[Congressional Record Volume 163, Number 118 (Thursday, July 13, 2017)]
[Senate]
[Pages S3984-S3988]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]



                         Healthcare Legislation

  Mr. CASSIDY. Mr. President, I rise to speak to the repeal and replace 
effort that is before us, and the challenge has been how to do so. 
Senator McConnell has recently introduced a bill, and as we pore over 
it, there is much to like, but quite likely, there will be some 
Senators who will still express reservations as to whether this 
amendment adequately fulfills President Trump's campaign pledges--those 
pledges specifically to continue coverage, care for those with 
preexisting conditions, eliminate mandates, and lower premiums.
  If more is required, Senator Lindsey Graham and I have actually come 
up with an amendment that we will add to the bill being offered. It 
doesn't replace it but, rather, it adds to it. In it, we return to 
conservative solutions that devolve power back to States and rely upon 
the States to, in turn, devolve power to the patient.
  So what does this bill do? What we do basically is take the dollars 
that the Federal Government would give to a State under ObamaCare and 
we give those same dollars in the form of a block grant. We allow the 
State to then administer the money in its best way to, one, give 
patients the power, and two, fulfill President Trump's pledges.
  We think this works. It is a 10th Amendment solution in which that 
which is not specifically given to the Federal Government is, in turn, 
given to the State. Let the States decide what they want to do. Some 
object. They say: Oh my gosh. A conservative State may do something 
that we don't think--whoever is speaking--it should be allowed to do. 
Another might say: Well, I don't think a liberal State should be 
allowed to do that. Under our bill, we devolve to the State, so a blue 
State can do a blue thing and a red State can do a red thing. Let's let 
our States be the laboratories of democracy that teach each other the 
best way in which to insure others. But we say it will be the State 
that has the power and not the Federal Government.
  If you oppose this approach, it means you would trust a Washington 
bureaucrat more to address the needs of your State than you would trust 
the people of your own State.
  We would still have those protections which would allow folks to get 
the adequate coverage they need. There would still be--for example, 
preexisting conditions will be covered, fulfilling President Trump's 
pledge to that end. We would fulfill what I call the Jimmy Kimmel 
test--that everybody who is ill or has a loved one who is ill would 
have adequate resources to have that person's illness addressed.
  We have a precedent as to how this is done. Congress, I am told, when 
it addressed the Temporary Assistance for Needy Families Program, gave 
the dollars necessary, with flexibility to the States. Although at the 
time the solution was criticized as giving too much money to the 
States, since, the Federal Government has not had to put in more money. 
Because of the flexibility, the States have been able to use the 
dollars allocated in such a way as to meet the needs of the population.
  So what could a State do with these dollars?
  It could help those patients who are at higher risk or higher cost 
purchase

[[Page S3985]]

