finance, U.S. Senate, 
         Washington, DC.
       Dear Ranking Member Grassley: You requested that we provide 
     you with an analysis of the incidence of the insurance 
     industry fee provision of S. 1796, the ``America's Healthy 
     Future Act,'' our estimate of the effect on the after-tax 
     price of purchased health insurance, and a distributional 
     analysis of the provision.


                         insurance industry fee

       Sec. 6010 of S. 1796 would impose an annual fee on any 
     covered entity engaged in the business of providing health 
     insurance with respect to United States health risks. Under 
     the provision, employers who self-insure their employees' 
     health risks and governmental entities are not covered 
     entities.
       The fee applies for calendar years beginning after 2009. 
     The aggregate annual fee for all covered entities is $6.7 
     billion. Under the provision, the aggregate fee is 
     apportioned among the covered entities based on a ratio 
     designed to reflect theft relative market share of U.S. 
     health business.
       For each covered entity, the fee for a calendar year is an 
     amount that bears the same

[[Page S1193]]

     ratio to $6.7 billion as (1) the covered entity's net 
     premiums written during the preceding calendar year with 
     respect to health insurance for any United States health 
     risk, bears to (2) the aggregate net premiums written of all 
     covered entities during such preceding calendar year with 
     respect to such health insurance.


                  incidence of insurance excise taxes

       The proposed fee is similar to an excise tax based on the 
     sales price of health insurance contracts. The effective 
     excise tax rate varies from year to year depending upon the 
     aggregate value of health insurance sold. The economic 
     incidence of an excise tax imposed on sale of health 
     insurance contracts (that is, who actually bears the cost of 
     the tax) may differ from the statutory incidence of the tax 
     (that is, the person on whom the tax is levied). Taxes may be 
     borne by any of the following: consumers in the form of 
     higher prices; owners of firms in the form of lower profits; 
     employees in the form of lower wages; or other suppliers to 
     firms in the form of lower payments. This makes 
     generalizations about the incidence of taxes difficult to 
     make. Nonetheless, two principles have general validity. 
     First, economic incidence does not depend on whom the tax is 
     levied. Whether the statutory incidence of the tax is on the 
     consumer, the employer, or the insurer, the economic 
     incidence is the same regardless of who writes the check to 
     the government. Second, taxes are shifted from those who are 
     more sensitive to price changes (economists describe these 
     individuals and entities as having more ``elastic'' supply 
     and demand) to those who are less sensitive to price changes 
     (those with more ``inelastic'' supply and demand).
       In the case of competitive markets, an excise tax generally 
     is borne entirely by consumers in the form of higher prices 
     in the long term. An excise tax increases the cost of 
     producing an additional unit, or incremental cost, of the 
     taxed good by the amount of the tax. In a competitive market, 
     market forces cause the after-tax price of a good to equal 
     the additional cost of producing and selling another unit of 
     the good. Competition drives the price down to equal the 
     incremental cost of the provision of the good or service, 
     including the return to incremental invested capital. If 
     supply is perfectly responsive to price changes, any price 
     above incremental cost would induce new firms to enter and 
     increase production until prices were bid back down to 
     incremental cost. Similarly, any price below incremental cost 
     would induce firms to exit or reduce production (because they 
     would now be losing money selling the taxed good). The 
     reduction in supply allows prices to increase back up to 
     incremental cost.
       This response may be observed even if some of the 
     participants in the competitive market do not seek to 
     maximize profits as their primary objective. Tax-exempt and 
     nonprofit producers may also pass on the tax as they also 
