[Congressional Record Volume 163, Number 121 (Tuesday, July 18, 2017)]
[Senate]
[Pages S4041-S4051]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]



                               Healthcare

  Mr. UDALL. Mr. President, thank you for your recognition.
  Let me just say, at the beginning, I thank the Chair for the 
bipartisanship with which we both work on the Indian Affairs Committee. 
I very much appreciate that.
  We are here with a few Members. I rise with my colleagues from the 
Senate Committee on Indian Affairs. I think Senator Heitkamp, Senator 
Franken, and, maybe, others will join us. I join them in reminding the 
Congress of its duty to Tribes and in its standing up for the 
healthcare of American Indians and Alaska Natives across Indian 
Country.
  Most of us are aware of the health disparities facing Native 
communities. We have seen the news about the failings of the Indian 
Health Service, and many of us have heard directly from Tribal leaders 
and Native constituents about the barriers to healthcare access on 
reservations, pueblos, and in villages, but the Members of the Senate 
on the Indian Affairs Committee are uniquely aware of the complex ways 
that the Tribal healthcare system works and how those systems will be 
catastrophically disrupted by TrumpCare and the repeal of the 
Affordable Care Act.
  The U.S. Government has a trust responsibility to provide American 
Indians and Alaska Natives with comprehensive, quality healthcare. The 
U.S. Constitution, treaties, and long-settled legal precedents are the 
basis for this responsibility. The Indian Health Service is the primary 
agency for fulfilling this obligation, but our trust responsibilities 
do not end there. The Medicaid and Medicare Program, Planned 
Parenthood, and other public health services all play key roles in the 
delivery of Native healthcare, and because the IHS is so consistently 
and severely underfunded, the ACA has made a huge difference.
  Each fiscal year, the IHS receives a finite allocation of 
discretionary funding that it must stretch in order to meet the 
healthcare needs of 2.2 million Native Americans. That leaves the IHS 
with just over $3,500 per person--less than one-third of the national 
average--for healthcare spending. As a result, without additional 
resources, the IHS is forced to ration care, which limits Native 
families to hospitals and clinics that can only provide ``life and 
limb'' emergency medical services. Basic preventive care, like wellness 
visits, prenatal exams, and mammograms, have frequently been 
unavailable to most IHS patients.
  ``Don't get sick after June,'' which is the unofficial motto given to 
the Indian Health Service on many Indian reservations, has, tragically, 
become

[[Page S4042]]

