[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
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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
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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.
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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.
____________________