the coverage they need, perhaps in a reinsurance or in an invisible 
high-risk pool that would allow premiums to be lowered for those 
individuals and for all.
  It could maintain status quo. Those folks getting tax credits instead 
could have these dollars fund their purchase of insurance. It could be 
used together with Senator Cruz's amendment, which would allow a health 
savings account to be used to purchase health insurance. The individual 
could set up such an account, the State could fund it, and then these 
dollars could then be used to purchase insurance. I like that, 
personally. That particular provision was in the Cassidy-Collins bill, 
the Patient Freedom Act, and it dovetails very nicely with block-
granting these dollars back to the States to care for someone.
  It could directly contract with providers to provide assistance to a 
specific population. So imagine you have an Indian reservation--or if 
not an Indian reservation, which might be covered under another source 
of funding, another fairly isolated population that does not have 
access to healthcare, the State could say: OK, we are going to come in 
and provide providers specifically for that population.
  Alaska may adopt this because they have 700,000 people stretched over 
a land mass almost as big as the lower 48, and that might be a solution 
Alaska comes up with, but the point being, the solution would be 
specific for that State. Unlike ObamaCare, in which, out of Washington, 
DC, Washington bureaucrats dictate that the same approach be taken 
across the Nation no matter how different the States are, in this, the 
money is given to the State, and the State is asked to provide for 
their citizens in a way specific for the needs of that State.
  We think the Graham-Cassidy amendment returning power to States and 
to patients is a conservative solution which ultimately gives the 
patient more power. I will repeat. This does not replace that bill 
which is being offered by Senator McConnell. It would be an amendment 
to that. And if it turns out that some Senators feel as if that 
particular bill is not adequate to fulfill President Trump's campaign 
promises, we think this amendment could take the bill the rest of the 
way.
  Mr. President, 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. Without objection, it is so ordered.
  Ms. CANTWELL. Thank you, Mr. President.
  I know my Republican colleagues are working on versions of the 
healthcare bill they have been talking about today, and I know my 
colleagues are going to try to say they are protecting the sickest of 
Americans, and they are saying they do want to ensure that people with 
preexisting conditions don't have to pay through the nose when they 
need care. I think the President called the House version of this 
attempt a mean bill, and I think the original Senate bill was just as 
mean, if not meaner, with the number of people who would be cut off of 
Medicaid over a period of time and left without access to care.
  Today's bill also includes an amendment or a package of ideas by my 
colleagues from Texas and Utah--a provision that allows insurers to 
sell junk insurance on the individual health insurance market. As long 
as they offer at least one plan that is real insurance, insurers could 
offer a bunch of plans that, as CBO has said, are not really insurance; 
that is, they just cover one or two things. Yes, they would be cheaper, 
but if CBO doesn't consider these types of plans insurance, how are 
they insurance?
  I think the whole notion of junk insurance being invested into this 
bill is very problematic. Under junk insurance plans, they can limit or 
deny coverage of essential benefits, including hospitalization, 
maternity care, preventive care, prescription drugs, laboratory care, 
and substance abuse treatment. That is what they can limit. We wouldn't 
want those limited. This is why CBO says that if you can't go to the 
hospital and get care, then it is not really insurance. I have to agree 
with them on that.
  These plans could charge people more or simply deny them based on 
preexisting conditions, and these plans could pay out less than 60 
percent of the healthcare expenses, leaving the beneficiary with 
unbelievable, insurmountable deductibles that would be hard to pay. 
These plans could also impose an annual or lifetime cap on insurance.
  I had a young woman come to my office today who was treated at 
Seattle Children's Hospital in our State. This family actually lives in 
a neighboring State, but Seattle Children's Hospital is such a regional 
entity in the State of Washington, in Seattle, and we are so proud of 
that. They told me about the debilitating disease this young child was 
born with and how many surgeries she has had. Literally, with the brain 
treatments she has had to receive, she and her mother told me that if 
there had ever been any lifetime caps, they would have exhausted them 
in the first few years. I am so proud that she came to see us today and 
is continuing to talk about why capping healthcare plans would be so 
devastating to somebody like her.
  We don't want to create two markets of insurance. We don't want the 
one that is the real plan, real insurance, and the one where everybody 
goes and buys insurance that even CBO says is not real insurance.
  I know that probably in the last few days of discussion, people have 
said: Ok, we will put a bunch of money in to help the real, or 
regulated market. I talked to my insurance commissioner in the State of 
Washington, and he said: Listen, when you don't spread out risk, you 
are not going to have a market and you are going to create problems.
  So the notion that you think that catastrophic out-of-pocket costs 
won't be borne by these individual patients, I think, is wrong or that 
these higher premiums and deductibles could be paid by these 
individuals. It turns out that these junk plans, as I said, do not even 
count as insurance, and everybody who is in the real insurance market 
would then end up having to pay more.
  The bill explicitly states that non-compliant plans will not count as 
creditable coverage for the purpose of individuals demonstrating that 
they have insurance.
  I am checking with my staff.
  Is that right? Is that what is in the proposal?
  Yes. The bill explicitly states that noncompliance plans will not 
count as credible coverage for the purpose of individuals demonstrating 
that they have insurance.
  Under this bill, if someone gets one of those junk plans--if somehow 
you see that marketed and you buy into it because you think it is cheap 
and you think it is the greatest thing ever--and then you try to enroll 
in a comprehensive plan, there is a good chance that you will get a 
lockout period of 6 months before you can get coverage.
  Why am I here talking about this? Because the State of Washington 
tried this. We tried this approach in the 1990s. After our State had 
passed a major healthcare reform bill in the 1990s, a group of State 
legislators allowed these junk plans to be sold along with compliant 
plans. Guess what happened? Nearly all of the insurers in our State 
pulled out of the individual insurance market, and a death spiral 
ensued. Why? Because the cost then of that individual market was so 
high and so great that they could not service it.
  They said: Oh my gosh, if I have to offer a compliant plan along with 
this junk insurance, I cannot make the compliant plan work because it 
costs so much. We are not staying.
  This very important experience taught us that that is not the way for 
us to spread risk.
  I am concerned--and I have heard from a number of patient advocacy 
groups, not just the young woman from Seattle Children's Hospital who 
came to see me today but consumer groups and health insurers 
themselves, like America's Health Insurance Plans, Blue Cross Blue 
Shield Association, AARP, American Cancer Society's Cancer Action 
Network, American Diabetes Association, American Heart and Lung 
Association, Cystic Fibrosis Foundation, March of Dimes, National MS 
Society, National Health Council, and the National Coalition for Women