the epitaph of too many Tribal members whose cancers have grown 
undetected, whose diabetes have gone untreated, and whose high-risk 
pregnancies have gone unnoticed. In seeing this catastrophic need for 
healthcare dollars, Congress enacted a series of laws that supplement 
IHS's resources. The Affordable Care Act is the most recent and now is 
the most significant.
  Nearly 287,000 American Indians and Alaska Natives from 492 Tribes--
almost 90 percent--have benefited from the ACA's Medicaid expansion. 
Another 30,000 individual Native Americans have private insurance, 
thanks to the ACA's individual marketplace and the Native cost-sharing 
subsidies. In my home State of New Mexico alone, Medicaid expansion has 
insured an additional 45,600 Native Americans. Thanks to the Medicaid 
expansion and increased access to the individual insurance market, 63 
percent of IHS patients have healthcare coverage that allows them to 
receive care above and beyond the level of life and limb. Because of 
the ACA, the IHS now receives almost $1 billion to supplement its 
healthcare delivery, and that is an increase of 21 percent.
  We can see the results. Not only are people healthier, but they are 
more productive. Health insurance has allowed Native Americans to 
finish school, return to work, and lead productive lives instead of 
worrying that their next illnesses could lead to an IHS referral denial 
or ruin them financially.
  It has also improved the economy in Indian Country. The ACA has 
created new healthcare jobs, and it has led to the construction of new 
medical facilities. It has meant dialysis clinics on New Mexico 
pueblos, new hospitals for the Choctaw in Mississippi, and thousands of 
jobs for Montana's Blackfeet Indian Reservation. These are just a few 
examples of a nationwide trend.
  TrumpCare will undo this progress. It will undo the newly expanded 
access to care. It will shut down those new healthcare facilities. It 
will freeze the economic progress of those areas. These are not just 
numbers and statistics. We are talking about people's lives. 
Individuals will be harmed by TrumpCare and the evisceration of 
Medicaid.
  Let me tell you about Rachel, Justin, and their two children--Adalie 
and Jude. They are one Native family whose lives have been changed for 
the better under the Affordable Care Act and the Medicaid expansion. 
Rachel and Justin are from the Laguna Pueblo in New Mexico.
  Here is a photo of them right after Jude was born in August 2015.
  Before the ACA and Medicaid expansion, Rachel received hit-or-miss 
care from the IHS, but when she enrolled at the University of New 
Mexico, she was able to qualify for Medicaid because of the expansion. 
This meant that when Rachel and Justin decided to start a family, 
Rachel had access to preventive services, including prenatal and 
maternity care. Rachel was able to get the care she needed when she 
became pregnant with Adalie. Rachel's prenatal care became even more 
important when they decided to add to their family when Rachel was in 
graduate school at UNM. That pregnancy with Jude had serious 
complications. The doctors figured out that Rachel did not have enough 
amniotic fluid to support Jude, and she had to have a C-section.
  Medicaid expansion allowed Rachel to complete her college education 
and to get a master's in public administration without her worrying 
about healthcare for her and her children. Medicaid expansion meant 
that Rachel was able to get the preventive care she needed to make sure 
that she and Jude were healthy.
  Rachel recently got a job offer to work in her chosen field, but now 
that she is able to get off Medicaid, she is worried that the 
Republican healthcare proposals will make insurance coverage 
ineffective or unaffordable. Even though she lives near her Tribe's IHS 
facility in the Albuquerque area, she knows that she cannot depend on 
the IHS to guarantee critical care if insurance premiums become 
unaffordable. Once again, Rachel is worried about the future of her 
family's healthcare.
  Rachel is one of thousands of Native Americans whose lives have been 
dramatically helped by the Affordable Care Act and who are scared that 
TrumpCare will leave them unable to get the healthcare that their 
families need in the future.
  If this bill becomes law, Tribal communities will be forced back to a 
system of healthcare rationing. If the President and the Republican 
leadership eviscerate the Medicaid Program and Federal supports for 
public health programs, Native American lives will be lost. There is no 
doubt about it. Let me say this plain and simple: TrumpCare would 
devastate Indian Country, and it must be stopped.
  Just this morning, as vice chair of the Indian Affairs Committee, I 
held a roundtable with Tribal leaders and Native health experts to hear 
more about how the Republicans' healthcare proposals would impact 
Tribes. I thank the leaders who came in to talk with me and my 
colleagues on the committee. Senator Franken, Senator Heitkamp, Senator 
Tester, and Senator Cantwell were there.
  All came to hear these Native leaders, and their insight into the 
damage this bill could do to Native communities was profound. The 
Turtle Mountain chairman from North Dakota reported that ``don't get 
sick after June'' is no longer true on his reservation because of the 
ACA and Medicaid expansion. Panelists warned that the rollback of 
Medicaid would be devastating to Tribal members, and a representative 
from the San Felipe Pueblo reminded us that Indian health is not an 
entitlement; it is an obligation.
  Now the Republican leader and the President are moving in an even 
more dangerous direction. They are pushing to repeal the ACA without 
having any replacement, which would strip healthcare from over 30 
million Americans. It would devastate anyone who is sick today, anyone 
who relies on insurance one gets through the Medicaid expansion or the 
Affordable Care Act, and it sets up a disaster for anyone who might get 
sick after its repeal because it would destabilize insurance markets 
and would throw our economy into turmoil, killing up to 50,000 jobs in 
New Mexico alone. As often happens with policies that hurt the most 
vulnerable, Indian Country would be hit the hardest.
  Traditionally, the Senate has worked on a bipartisan basis to address 
Native American issues. That tradition must continue now. We must work 
together to find a sustainable solution so that Native Americans can 
get affordable, quality healthcare when they need it.
  Mr. President, I ask unanimous consent that a copy of a letter from 
the National Congress of American Indians, National Indian Health 
Board, National Council on Urban Indian Health, and the Self-Governance 
Communication and Education Tribal Consortium sent to Republican 
leadership on June 27, 2017, and shared with the Senate Committee on 
Indian Affairs be printed in the Record. This is just one example of 
the many such letters sent to the Senate over the last few months, and 
I will submit those additional letters as part of the record at our 
next Indian Affairs Committee Hearing.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                                    June 27, 2017.
     Re Tribal priorities in Senate healthcare reform legislation.