     face the increased incremental cost, which they will need to 
     recover. If they cannot, for example, raise additional funds 
     from donors, effectively passing the tax on to them, their 
     alternative is to pass on the tax to consumers in the form of 
     higher prices.
       While consumers are thought to bear the burden of excise 
     taxes in competitive markets, some may question the degree of 
     competition in health insurance markets. Recent surveys have 
     noted that many markets are characterized by the presence of 
     only a few firms. Additionally, there may exist barriers to 
     entry in the health insurance market, including multiple 
     State regulatory requirements, the cost of establishing 
     health provider networks, health provider network effects 
     (i.e., the value of a health provider network to consumers 
     rises with the size of the network), and efficiencies in 
     risk shifting and risk distribution for large firms.
       However, the absence of many competitors does not by itself 
     imply that there is no competitive pressure on prices. The 
     threat of potential entrants may provide competitive price 
     pressure on the existing firms. Furthermore, the option to 
     self-insure may provide a source of potential competition for 
     full, purchased insurance, at least for larger firms.
       If the insurance industry is not perfectly competitive in a 
     particular market, the question remains as to what extent an 
     insurance excise tax would be borne by consumers or producers 
     in that market. Theoretical analysis has shown that, 
     depending upon market conditions, the price could increase 
     by: (1) more than the amount of the tax; (2) exactly the 
     amount of the tax; or (3) less than the amount of the tax. 
     Various empirical studies have examined the effect of excise 
     taxes on prices in less than perfectly competitive markets. 
     Studies of the tobacco industry suggest that manufacturers 
     pass on more than the full amount of the tax, while studies 
     of less than perfectly competitive retail gasoline markets in 
     rural areas suggest that producers pass on nearly all of the 
     tax. Even in the rural retail gasoline markets in which gas 
     stations may be the sole provider of gasoline for many miles 
     and firms exhibit some pricing power, nearly 95 percent of 
     the excise tax is still passed on to consumers.
       While uncertainty exists, we assume that a very large 
     portion of the excise tax on purchased insurance will be 
     borne by consumers in most markets, including in some markets 
     with a high level of concentration among market participants 
     covered by the proposed excise tax. In the context of general 
     health care reform legislation, this assumption is further 
     supported by the presence of an excise tax on individuals 
     without minimum essential benefits coverage, which is likely 
     to make demand for insurance somewhat less sensitive to 
     changes in price, as consumers will have to buy insurance or 
     face a penalty. While consumers (or employers) may respond by 
     changing their insurance coverage from more expensive 
     coverage to less expensive plans to offset any potential 
     price increase, this behavior too is properly characterized 
     as the consumers bearing the burden of the excise tax by 
     accepting lower quality (for example, a more restricted 
     physician network) for the same price rather than paying a 
     higher price for the quality of insurance that they would 
     prefer if there were no tax. To the extent that firms can 
     avoid the tax by switching from full insurance to self-
     insurance, this may suggest that insurers are unable to pass 
     on the full cost of the excise tax on purchased insurance. 
     Increased self-insurance from firms avoiding the excise tax 
     may increase the cost of this health benefit to employees as 
     firms that previously chose full insurance, presumably 
     because it cost less in the absence of the excise tax than 
     self-insurance, switch to higher cost self-insurance. 
     Additionally, to the extent that insurers maintain some 
     pricing power in the administrative services that they 
     provide self-insurers, the self-insurance market may bear 
     some of the burden of the excise tax as well.