[[Page S3986]]

with Heart Disease. All of these organizations do not like this idea of 
junk insurance, of saying you can have a compliant plan that is real 
insurance and a marketplace in which there are things that are not 
really insurance, because then people are going to go buy a bunch of 
things that are not really insurance and then not have the ability to 
get cost and care and run up uncompensated care. Then you are going to 
make the real market unsustainable and unsupportive, and the rates are 
going to go so high that people are just going to pull out.
  A group of 10 of those leading patient advocacy groups wrote:

       Under the amendment, insurance companies would be allowed 
     to charge higher premiums to people based on their health 
     status--in addition to opting out of other patient 
     protections in current law, such as the guarantee of 
     essential health benefits--

  Those are the things I was going over a few minutes ago--

     and the prohibition on annual and lifetime coverage caps.

  They go on to write:

       Separating healthy enrollees from those with preexisting 
     conditions will also lead to severe instability of the 
     insurance market. This is unacceptable for our patients.

  Yesterday, America's Health Insurance Plans wrote:

       Allowing health insurance products governed by different 
     rules and standards would further destabilize the individual 
     market and increase costs for those with preexisting 
     conditions.

  That is the largest health insurance group in the country, and they 
are writing this.
  If they are telling us in advance that this is going to really 
destabilize the market and cause problems, we should listen because 
right now what we have had is an expansion of Medicaid and covering 
more people, raising the GDP and helping areas of our States and 
country and creating more stability.
  We have had some challenges in the individual market. We should fix 
that. We should definitely drive down the cost of the delivery system 
by continuing to improve it. But the notion that this is the fix for 
the individual market when the providers are telling us it is going to 
destabilize the market and drive us out--we should understand what the 
result of that is going to be.
  Yesterday, the Blue Cross Blue Shield Association wrote:

       The result (of Cruz/Lee) would be higher premiums, 
     increased Federal tax credit costs for coverage available on 
     the exchanges, and insurers exiting the market or pricing 
     coverage out of reach of consumers.