     Hon. Mitch McConnell,
     The Capitol,
     Washington, DC.
       Dear Senator McConnell: On behalf of the National Indian 
     Health Board (NIHB), the National Congress of American 
     Indians (NCAI), National Council on Urban Indian Health 
     (NCUIH), Self-Governance Communication and Education (SGCE), 
     and the Tribal Nations of the United States we serve, we 
     write to convey and explain our strong and united opposition 
     to the Senate's Better Care Reconciliation Act of 2017 (BCRA) 
     in its current form.
       While the legislation mirrors several provisions of the 
     House bill that are of critical importance to Indian Country, 
     we have grave concerns about other aspects of the BCRA that 
     make it impossible for us to support the legislation in its 
     current form. Specifically, we cannot support legislation 
     that would gut the Medicaid program or eliminate cost-sharing 
     protections for American Indians and Alaska Natives (AI/ANs). 
     Most importantly, we request that the legislation:
       1) Maintain Medicaid funding based on need, rather than 
     capping it according to a complicated per capita allocation 
     formula or through capped block grants.
       2) Continue Medicaid Expansion, and at the very least, 
     continue Medicaid Expansion for AI/ANs
       3) Protect AVANs from barriers to care that are 
     inconsistent with the federal trust responsibility, such as 
     work requirements under Medicaid

[[Page S4043]]

       4) Retain cost-sharing protections at Section 1402 of the 
     Patient Protection and Affordable Care Act (ACA); and
       5) Maintain funding for preventative services, including 
     the Prevention and Public Health Fund and women's health 
     services.
       As you know, the federal government has a trust 
     responsibility, agreed to long ago and reaffirmed many times 
     by all three branches of government, to provide healthcare to 
     Tribes and their members. Both Medicaid and IHS funding are 
     part of the fulfillment of the trust responsibility.
       However, the federal government has not done its part to 
     live up to the responsibility to provide adequate health 
     services to AI/ANs. IHS funding is discretionary and is 
     appropriated every year and distributed to IHS and Tribal 
     facilities across the country. But IHS appropriations have 
     been about 50% of need for decades, and Medicaid revenue is 
     essential to help fill the gap. When demand for services is 
     higher than the funds available, services must be prioritized 
     and rationed. As a result of this chronic underfunding, 
     historical trauma, and a federal-state centric public health 
     system, AI/ANs suffer from a wide array of health conditions 
     at levels shockingly higher than other Americans. Nationally, 
     AI/ANs live 4.5 years less than other Americans, but in some 
     states life expectancy is 20 years less. This is not 
     surprising given that in 2016, the IHS per capita 
     expenditures for patient health services were just $2,834, 
     compared to $9,990 per person for health care spending 
     nationally. The Senate should pass reform legislation only if 
     it does not reduce access to care for AI/ANs, or further 
     strain the already stretched resources of Indian Health 
     Service, Tribally-operated, and urban Indian health programs 
     (collectively called the ``I/T/U'').