      effect of the fee on the cost of purchased health insurance

       The aggregate value of the proposed fee is the same for 
     each year. The current law baseline for health insurance 
     premiums projects rising health insurance premiums annually 
     through the budget period. Consequently the magnitude of the 
     proposed fee declines annually relative to the sale of health 
     insurance. Given the incidence analysis discussed above, 
     while there is imcertainty, we expect a very large portion of 
     proposed insurance industry fee to be borne by purchasers of 
     insurance in the form of higher premiums. Our estimate is 
     that the premiums for purchased health insurance policies, 
     including the tax liability, would be between 1.0 and 1.5 
     percent greater than they otherwise would be as a consequence 
     of the industry fee for calendar years 2010, 2011, and 2012.


         distributional analysis of the insurance industry fee

       Regardless of the determination of the economic incidence 
     of the proposed insurance industry fee of S. 1796, at the 
     present time the staff of the Joint Committee on Taxation is 
     not able to distribute the effects across individuals on our 
     individual tax model. The proposed insurance industry fee 
     would apply only to the revenues from underwritten policies 
     sold to third parties. It would not apply to the value of 
     health benefits received by individuals through their 
     employers who self-insure the health risks of their 
     employees. Our individual tax model is based upon a sample of 
     approximately 180,000 actual tax returns. To distribute 
     proposed tax changes related to economic activity that is not 
     already reflected on the individual tax return we impute 
     values or statistically match supplemental information such 
     as data gathered by the Census Bureau, to the individual tax 
     returns of our model. For our quantitative analysis of 
     employer-provided health benefits we have made such 
     imputations of data relating to employees' employer-provided 
     health care benefits to the individual model. These 
     imputations are based on the data collected as part the 
     Medical Expenditure Panel Survey (``MEPS''), a survey 
     undertaken by the Agency for Healthcare Research and Quality 
     of the Department of Health and Human Services, However, the 
     imputations we have made to the individual tax model at this 
     time relate only to the value of employer expenditures for 
     the health care of their employees. These imputations do not 
     generally distinguish between the employers' purchased 
     insurance coverage and benefits for which the employer self-
     insures. Consequently, we are unable to distribute either the 
     economic incidence or the revenues generated from the 
     proposed fee of S. 1796, which applies only to purchased 
     health insurance,
       I hope this information is helpful to you. Please contact 
     me if we can be of further assistance,
           Sincerely,
                                               Thomas A. Barthold.

  Mr. HATCH. While we are setting the record straight on ObamaCare, my 
colleagues on the other side have repeated a particular false claim 
that needs correction. My Democrat friends are fond of characterizing 
the repeal of ObamaCare as a tax cut for high-income earners and a tax 
increase for low- and middle-income taxpayers. That claim is simply 
false.
  According to JCT, the Joint Committee on Taxation, the Affordable 
Care Act imposed significant and widespread tax increases on taxpayers 
earning less than $200,000 a year, despite President Obama's repeated 
promises that the law would not do so. In fact, in 2017, a single 
provision--the reduction in the deductibility of catastrophic losses--
is projected to raise taxes on 13.8 million taxpaying families and 
individuals, mostly from the middle class. That is more than the number 
of taxpayers who receive exchange credits and other premium subsidies 
under

[[Page S1194]]