  I believe our goals should be trying to drive down the cost of 
insurance. We have lots of ideas about that, and I want to work with 
our colleagues on that, but I am very concerned that this approach to 
try to get people supporting a Senate proposal is the wrong approach 
and will drive people out of the market.
  I think the bill is still a war on Medicaid. The bill still 
permanently cuts and caps the Medicaid Program. I have said numerous 
times that we saved $2 billion in the State of Washington by 
rebalancing people off of nursing home care and on to community-based 
care. It is a great concept. Look, we have a lot of people who are 
going to live longer. We have baby boomers who are reaching retirement. 
The number of people who are going to demand services, whether from 
Medicaid or Medicare, is going to be increased just because of the 
population bubble. We should be doing things to drive down the costs of 
care.
  There are great ideas, and I was able to get some of those in the 
bill. We ended up passing those things, and some States are actually 
working on that. More than 15 States are actually working on that 
concept of rebalancing to community-based care and making long-term 
care more affordable under this provision. I guarantee you that we have 
to do that, but if you permanently cap or cut Medicaid, you are going 
to have veterans who use access to Medicaid for care who are not going 
to get care. You are going to get people who need opioid treatment.
  I find it interesting that we would have this program over here. I 
see that my colleague from Michigan is on the floor. We call it the 
Saginaw Health Clinic.
  One would say: OK, Saginaw Health Clinic, there is a bunch of money 
in this bill. Apply for opioid help.
  They would say: OK. We are going to get $10 million.
  When you walk in the door of the opioid Saginaw Health Clinic, the 
first thing they will ask is if you are on Medicaid. If you are not on 
Medicaid, you are not going to get any opioid help.
  So the notion that we would cut people off of Medicaid but put more 
money in the opioid problem is not what we need to do to solve our 
challenge. What we need to do is make sure we are delivering the most 
cost-effective care as possible and make sure people are getting access 
to care.
  That is why I have been all over the State of Washington. I have met 
so many people. I have met people at healthcare facilities who have 
told me that some of their highest costs were from a patient who 
continually came to see them in the emergency room, maybe 30 times a 
year, because he did not have coverage, so he drove up the cost for 
everybody. They said they finally got this person on the Medicaid 
expansion. Guess what. They do not have those costs anymore in their 
hospitals and facilities. It has driven down the costs.
  I do not want to see people kicked off of Medicaid. I do not want to 
see it cut in a declining budget. I want us to improve Medicaid and 
make it more cost-effective and more utilized and supported.
  Estimates by the CBO of the original Senate bill are that the 
Medicaid cut would be $772 billion over the next decade and that the 
Federal investment would be cut by 35 percent within the next two 
decades, relative to current law projections. That is a lot of 
consequence for the Medicaid population. I think that is why we have so 
many groups and organizations here that are anxious about this proposal 
and where we go. We definitely want to talk to our colleagues.
  One former CBO Director said, the junk insurance idea is ``a recipe 
for a meltdown.'' This is someone who served in past Republican 
administrations, and I take his word seriously.
  I think what we need to do is work together to make sure we get a 
program that addresses our most fundamental issues--the challenges in 
the individual market, keep addressing how we keep and stabilize a 
population on the most affordable rates there are, and keep the things 
we know have worked very well, like the Medicaid expansion. It has 
worked. It has supported people, and it has helped us stabilize the 
market.
  I will remind my colleagues, too, that the State of New York took one 
provision of the Affordable Care Act and has 650,000 people in New York 
on a very, very affordable insurance plan. We think that if you are an 
individual in the individual market, you should be able to get the same 
clout as somebody who works for a large employer. You should be able to 
go in and buy in bulk as a class, as a group of people, and when you 
buy in bulk, you should get a discount. That is what we think will help 
us in the individual market to drive down these costs for what is about 
7 percent of the marketplace.
  I urge my colleagues to reject this latest proposal. Let's get 
serious about fixing the things that we know we can fix and improve 
upon, but for the over 22 million Americans who are very nervous about 
this proposal because they know they are going to get cut off of care, 
let's not do that to them. Let's improve where we need to go in 
affordability in the healthcare arena and not think that a junk 
insurance program or cutting people off is the solution for the future.
  Thank you, Mr. President.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Michigan.
  Ms. STABENOW. Mr. President, first, I want to thank my friend from 
Washington State, who has been such a leader on healthcare.
  In looking at her chart, at the junk insurance amendment and all of 
the groups opposing it, it reminds me of the calls I used to get prior 
to the Affordable Care Act from someone who was healthy and young and 
had a policy for years that was only $50 a month. He thought it was 
great. Then, all of a sudden, he got sick or his child got sick.
  He called me up and said: I paid into insurance all of these years, 
and they only covered 1 day in the hospital.

[[Page S3987]]