                                Medicaid

       Cuts to the Medicaid program outlined in the BCRA are 
     especially troubling. Under a block grant per-capita system, 
     States will experience a dramatic reduction in federal 
     funding for their Medicaid programs. Most will have to either 
     reduce eligibility for the program or reduce or eliminate 
     benefits that are essential to many AI/ANs. Medicaid is a 
     crucial program for the federal government in honoring its 
     trust responsibility to provide healthcare to AI/ANs. Because 
     health care services are guaranteed for AI/ANs, cuts in 
     Medicaid only shift cost over to the IHS, which is already 
     drastically underfunded. Put simply, without supplemental 
     Medicaid resources, the Indian health system will not 
     survive.
       AI/ANs are a uniquely vulnerable population and uniquely 
     situated in the Medicaid program. Unlike other Medicaid 
     enrollees, because of the federal trust responsibility, AI/
     ANs have access to limited IHS services to fall back on at no 
     cost to them. As a result, Medicaid enrollment and 
     utilization incentives are completely different for AI/ANs in 
     Medicaid. Medicaid conditions of eligibility designed to 
     ensure that beneficiaries have ``personal investment'' do not 
     work when mandatory in Indian country. Instead of 
     participating in these programs, many AI/ANs will simply 
     choose not to enroll in Medicaid and fall back on the 
     underfunded IHS instead. This will deprive Tribal and urban 
     programs of vital Medicaid revenue and strain limited IHS 
     resources to the breaking point.
       Medicaid is a crucial program for the federal government to 
     fulfill the trust responsibility. Over 40 years ago, Congress 
     permanently authorized the IHS and Tribal facilities to bill 
     Medicaid for services provided to Medicaid-eligible AI/ANs to 
     supplement inadequate IHS funding and as part of the federal 
     trust responsibility. At the same time, because Congress 
     recognized that ``. . . it would be unfair and inequitable to 
     burden a State Medicaid program with costs which normally 
     would have been borne by the Indian Health Service,'' it 
     ensured that States would not have to bear any such costs, by 
     providing that States would be reimbursed at 100 percent 
     Federal Medical Assistance Percentage (FMAP) for services 
     received through IHS and Tribal facilities.
       The Senate Finance Committee, which has primary legislative 
     responsibility for the Medicare and Medicaid programs, 
     adopted a similar reimbursement provision as a part of H.R. 
     3153, the Social Security Amendments of 1973. In its report 
     on the legislation, the Finance Committee justified the 100 
     percent FMAP by noting:
       `` . . . that with respect to matters relating to Indians, 
     the Federal Government has traditionally assumed major 
     responsibility. The Committee wishes to assure that a State's 
     election to participate in the Medicaid program will not 
     result in a lessening of Federal support of health care 
     services for this population group, or that the effect of 
     Medicaid coverage be to shift to States a financial burden 
     previously borne by the Federal Government.''
       In light of this legislative history, Tribes are pleased to 
     see the 100 percent FMAP preserved in the BCRA. As the Senate 
     considers this proposed legislation, please ensure that this 
     remains in place. In addition, because the federal trust 
     responsibility also follows AI/ANs off of reservations, 100 
     percent FMAP should also be extended to services provided 
     through urban Indian health programs (UHIPs).
       With regard to Medicaid, we respectfully request that the 
     Senate:
       1) Continue to Fund Medicaid Based on Need without Caps
       Medicaid is an important tool through which the federal 
     government uses to fulfill its trust responsibility to 
     provide for Indian health care.
       The cuts proposed by Sections 133 and 134 of the BCRA would 
     be devastating to Tribal and urban health programs. BCRA 
     would make cuts to Medicaid that are even higher than those 
     proposed by the House of Representatives. BCRA's caps are 
     tied to a lower inflation factor beginning in 2025 that would 
     result in even higher cuts to State Medicaid plans.
       We were encouraged to see that BCRA contains provisions 
     that would prevent the cost of care provided to AI/ANs from 