current law. That is just one example. There are others.
  Fortunately, we have been able to forestall the impact of a number of 
the ObamaCare tax provisions. We have fought and negotiated long and 
hard to do so, but virtually all of those taxes are still looming on 
the ObamaCare horizon.
  Most of us on the Republican side have been fighting these taxes more 
or less since the day ObamaCare was signed into law. We have 
highlighted their harmful impact on the economy and decried the crony 
capitalism that was behind the effort to draft and enact them.
  Given this long history, at least in my view, it is essential that we 
repeal all of these taxes, along with the rest of ObamaCare. It is 
difficult to imagine how Republicans, who are now in the majority in 
large part due to the promises we made to repeal and replace the 
Affordable Care Act, can now sift through ObamaCare's taxes and decide 
which ones are the least objectionable so that we can use them to pay 
for our own healthcare reforms.
  ObamaCare isn't problematic simply because healthcare costs are not 
going up; it was fundamentally flawed at the outset. The way the law 
was drafted was, and still is, a problem. The way the law was 
negotiated--with stakeholders being played against each other--was, and 
still is, a problem. Of course, the way the law was paid for was, and 
still is, a problem. The ObamaCare taxes are a big part of this 
equation. In my view--and, I think, the view of the vast majority of my 
Republican colleagues--they have to go.
  As I said, there really are not widespread disagreements among 
Republicans on these issues. Overall, we broadly agree on the 
fundamental issues surrounding ObamaCare, and, as I noted last week, it 
is not all that problematic to have some differences of opinion on the 
initial stage, so long as we can overcome those differences in the end. 
I think we can do that. More importantly, I think we will.
  Mr. President, I yield the floor.
  The PRESIDING OFFICER (Mr. Lee). The Senator from Illinois.
  Mr. DURBIN. Mr. President, pending before the U.S. Senate is the 
nomination of Mick Mulvaney, a Congressman who is seeking to be the 
Director of the Office of Management and Budget.
  If you were to ask the people of America about the Cabinet positions 
filled by the President, the one they probably would miss is the Office 
of Management and Budget. It turns out to be one of the more important 
positions, but it is not as well known historically as Treasury 
Secretary, Secretary of State, and Attorney General. It is an important 
job. It is one of the most consequential jobs because the Director of 
the Office of Management and Budget is responsible for preparing the 
President's budget, setting the priorities of the Federal budget, and 
overseeing the performance of Federal agencies. It is a big and 
challenging job.
  Many other nominees for positions in the Cabinet are well known and 
have been debated on the floor of the Senate. Today I come to say a few 
words about the record of this Congressman, Mick Mulvaney, who is 
seeking this directorship of the Office of Management and Budget. It is 
a very interesting record.
  It is not unusual for Members of the House and the Senate to have 
unusual positions on issues. I guess each one of us has something we 
believe intensely that other people question. When it comes to 
Congressman Mulvaney, there is a long litany of positions he has taken 
that are far out of the mainstream of either political party. Yet 
President Donald Trump decided this is the man, this is the person he 
wanted to head up his budgeting effort. This is the person he wants to 
set the priorities for spending in the United States of America during 
his Presidency.
  If you look at the record of Mick Mulvaney, you will find that he has 
had an eagerness to dictate large and draconian cuts across the Federal 
Government in some of our most important and most cherished programs. 
Let me tell you about a few that highlight his record in Congress. Each 
one of these that I will speak to, if advanced by the Director of the 
Office of Management and Budget, would have far-reaching consequences 
on families and individuals across the United States, not only in the 
operation of government but also in the effectiveness of our Federal 
workforce.
  To start with--and this, I think, is the right place to start--
Congressman Mulvaney, who seeks the position of Director of the Office 
Management and Budget, has repeatedly led efforts to shut down the 
Federal Government. When Mr. Mulvaney and the Republicans succeeded in 
shutting down the government for 16 days in 2013, it cost the American 
economy $20 billion. Do you remember that?
  Rush Limbaugh got on his radio show and said: If they shut down the 
government, no one will even notice.
  Guess what, Mr. Limbaugh. They noticed.
  All across America, working families paid the price for that foolish 
political act of shutting down the government. The real cost of the 
government shutdown is not just measured in dollars. The real cost is 
in hardships unnecessarily created, hardships for Federal employees who 
didn't receive their checks on a timely basis, hardships for people 
struggling to survive in America, who relied on programs like food 
stamps. We call them SNAP benefits now. They had their food in jeopardy 
and endangered because Congressman Mulvaney and his friends thought 
that a display of political power--shutting down the government--was 
the right recipe for America.
  These government shutdowns delayed 2 million Federal workers from 
receiving their checks, real people with real families to feed. 
Congressman Mulvaney doesn't seem to care about these real-world 
consequences of a shutdown. Instead, he called the shutdown of the 
Federal Government ``good policy.'' Those are his words: ``good 
policy.''
  Then, when we finally reached an agreement to reopen the government, 
he was one of the few Members of the House to vote against the 
compromise in reopening the government.
  In recent years, he has repeated his calls. He is willing to shut 
down the government of the United States of America to defund Planned 
Parenthood. This man wants to craft our national budget, and he would 
shut down the government over one provision in that budget? That is 
what he said.
  Time and again, he has taken extreme positions on the Federal budget. 
We have a standing tradition in the House and the Senate. Since not one 
of us can predict when the next natural disaster is going to occur, we 
try to help one another.
  I have voted for funds during the course of my congressional career 
for disasters in probably every State in the union. Do you know why? 
Because I knew the day would come--and it did, several times during my 
tenure in the House and Senate--when there would be a natural disaster 
in my State, and we needed a helping hand, emergency disaster 
assistance. That is a tradition which has been around Congress--I can 
go back almost centuries to see it in past history.
  Listen to what Congressman Mulvaney did. He tried to block emergency 
disaster assistance to States that desperately needed the help of the 
Federal Government in their recovery efforts. He offered a poison pill 
amendment to the Hurricane Sandy relief package that would have 
required across-the-board cuts in military spending--military 
spending--to pay for disaster relief from Hurricane Sandy. Then he went 
further and said: Not just military spending, I want cuts in 
entitlement programs--Medicare, Medicaid. Let's cut the healthcare 
assistance for Americans to pay for that disaster. That is his idea of 
social justice.
  Despite President Trump's campaign promises to rebuild the Nation's 
crumbling infrastructure, Congressman Mick Mulvaney has taken an 
extraordinary and extreme view. He wants to eliminate Federal funding 
for transportation projects. He cosponsored a bill that would slash the 
Federal gas tax. That is how we pay for repairing Federal roads and 
mass transit across America. He isn't interested in fixing the highway 
trust fund solvency problems. His solution is to bankrupt it.
  This is the man who wants to write the budget for America? His 
extreme ideology would threaten billions of dollars that my State 
receives in Federal transportation funds. We put money into the Federal 
highway trust fund,