  I remember having that conversation with somebody--or no days in the 
hospital. That is what you call a junk insurance plan.
  This latest version of the healthcare bill would allow that to come 
back so that somebody will have the false confidence in paying $30, 
$40, $50 a month and thinking he has insurance. Then, if something 
happens, he will find out it is just a bunch of junk and that it does 
not cover anything. That is going to be legal again. Right now, it is 
not legal to do that. With health reform, we stopped that. But that 
would be legal again under this proposal, and I am deeply concerned 
about that.
  I am obviously rising to talk about the Republican healthcare bill. I 
do not believe it is a healthcare bill, but that is what we are 
debating, is healthcare or whether healthcare will be taken away. What 
I would rather be doing is working with my friend who is in the chair 
on lowering the cost of prescription drugs. We have worked on many 
things together--mental health and addiction services. I would rather 
be doing that than debating what we are debating. I would rather be 
focused on how we lower the cost of prescription drugs, which is the 
cost I hear about the most from my constituents, or about other out-of-
pocket costs for people who are in the private insurance system, the 
individual insurance market.
  We do have situations in which copays and deductibles are too high in 
the private insurance market. Gutting Medicaid will do nothing about 
that--nothing. It will just take away healthcare from tens of millions 
of people. It will not change the private insurance market at all, 
which is where I believe we need to focus, and I am anxious to do that 
and work across the aisle in order to do that.
  I want to make sure we are talking about building on healthcare 
coverage, lowering costs, and tackling prescription drug costs. 
Instead, this bill would take away healthcare from millions of 
Americans. We know that from the nonpartisan Congressional Budget 
Office. We don't know yet how many millions under the current version, 
but we know that at some point, we will get a score on that from the 
Budget Office. We know it will be a lot of people who are going to lose 
their insurance, and they don't need to lose their insurance in order 
to tackle bringing down the cost of insurance.

  So what do we know about this proposal? The versions keep changing, 
but it is the same old song over and over again--a little bit of 
change, a little bit of different refrain, but it is the same old song 
in the end. What we know is that doctors don't like it and nurses don't 
like it, hospitals don't like it, insurance companies don't like it.
  People in Michigan don't like it. They have called and written and 
told me in person, people approaching me in Fourth of July parades. 
People are scared. They are concerned. A woman's mom is in a nursing 
home who has Alzheimer's disease, and she is panicked. Three out of 
five seniors in nursing homes in Michigan are there with the help of 
Medicaid health insurance. Others are deeply concerned about their 
family members, their children, themselves.
  This is called the Better Care Act, but there is nothing better about 
it. Democrats have ideas to actually make our healthcare system better, 
by stabilizing our insurance markets and making premiums more 
affordable. My friend Senator Shaheen of New Hampshire introduced the 
Marketplace Certainty Act. It would ensure cost-sharing payments that 
were part of healthcare reform, that they would actually remain in a 
stabilizing way so they could be counted on. This would offer peace of 
mind to families and stability to the market.
  Senators Carper, Kaine, Nelson, and Shaheen introduced the Individual 
Health Insurance Marketplace Improvement Act, which would create a 
permanent reinsurance program, which we had before--before it was 
changed 2 years ago--to stabilize the market and bring down premiums.
  There have been things that would happen to destabilize the markets. 
Two years ago, there was an action, and now with a new administration 
we need to stop that and reverse it and stabilize the markets.
  Senator Heitkamp has a proposal that helps more families afford 
health insurance by smoothing out the individual market tax credit 
cliff that is there--the tax credits that help low-income, moderate-
income people be able to afford insurance--to fix that in a way that is 
more beneficial to families.
  Senator McCaskill's Health Care Options for All Act would allow 
people who live in a county without an insurer on the exchange--they 
don't have anybody in the private individual marketplace exchange, no 
insurance company--to sign up for the same exchange plans we have. 
There are people being covered. We hear a lot about Iowa, for instance. 
Even though there may be no private insurance companies doing a private 
marketplace option, Senators, Representatives, our staffs who are 
required to be in, as they say, ObamaCare or the Affordable Care Act, 
have an exchange. So to help people immediately, we could allow the 
people of Iowa to get the same option that their Members of Congress in 
Iowa have and that their staffs have. That would be possible, as a way 
to address this issue in the short run and to help people. I don't know 
why somebody who is in Iowa or Michigan or anyplace else shouldn't be 
able to get the exact same coverage a Member of Congress can get.
  Here is what we do know in terms of the ideas in the bill. Our 
Republican colleagues know how unpopular the bill is. A new poll found 
that only 12 percent--12 percent--of Americans support this bill. It is 
so unpopular they have been trying to rewrite it and get enough votes 
to pass it. We keep hearing about changes, but unfortunately none of 
these amendments make it better. In some cases, like the junk insurance 
policies that will be allowed, they actually make it worse.
  Now, the proposal that would provide $45 million to tackle the opioid 
epidemic, even Republican Ohio Gov. John Kasich said it would be like 
spitting in the ocean. It is not enough, he said. I appreciate the 
focus on that. It is a horrible epidemic. It is an epidemic in Michigan 
and across the country, but it is certainly not enough to make up for 
the huge cuts to Medicaid insurance--healthcare insurance, as the 
Senator from Washington State indicated.
  The other proposal that we understand is in the new bill, as I 
mentioned before, would give insurers the freedom to once again refuse 
to cover basic health services like maternity care or addiction 
treatment, as long as one plan they offer, among many, would include 
essential health benefits. So everything else could be junk, and there 
would be one high-cost plan that would actually cover things families 
need.
  Insurance companies themselves know this is a terrible idea. In a 
letter to Senator Cruz and Senator Lee, Scott Serota, president and CEO 
of Blue Cross Blue Shield Association, wrote that their plan ``is 
unworkable as it would undermine pre-existing condition 
protections, increase premiums and destabilize the market.'' That is 
what is viewed as this great new provision in the bill.

