[Congressional Record Volume 163, Number 77 (Thursday, May 4, 2017)]
[Senate]
[Pages S2762-S2763]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]



                         Healthcare Legislation

  Mr. ALEXANDER. Mr. President, the House of Representatives has just 
passed a bill that would make major changes in the Affordable Care Act 
by a vote of 217 to 213. I congratulate the House. The Senate will 
carefully review the House bill, and we will go to work on a Senate 
bill.
  Here are my goals for a Senate bill. I don't pretend to speak for 
every Member of the Senate or even every Republican, but these are my 
goals for a bill we will fashion here.
  No. 1, rescue the thousands of Tennesseans and millions of Americans 
who, under the Affordable Care Act, will be trapped in ObamaCare 
exchanges with few or zero options for health insurance in the year 
2018 unless Congress acts.
  My second goal is to lower premium costs. Premium costs have 
increased and, in some States, are going through the roof under the 
Affordable Care Act.
  No. 3, gradually transfer to the states more flexibility in 
administering the Medicaid program and do that in such a way as to not 
pull the rug out from under those who rely on the Medicaid program.
  No. 4, make sure those who have preexisting health conditions have 
access to health insurance. This is one thing in the Affordable Care 
Act that has strong support from just about everybody, including the 
President, that if you have a preexisting condition, you must have 
access to healthcare. We need to make sure that is still true in any 
bill we create in the Senate.
  There is some urgency here because of what is happening in the 
individual market. When we say ``individual market,'' here is what we 
are talking about. Most Americans get their insurance either from the 
government or on the job. About 18 percent of Americans get their 
insurance through Medicare. We are not talking about Medicare today. 
The bill in the House or the bill we will create in the Senate does not 
affect Medicare.
  About 60 percent of Americans get their insurance on the job and 
about 20 percent or so through Medicaid, and that leaves about 6 
percent who go into an Obamacare market to buy it. Many of these 
Americans buy their insurance on marketplaces or exchanges created by 
the Affordable Care Act. We call those the ObamaCare exchanges. About 
85 percent of those who buy their insurance on the exchanges have a 
government subsidy to help them buy the insurance.
  As every day goes by, we hear and we are going to continue to hear 
about insurance companies pulling out of counties and States. Yesterday 
we heard that the only insurer left in Iowa is now likely to leave. 
That means more than 70,000 people on the exchanges will have no 
insurance to buy. Most of them will have subsidies from the government. 
So it is like thousands of people in Iowa have bus tickets in a town 
where no buses run.
  That is what is happening right now because of the 2010 law that we 
call the Affordable Care Act. I know this all too well because 34,000 
people in Knoxville, TN, my home area, are going to have subsidies in 
2018 but no insurance to buy with their subsidies unless Congress 
acts. That is because of the 2010 law that we seek to change. In 2016, 
last year, 7 percent of counties in the United States had just one 
insurer offering plans on their Affordable Care Act exchanges. This 
year, 2017, that number jumped to 32 percent. In one in three counties 
in the United States, if you have a subsidy to buy insurance on the 
ObamaCare exchange, you had only one insurance company offering you 
insurance. Five entire States have only one insurer offering ACA plans 
in their entire State this year: Alabama, Alaska, Oklahoma, South 
Carolina, and Wyoming. That is because of the Affordable Care Act 
passed in 2010.