[[Page S1195]]

too, every time we buy a gallon of gas in Illinois. He would cut back 
on the resources coming back to my State and others to repair the very 
roads we drive on.
  He has consistently supported across-the-board cuts for the 
Department of Defense, regardless of those affected. Just a few minutes 
ago, Senator John McCain, the senior Senator from Arizona, came to the 
floor to announce that because of Congressman Mulvaney's positions on 
cuts in the military, he--Senator McCain--would oppose the appointment 
of Mulvaney as head of OMB. Senator McCain said that it is a rare day 
when he comes out against a Presidential nominee of his own party. But 
he thinks Mulvaney's record is worrisome, and I couldn't agree 
more. The positions that Congressman Mulvaney has taken are reckless 
and would jeopardize the economic security of working families and put 
our Nation and economy at risk.

  Possibly one of the most troubling positions that Congressman 
Mulvaney has taken is the fact that he is opposed to the Federal 
Government spending funds for medical research. Last year when Congress 
was deliberating how to combat the Zika virus, Representative Mulvaney 
wrote this on his Facebook page: ``Do we really need government-funded 
research at all?''
  Let's think about that for a moment. Do we really need government-
funded medical research in the United States? Do we need the National 
Institutes of Health, the Department of Defense, and the Veterans' 
Administration investing in trying to find new cures for diseases?
  Government-funded research in the Department of Defense has produced 
fascinating insights into the biology of breast cancer that have 
greatly impacted the treatment of that disease and saved lives in 
America. Look at the revolutionary Department of Defense-funded work 
that led to the development of the innovative drug Herceptin. 
Government-funded research, which Congressman Mulvaney does not believe 
we should do, at the National Institutes of Health has accomplished the 
following. It has cut the U.S. cancer death rate by 11 percent in women 
and 19 percent in men. And Congressman Mulvaney says: Do we really need 
to do that? Is that important? I would guess that his family, like 
every family in America, has a story to tell about cancer--what it has 
meant, the devastation it has created, the deaths that have resulted.
  But Congressman Mulvaney doesn't get it. He just doesn't understand 
anything as basic as investing in medical research to save lives. HIV/
AIDS is no longer a death sentence in America. I saw Magic Johnson just 
a few weeks ago at a farewell party for President Obama. I remembered 
the day in the House of Representatives when I was told that he had 
AIDS. We assumed he would die in just a short period of time. But that 
was over 25 years ago. He has survived because of research that was 
done at the National Institutes of Health, and he is not alone. There 
are thousands just like him.
  When I was a kid, polio was something every mother and father were 
frightened of. What in the world was happening? How could your child be 
infected with polio and end up being crippled for life? Our Republican 
leader here, Mitch McConnell, went through that in his childhood and 
has talked about that episode in his life and how devastating it was. 
He has had a full life since then, but he has overcome the problems of 
that disease. I remember as a kid in grade school, when they announced 
that our government research had come up with a vaccine that would 
protect kids from polio. That, to me, was a breakthrough, and one that 
I welcomed and our family welcomed.
  Congressman Mulvaney questions whether or not medical research should 
continue, even in the light of the achievements in eradicating polio 
and small pox and other diseases in our country. These advances didn't 
just magically happen because of the miracle of the marketplace. They 
occurred because of sustained taxpayer investment in Federal medical 
research.
  I will tell you this. If he wants to make a referendum in the Senate 
or the House on medical research a part of his budget debate, I welcome 
the challenge. I believe that Members of both political parties would 
stand up for medical research, despite Congressman Mulvaney's extreme 