  He added: ``The result would be higher premiums, increased federal 
tax credit costs for coverage available on exchanges, and insurers 
exiting the market or pricing coverage out of reach of consumers.''
  In other words, premiums would skyrocket for older people, people who 
take prescription drug medications, people with chronic conditions. 
Everyone else would be left with the junk insurance policy that doesn't 
cover really anything, and they feel OK unless they get sick. We would 
all be stuck with a fragmented, destabilized insurance market.
  Remember preexisting conditions? This would bring them right back.
  This bill is wrong for many, many people, but let me mention Felicia. 
In 2011, she was an AmeriCorps member serving in Lansing who didn't 
have health insurance. When she started feeling tired all the time and 
losing weight, she went to the Center for Family Health in Jackson.
  Felicia was diagnosed with stage IV Hodgkin's lymphoma. The Center 
for Family Health helped her get coverage through Medicaid and care at 
the University of Michigan, including chemotherapy and later a stem 
cell transplant.
  Felicia writes:

       Now I am feeling awesome. I am cancer-free, and I am 
     working part time while I am

[[Page S3988]]

     finishing up college. I feel that I owe my life to the Center 
     for Family Health.

  Felicia knows the importance of comprehensive health coverage. It 
saved her life.
  Nick and Chelsey know it too. They and their three young children are 
covered by Healthy Michigan, our State's Medicaid expansion. Nick and 
Chelsey are both employed full time. Chelsey also attends college full 
time.
  During a routine visit, doctors discovered that her oldest son was 
born with an obstructed kidney, which had lost one-third of its 
function by the time he was 5 years old. Thanks to the Medicaid 
expansion, he was able to have surgery before his kidney lost all 
function. Without the Medicaid expansion, which ends under the 
Republican bill, these working parents and their three children 
couldn't afford healthcare coverage, let alone surgery.
  Margo knows this because she sees it every day. She manages a clinic 
in Kent County on the west side of the State. She said the lives of 
patients are much different today than they were a few years ago. Margo 
wrote:

       Seeing working people who have struggled all of their adult 
     lives to manage their chronic health conditions finally have 
     access to regular doctor visits, health education, and 
     prescription medications has been a tremendous relief. You 
     cannot imagine the sense of dignity our patients feel.

  She added:

       Please see it in your heart to care about the people of 
     Michigan who work but do not get insurance through their 
     employer.

  So, finally, let me just say, doctors know this is a bad bill. Nurses 
know this is a bad bill. Hospitals know this is a bad bill. Insurance 
companies know this is a bad bill. I know that even many of my 
Republican friends know this is a bad bill. Their amendments haven't 
changed that. Costs go up and care goes down. Preexisting conditions 
come back. Millions lose their coverage.
  What we should be doing is working together to stabilize the 
marketplace, reduce out-of-pocket costs, and lower the outrageous costs 
of prescription drugs--by the way, not giving a tax cut to prescription 
drug companies, as is in this bill, and other companies as well.
  Felicia, Nick, Chelsey, and millions more like them in Michigan and 
across this country deserve that much.
  I sincerely hope that when it comes time to vote on whether to 
proceed to this bill, that the majority of the Members in the Senate 
will say no.
  Thank you, Mr. President.
  The PRESIDING OFFICER. The majority leader.

                          ____________________