     counting against either a per capita cap or a block grant. 
     However, we request that urban Indian health programs be 
     included in the exemption as well. Faced with the cuts 
     proposed in Sections 133 and 134 of the bill, most States 
     will be forced to make cuts to eligibility and/or services in 
     future years. This will affect all providers and recipients, 
     including Tribal/urban providers and AI/AN patients. This 
     will lead to significant cuts in Medicaid revenues for I/T/
     Us, and will threaten our ability to provide healthcare 
     services to our people. The Indian healthcare delivery system 
     will not succeed if faced with the cuts proposed in BCRA.
       To the extent that the Senate bill maintains such dramatic 
     caps, it should work with Tribes to develop a mechanism to 
     exempt reimbursements for services received through IHS/
     Tribal/Urban facilities from any State-imposed limitations on 
     eligibility or services that may result from these caps. Such 
     reimbursements would be covered by 100 percent FMAP and 
     therefore will not affect State budgets.
       We also request language be added to the bill that requires 
     States with one or more Indian Tribes or Tribal health 
     providers to engage in Tribal consultation on a regular and 
     ongoing basis, and prior to the submission of any Medicaid or 
     CHIP State Plan Amendment, waiver applications, demonstration 
     projects or extensions that may impact them as Medicaid 
     providers or their Tribal members as Medicaid recipients.
       2) Preserve Medicaid Expansion
       Medicaid Expansion has increased access to care and 
     provided critical third-party revenues to the Indian health 
     system. The uninsured rate for Native Americans has fallen 
     nationally from 24.2% to 15.7% since the enactment of the 
     Affordable Care Act, due in large part to Medicaid Expansion. 
     This has resulted in health care services to AI/AN people who 
     might not have normally received care. It has also resulted 
     in saved revenues to the Medicaid program through preventing 
     more complex and chronic health conditions and saved the 
     Medicaid program money. Medicaid Expansion has increased 
     Medicaid revenues at IHS/Tribal/Urban health programs that 
     are being reinvested back into both the Indian and the larger 
     national health care system.
       The BCRA would roll back federal funding Medicaid Expansion 
     by 2024. The Senate should preserve Medicaid Expansion as an 
     option for States on a permanent basis. While BCRA contains 
     important provisions designed to equalize funding between 
     Expansion and non-Expansion States, we are concerned that the 
     funding made available to non-Expansion States is 
     insufficient to match that which has been provided to 
     Expansion States. At the very least, Expansion should be 
     retained for the AI/AN population under a special Medicaid 
     optional eligibility category for State Plans in recognition 
     of the federal trust responsibility.
       3) Exempt AI/ANs from Work Requirements
       The BCRA would allow the States to impose mandatory work 
     requirements as a condition of Medicaid eligibility, and 
     incentivize States that impose such requirements with a 5 
     percent increase in FMAP to reimburse them for the 
     administrative costs of implementing such a requirement.
       As noted above, mandatory work requirements will not work 
     in Indian country because the incentive structures are 
     completely different. Unlike other Medicaid beneficiaries, 
     AI/ANs have access to IHS services. If work requirements are 
     imposed as a condition of eligibility, many AI/ANs will elect 
     not to enroll in Medicaid. As a result, rather than 
     encouraging job seeking or saving program costs, mandatory 
     work requirements will discourage AI/ANs from enrolling in 
     Medicaid and place pressure on the already underfunded INS. 
     Further, cash jobs are scarce or non-existent in much of 
     Indian country, making work requirements impossible to meet 
     and job training programs an exercise in futility.
       Tribes fully support work programs and employment, but we 
     believe such programs should be voluntary so as not to 
     provide a barrier to access Medicaid for our members. Again, 
     this is consistent with over 40 years of Medicaid policy for 
     Indian Country. To the extent it considers imposing work 
     requirements, the Senate should exempt AI/ANs from any work 
     requirements.