positions.
  So when someone asks if we really need government-funded medical 
research, the answer on behalf of cancer patients who are beating the 
disease, on behalf of HIV/AIDS patients who are living longer and 
normal lives, on behalf of all those families hoping and praying that 
some Federal researcher will come up with a breakthrough for 
Alzheimer's, for autism, or Parkinson's or diabetes--the answer, 
Congressman Mulvaney, is unequivocally, yes. America needs to invest in 
medical research. And the fact that you would question it really raises 
the question of your judgment.
  Let me tell you another thing that he is for, which I think is the 
single most irresponsible budgetary position he has taken. He has been 
an opponent of raising the country's debt ceiling.
  What is the debt ceiling? That is America's mortgage. That is the 
amount of debt we incur as a nation. It is a mortgage that is incurred 
for things that we have already spent money on. So when we come and 
vote for $600 billion for the Department of Defense and the 
intelligence agencies and we don't have enough money coming in taxes to 
pay for it, we have to extend America's mortgage to cover it. 
Congressman Mulvaney says that is the wrong thing to do--extending the 
debt ceiling of this country. While running for Congress, Congressman 
Mulvaney, who now wants to manage our Nation's budget, pledged he would 
never ever vote to raise the country's debt ceiling. He voted against 
it four different times.
  In 2011, when we were just about to breach the debt limit and default 
on our national debt for the first time in the history of our country, 
Mulvaney was a leading voice in support of default. He called it a 
``fabricated crisis,'' and accused both parties of ``fear mongering.''
  I am not sure what is more disturbing--Mr. Mulvaney's willingness to 
default on our country's obligations, the full faith and credit of the 
United States, or his lack of appreciation for the devastating economic 
consequences which would follow. I can tell you what is at risk with 
that kind of reckless attitude toward our Nation's debt. What is at 
risk are the savings and investments and retirement accounts of 
ordinary Americans across the Nation. Mr. Mulvaney may be willing to 
gamble the full faith and credit of the United States; I am not. 
Forcing the Federal Government to default on the Nation's debt would 
harm the economy and affect the government's ability to make payments 
to Social Security and Medicare recipients, military personnel, 
veterans, Federal employees, defense contractors, State governments, 
and to the bondholders of the United States, here and overseas.
  We would lose our credibility if Mr. Mulvaney had his way and allowed 
us to default on our national debt. We should not ever consider 
confirming an OMB Director who has repeatedly risked the economic 
security of our Nation to score political, rhetorical points.
  Throughout his campaign, President Trump promised to protect Medicare 
and Social Security and make decisions that would ``benefit American 
workers and American families.'' That is a quote. However, instead of 
making good on the promise, President Trump has chosen a man to head 
the Office of Management and Budget who has led calls for devastating 
cuts to Federal programs that millions of Americans rely on every day.
  Mr. Mulvaney has said he wants to ``end Medicare as we know it,'' and 
he has called Social Security a ``Ponzi scheme.'' He has called for 
raising the retirement age for Social Security to 70, from the 67 that 
it currently is. Well, 3 more years at work may not mean much to a 
Member of Congress, because we sit down a lot in these comfortable 
chairs and people bring us things when we need them. But 3 more years 
of working before you qualify for Social Security means something to a 
waitress, whose hips and ankles and knees have been bothering her for 
years, but she has no choice but to get up every morning, go to work, 
carry those trays, and try to bring enough money home to help a family. 
It means something to someone who works in a coal mine--I guarantee you 
that--3 more years at work, exposing yourself to the lung diseases and 
other things

[[Page S1196]]