  Unfortunately, every day we are going to be hearing not just about 
insurers leaving counties and States, but about the ones that remain 
because they are going to be charging sky-high premiums.
  Premiums went up by as much as 62 percent this year in Tennessee and 
by 116 percent in Arizona. As the new rate increases are proposed to 
the States over the next few weeks and months, our constituents are 
going to be saying: What are you going to do about that? So there is an 
urgency, but we want to get it right.
  So, again, here are my goals for the Senate bill we will write in the 
next few weeks:
  No. 1, rescue--and ``rescue'' is not too strong a word--the millions 
of Americans across this country who are going to have few or zero 
insurance options in the year 2018 because of collapsing ObamaCare 
exchanges, unless Congress acts.
  No. 2, lower premium rates because, in many States, premiums are 
going through the roof under the Affordable Care Act.
  No. 3, gradually transfer to States more flexibility in managing 
their Medicaid programs. About 18 percent of Americans get their 
insurance on Medicaid. We will do so in a way that does not pull the 
rug out from under those who are currently served by Medicaid.
  Finally, preexisting conditions--make sure Americans who have 
insurance for preexisting conditions continue to have access to it. If 
you are on Medicaid or if you are on Medicare or, in almost every case, 
if you get insurance on the job, you have insurance for preexisting 
conditions. Under the Affordable Care Act in 2010, there had to be 
insurance for people with preexisting conditions. We want to make sure 
that those Americans continue to have access if they have a preexisting 
condition.
  We will move ahead with deliberate speed. We are doing that because 
the exchanges are collapsing, people could be without insurance, and 
premiums will go up if we don't act, but we want to get it right. There 
will be no artificial deadlines. We will carefully consider the 
legislation passed by the House. We will work together carefully to 
write our own bill. We will make sure we know what our bill costs when 
we vote on it. In fact, by law, we have to do that. We will get it 
right, and then we will vote. And hopefully, Mr. President, the end 
result will be significant improvements for most Americans, giving them 
more choices of health insurance at a lower cost, and do that by 
gradually transferring more decisions from Washington, DC, to the 
states and to individuals.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Louisiana.
  Mr. CASSIDY. Mr. President, I followed the remarks of the Senator 
from Tennessee. We speak to the American people in light of the House 
just voting 217 to 213 to repeal and replace ObamaCare. If there is 
somebody watching right now, quite likely she is concerned about her 
healthcare premiums.
  On the campaign trail--I remember this so vividly--on the campaign 
trail when I was running for the Senate, I was in Jefferson Parish, on 
Veterans Boulevard, and a woman named Tina came up. I am going to 
paraphrase what she said a little bit because this is a G-rated 
program. She said: My name is Tina, and I am angry. I am paying $500 
more a month, $6,000 more a year. My husband and I have no children and 
I have had a hysterectomy, and I am paying for pediatric dentistry and 
obstetrical benefits. I am angry.
  If there is something right now that the average middle-class voter 
is saying about his or her insurance premiums, it is that they are 
angry. They feel they are being forced by Washington to buy things they 
do not need and sacrifice other parts of their budget because if they 
do not, they know the Federal Government will come after them with the 
force of law, penalizing their family, and they do not want that.
  So what can we do? First, we acknowledge, as the House has, that 
ObamaCare is not working. Premiums are going up 20 to 40 percent per 
year. In Eleven States, so I am told, individual markets are in a death 
spiral.
  I could go through that, which we already know. President Trump knew 
it. As Candidate Trump, President Trump pledged four major things:
  No. 1, he pledged to eliminate mandates. The Senate is committed to 
working with the House and the President to eliminate those mandates. 
Washington, DC, should not tell you what to do.
  No. 2, he pledged to care for those with preexisting reasons. As 
Senator Alexander said, it is something that

[[Page S2763]]