that might come with the job. It means something to a truckdriver, 
spending days and nights on the road. It means something to people who 
have to move freight around. It is the kind of thing that means a lot 
to ordinary working people. It clearly doesn't mean anything to 
Congressman Mulvaney. Three more years working, as far as he is 
concerned, is an acceptable alternative.
  He wants to privatize Medicare and turn Medicare back into the loving 
arms of private health insurance companies, and let's see what seniors 
end up experiencing. Almost 60 million Americans now rely on Medicare. 
In Congressman Mulvaney's point of view, the guarantee of Medicare 
would end. This is the man President Trump has chosen to head the 
budget for the United States of America. Mulvaney has called repeatedly 
for cuts to Social Security, Medicare, and Medicaid, including a ``cut, 
cap, and balance'' budget, which would cut each of these programs by 25 
percent. When you say the word Medicaid, people have an image in their 
mind: Oh, that is health insurance for poor people. And that is 
generally correct, although it also covers disabled Americans. But do 
you know who the major recipients of Medicaid are in America? The 
largest single group of people receiving help from Medicaid are 
children--children in poor, low-income families who get medical care 
through Medicaid. The biggest expenditure for Medicaid is not children 
though. The biggest expenditure is for the elderly Americans who are 
living largely at institutional settings, in these care homes, nursing 
homes. Medicaid keeps them in that place with adequate medical care. So 
now comes Congressman Mulvaney and says: Let's just cut those by 25 
percent. There is one good way to reduce Federal spending.
  Really? So that means fewer immunizations for children. What does it 
mean for your mother or your grandmother in the nursing home when it is 
announced that we don't have enough money to cover the cost to keep her 
here in a good, safe, positive environment? For Congressman Mulvaney, 
it is just numbers on paper. For real families across America, it is 
the reality of life.
  Much like our new Secretary of Health and Human Services, Congressman 
Price, Representative Mulvaney wants to dramatically undermine the 
Medicare Program for our Nation's seniors. Let's look at what Medicare 
has meant to our country since it was created in 1965. Before Medicare, 
only 51 percent of Americans 65 and older had health care coverage. 
Nearly 30 percent lived in poverty. Today, 98 percent of seniors have 
health care, and less than 10 percent live below the poverty line. Has 
Medicare work? You bet it has. It has provided health insurance for 
seniors, and it has given people dignity and independence in their 
senior years--something that everyone should value. And, incidentally, 
the life expectancy of Americans has grown by 5 years since we created 
Medicare. It is working. Medicare helps seniors, helps their families, 
and it helps America. But Congressman Mulvaney doesn't get it.
  This man has been chosen by President Trump to write the budget of 
America. Why is Congressman Mulvaney so hell-bent on ending a program 
like Medicare that 98 percent of our Nation's seniors depend on? Well, 
I can tell you, if his comments on Medicare scare you, on Medicaid he 
is even worse. This program, combined with the Children's Health 
Insurance Program, ensures health coverage for 70 million Americans. 
One out of every five nationwide depend on Medicaid. It helps low-
income families, pregnant women, children, and those with disabilities. 
Currently, if you qualify for Medicaid, you are guaranteed to get 
health coverage. Congressman Mulvaney thinks he has a better idea. He 
wants to change that.
  Congressman Mulvaney wants to significantly cut the Federal funding 
for Medicaid and leave States to fend for themselves when it comes to 
caring for these 70 million Americans. Faced with less Federal funding, 
States would be forced to find ways to cut spending and save money. 
They might start Medicaid waiting lists or impose work requirements or 
slash benefits. At the end of the day, the result would be 
catastrophic.
  I just spent the last weekend in Southern Illinois. We had a 
roundtable down there to talk about the impact of the repeal of the 
Affordable Care Act. These hospital administrators from smalltown 
hospitals came in to tell me that losing Medicaid reimbursement could 
force them to dramatically cut their workforce and maybe even face 
closure. Here is Congressman Mulvaney suggesting: Let's just do that 
across America. I wonder where he lives. I wonder if there are any 
small towns or rural areas near him. I wonder if he values those 
hospitals the way the people living in communities that I represent 
value them. These are not only lifelines for people who desperately 
need timely, professional medical care, but they are the source of the 
best jobs in the community. Congressman Mulvaney could care less: Let's 
just keep cutting on Medicaid and see what happens.
  What will happen will be devastating.
  Mr. Mulvaney isn't content with just throwing seniors off Medicare 
and low-income families off Medicaid. He wants to punish women by 
taking away their healthcare providers and inserting his own decisions 
into their medical decisions. Mr. Mulvaney has repeatedly attempted to 
defund Planned Parenthood health centers, which provide women and men 
with important cancer screenings, family planning, STD testing, and 
other important health care services.
  The laws of the United States of America provide that not one penny 
can be given to Planned Parenthood for abortion services--not one penny 
under the law. Most people, if asked what percentage of the Planned 
Parenthood budget is actually spent on abortion services would get it 
wrong. The actual number is 3 percent. Ninety-seven percent of what 
Planned Parenthood does, in terms of family planning, cancer screening, 
STD screening, has no relation directly to abortion services, and that 
is compensated, but abortion services are not under the law. 
Congressman Mulvaney could care less. He would close down the sources 
of family planning in small towns and communities around America.