touches every family. The President was particularly concerned about 
those whose preexisting condition was opioid addiction. We have to 
recognize that they will not get better unless they receive treatment. 
It is better to treat than it is to incarcerate or to bury. So we must 
honor the President's pledge there.
  He also pledged to cover all and to lower premiums. It is this last I 
wish to focus on now.
  How do we lower premiums? How do we say to Tina, who 2 years ago was 
paying $500 more a month, that her premium will be lower? Well, there 
are several ways. Let me focus first on lowering the cost of care.
  Right now, healthcare is way too expensive. If you go in for an 
urgent care visit, you may pay $1,500 in one urgent care center and $50 
in another. As a patient, you do not know. You would never buy a car 
that way. Can you imagine walking into a car dealership, picking your 
car, and then saying: Bill me 6 months from now, and I will pay 
whatever you ask. No one would do that. We shouldn't ask the average 
patient to do it because when we hide those costs from the patient, we 
do not allow her to be a informed consumer. Lacking information, she 
inevitably pays more.
  So one thing I have proposed, along with Senator Collins and four 
other Senators--Senators from South Carolina, South Dakota, Georgia, 
and West Virginia--is price transparency, which is to say that when 
someone goes in to get their daughter's ear ache addressed, they know 
what it would cost at this urgent care center versus another.
  A good example of exactly what I am talking about--there was an 
article in the Los Angeles Times a few years ago about the cash price 
of a CT scan in the Los Angeles Basin. It would vary from $250 to 
$2,500, and the person purchasing the service with cash would never 
know.
  I envision a time when someone takes their smart phone and they scan 
a barcode, and the barcode says: You can go at midnight on Thursday and 
get a CT scan of your daughter for $250 or you can go right now and pay 
$2,500. You look at a quality code, and both have equal quality. I can 
see the mother turning to her daughter and saying ``Baby, we are 
staying up Thursday night'' because that mother knows she can take care 
of her family's financial health, as well as her daughter's health, 
just by being an informed consumer.
  So one way we lower premiums is by lowering the cost of healthcare, 
and the way we lower the cost of healthcare is by empowering patients 
with the knowledge of price.
  The second way we can manage to lower the cost of premiums is to take 
care of those who are sick. The Senator from Tennessee ended by 
speaking about our commitment to care for those with preexisting 
conditions. Of course it is in the interest of the patient that he or 
she who has cancer is able to get care for their cancer. Jimmy Kimmel 
just spoke about his son being born with a congential heart condition. 
He would have quickly died. Mr. Kimmel choked up as he spoke about it. 
Well, shouldn't every family have the reassurance that their child born 
in such a way would also have their needs addressed? I was struck that 
Nick Mulvaney, President Trump's OMB Director, agreed with Mr. Kimmel. 
This is not a Republican issue, not a Democratic issue; it is an 
American issue. But it is also in society's interest.
  I am a physician. I worked in a public hospital for the uninsured for 
30 years. I tell folks, as long as that emergency room door was open, 
no matter what time, day or night, in through that door came folks who 
had all kinds of healthcare conditions. Some of them would come every 
week. Some of them would come twice a week. We called them frequent 
fliers. They may have been addicted or mentally ill. They may have had 
terrible diabetes which was fully controlled or bad asthma, and they 
would come in with an exacerbation and could not breathe. Every time 
they came in, there was a $2,000 to $20,000 charge--every time. But if 
you manage that patient through a primary care office or an attached 
urgent care center, what you are charging $2,000 for here, you can 
manage for $150 there. Not only that, when you manage it for $150 
there, if that person actually works, she is more likely to hold a job, 
more likely to support her family, less likely to go on dependence, 
more likely to pay taxes. Society wins as she wins. That should be our 
goal. So another way to lower premiums is to actively manage the cost 
of disease.
  People always say: We want government to run like a business. Let me 
describe what happens in a large corporation. Take ExxonMobil. You will 
find that ExxonMobil has an insurance company, a third-party 
administrator. They look at someone who is a high-cost employee, and 
they actively engage in managing that patient's illness so that, one, 
they are better, but, two, they lower cost. We as a government should 
do that, which a responsible employer does as well.
  The last thing I want to mention is that the way to lower premiums is 
by expanding coverage. When Candidate Trump said he wanted to lower 
premiums and preserve coverage, he understood that the two are linked. 
If you have a big risk pool--and a risk pool is just the folks who are 
insured. Everybody who has insurance--that is called the risk pool. If 
it is big, with lots of young folks who are in their twenties, others 
in their thirties and forties, and then a few folks like me in their 
fifties, if someone gets sick, you spread the expense of that one over 
the many. Particularly if the many include the younger and healthier, 
there is a subsidy for the older and sicker.
  Go back to ExxonMobil. Let's imagine they have 50,000 employees. If 
they have 50,000 employees and 10 of them get cancer, have liver 
transplants, terrible car wrecks, or accidents, their premiums don't 
even blip. Because you spread the cost of these expensive illnesses 
over the many, all benefit, and cost is held down.
  So when President Trump pledged to preserve coverage, he was 
recognizing that nexus between having a big risk pool and lowering that 
premium.
  Let me finish by saying this: My commitment to Tina and my commitment 
to the voters of Louisiana and the people of the United States is to 
try to lower premiums. They cannot afford the un-Affordable Care Act. 
The way we can do that, which I have outlined today, includes 
empowering patients with the knowledge of price to lower the cost of 
healthcare; encouraging coverage that manages those who are sick so 
that those who are sick stay well and are less likely to consume 
expensive emergency room care, as an example, but are also more likely 
to live full, vibrant lives; and lastly, restoring what is called 
actuarial soundness, the law of big numbers, a risk poll in which if 
one of us gets cancer, that cost is spread over many.
  Mr. President, if we manage to lower premiums, we will fulfill our 
promise to the American people, and I look forward to working with my 
colleagues to fulfill that promise.
  Mr. President, I yield the floor.
  Mr. ALEXANDER. Mr. President, 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.
  Mr. GARDNER. 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.