  The concerns I have laid out today are just a few that I have about 
this nomination. The millions of hard-working Americans who believed 
President Trump's campaign promises, and as a champion for the most 
vulnerable, deserve far better than Congressman Mulvaney.
  There are real problems facing this Nation. Far too many people are 
struggling, and there is a lot of work to do. We cannot afford to risk 
our economic recovery, the retirement plans and savings of working 
Americans, the health of our children, the kind of care we want for our 
mothers and grandmothers--we cannot afford to risk them by appointing 
OMB Director Mick Mulvaney.
  I have no choice but to oppose Mick Mulvaney's nomination for 
Director of the Office of Management and Budget.
  Mr. President, Mick Mulvaney is a founder of the House Freedom 
Caucus, which has made repeal of the Affordable Care Act--without a 
replacement--one of their main causes. This is not about good policy or 
the real consequences for people around the country. This is about 
ideology.
  Mr. Mulvaney wants to rip health insurance away from nearly 30 
million people and deny people the important consumer protections they 
have come to depend upon. He would once again allow insurers to impose 
pre-existing condition exclusions and discriminate based on gender and 
cut off coverage when someone gets sick and needs it most.
  His answer to fixing our health care system is ``free-market 
competition'' and ``crackdown on frivolous lawsuits. Those might make 
good talking points, but they will not stabilize our insurance market 
and help people in need.
  The Illinois Hospital Association estimates that Republican plans to 
repeal the Affordable Care Act will result in the loss of up to 95,000 
jobs in Illinois--in hospitals, doctor's offices, construction, real 
estate, and beyond.
  Over the last month, I have been going around my State, meeting with 
hospitals and providers, talking to them about what repeal would mean. 
They are worried.
  You see, Illinois hospitals and health systems generate nearly $90 
billion in the State and local economies each year, and 1 in 10 jobs in 
Illinois is in

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health care. Hospitals are vitally important to our State's economy and 
vitally important to patients in need.
  Don't just take my word for it, Franklin Hospital CEO, Jim Johnson 
told me:

       In our community, at the time that the hospital in West 
     Frankfort closed, we [Franklin Hospital in Benton] managed to 
     stay open . . . they're just eaten up that they don't have a 
     hospital anymore. It's incredible what the loss of a hospital 
     can do to a small community. And I'm down there talking to 
     those guys every day because naturally I like them to use our 
     hospital . . . but those conversations, it has just torn this 
     community apart.

  In Illinois and nationwide, rural hospitals would be particularly 
hurt by Mr. Mulvaney and Republicans' prescription for chaos.
  In Illinois, 62 of our 102 counties are rural. We have 51 Critical 
Access Hospitals, which are the hubs of their communities. Rural 
hospitals typically are more reliant on Medicaid and Medicare, and have 
tighter operating margins.
  So what has the ACA meant for them? In States that expanded Medicaid, 
like Illinois, rural hospitals have seen greater financial stability 
thanks to the decrease in uncompensated care--or charity care--costs.
  Thanks to the Affordable Care Act, the uninsured rate in rural 
communities has dropped by nearly 40 percent. This is not only great 
for those individuals obtaining insurance, it is also great for the 
rural hospitals who are now getting paid for the health services they 
provide.
  Community Health & Emergency Services CEO Fred Bernstein told me:

       You can look at Cairo as the ghost of the future. Because 
     there is not much left that we have to lose . . . We've lost 
     the only grocery store, and the only drug store in Cairo. If 
     this Affordable Care Act thing isn't resolved and if we go to 
     block grant in the Medicaid program, there's not going to be 
     any resolution to those problems down there. We are not going 
     to be able to stay open. At least 72-74 percent of my 
     patients depend upon Medicaid . . . Without the expansions of 
     Medicaid that we've already seen, and without some of the 
     subsidies that those who can get some insurance will get to 
     keep that insurance, there's not going to be the ability to 
     afford any care for most of the people we serve.

  Since 2009, the number of rural hospitals in Illinois operating in 
the red has decreased by 46 percent. Put another way, 16 rural 
hospitals in Illinois are now on much more solid financial footing 
thanks to the ACA.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Arkansas.