                              Marketplace

       We also ask that the Senate amend the BCRA to maintain cost 
     sharing protections for AI/ANs. These protections were 
     included for AI/ANs in fulfillment of Congress and the United 
     States federal trust responsibility to provide health care to 
     Indians. Section 208 of the BCRA would repeal the cost-
     sharing subsidy program established by Section 1402 of the 
     ACA. However Section 1402(d) of the ACA also includes 
     important and critical cost sharing protections for AI/ANs 
     who have incomes at or below 300 percent of the federal

[[Page S4044]]

     poverty level, or who are referred for care through the IHS 
     Purchased/Referred Care (PRC) program. These cost-sharing 
     protections incentivize AI/ANs to sign up for health 
     insurance and also make it affordable. Eliminating them would 
     create a disincentive for AI/AN to sign up for insurance, 
     since they already have access to IHS services. This would 
     result in less third party reimbursements for the Indian 
     health system and have a destabilizing effect on the system's 
     ability to provide health care to AI/AN people. Dollar-for-
     dollar, leveraging cost sharing protections for AI/ANs and 
     thereby encouraging insurance coverage is a very efficient 
     means of moving the needle forward in meeting the federal 
     trust responsibility for health care resources.


                          Prevention Services

       We are also deeply concerned by the proposed reduction of 
     prevention services in the legislation. The elimination of 
     the Prevention and Public Health Fund will cripple Tribes' 
     efforts to support public health initiatives. Many Tribal 
     health programs rely on PPHF directed funding to keep their 
     public health systems operational. Unlike states, Tribes must 
     piece together a patchwork of funds, some of which are 
     derived from the PPHF, to administer basic prevention 
     services. Additionally, the reduction in funding for women's 
     health services around the country will have major impacts on 
     Tribal members, especially those who do not have direct 
     access to services on or near their reservation. The Senate 
     should restore cuts to the preventative services in the 
     legislation.
       Tribes support the inclusion of state funding to address 
     the opioid crisis. However, states do not often pass these 
     funds to Tribes. Drug-related deaths among AI/ANs is almost 
     twice that of the general population. To address this 
     problem, Tribes should either receive direct federal funding 
     to address the opioid crisis, or states should be required to 
     engage in state-Tribal consultation on the use of funds 
     appropriated for the states.
       In conclusion, the undersigned organizations must oppose 
     the BCRA in its current form. We could support the 
     legislation only if needs-based finding for Medicaid is 
     preserved, Medicaid Expansion is continued, and the other 
     changes outlined above are made to the bill before passage. 
     In fulfillment of the trust responsibility, current 
     exemptions for AI/ANs from health insurance premiums, co-
     pays, and cost sharing must be preserved, and Medicaid-
     eligible AI/ANs must be allowed access to the program without 
     further requirements attached to ensure additional burden is 
     not placed on very limited IHS appropriations. Tribes across 
     the country are eager to come to the table to discuss how 
     shortcomings in the current healthcare system can be 
     addressed, without wreaking immeasurable harm on our health 
     programs and the people we serve.
       If you have any questions please do not hesitate to contact 
     NIHB's Executive Director Stacy A. Bohlen.
           Sincerely,
     Vinton Hawley,
       Chairperson, National Indian Health Board.
     Ashley Tuomi,
       President, National Council on Urban Indian Health.
     Brian Cladoosby,
       President, National Congress of American Indians.
     W. Ron Allen,
       Board Chairman, Self-Governance Communication & Education 
     Tribal Consortium.

  Mr. UDALL. Thank you, Mr. President.
  While this small effort cannot fully replace the necessary 
government-to-government consultation we owe Tribes on this issue, I 
hope it reminds us of our Federal obligations to Tribes and to all 
Native Americans. TrumpCare would turn back the clock. It would violate 
our trust responsibilities. It would endanger the lives of Native 
families. We cannot let that happen.
  Senator Franken has been such an advocate on the Indian Affairs 
Committee for Tribes in his State and across the Nation. All of us have 
worked extensively to try to improve a situation about which, many 
times, we hear from Tribal members is despairing. I really appreciate 
his effort and thank him for coming to the floor today and 
participating in this discussion about Indian healthcare and what these 
Medicaid expansions mean.
  I yield the floor to my colleague and friend from the great State of 
Minnesota, Senator Franken.
  The PRESIDING OFFICER. The Senator from Minnesota.
  Mr. FRANKEN. Thank you, Mr. President.
  I thank my vice chairman of the Indian Affairs Committee, and I thank 
the Presiding Officer, who chairs the committee. I am honored to serve 
under both of them.
  I rise to discuss the devastating effects the various Republican 
healthcare proposals that have been made would have on Indian Country.
  Republicans are now considering a straight repeal of the Affordable 
Care Act, with no replacement. This policy, like others that have come 
before it, would have a devastating effect on Native communities. 
Today, I want to describe some of the healthcare challenges that these 
communities face, how the Affordable Care Act has helped to address 
some of those challenges, and how repealing the Affordable Care Act 
would undermine these gains and further jeopardize healthcare for an 
already vulnerable population.
  I have served on the Indian Affairs Committee for the past 8 years, 
and I am continually shocked by what I hear almost every week from 
Tribal leaders and other witnesses about the challenges that face 
Native communities. One of the biggest challenges is that the Federal 
Government consistently falls short of its responsibilities to Indian 
communities. There is a lack of attention to the concerns of Native 
communities. There is a dysfunctional bureaucracy and a Congress that 
doesn't adequately fund Indian programs, and this can create a vicious 
cycle. When programs don't have adequate funding, they don't work as 
they should.

  Some of my colleagues who have failed to provide Indian Country with 
the funding they need point to the resulting program inefficacies as 
justification for continuing to cut and underfund critical programs. 
That just doesn't make sense to me. Healthcare has fallen prey to this 
vicious cycle even though the Federal Government has a trust 
responsibility to provide healthcare to Tribes and to their members.
  Medicaid and the Indian Health Service are both part of this trust 
responsibility. Over the years, the Indian Health Service has suffered 
from lack of resources, poor staffing, and other challenges. The vice 
chairman was right: ``Don't get sick after June'' is unfortunately 
something we hear over and over again, and it is said with some irony 
but also hurt in Indian Country because the funding runs out then.
  These challenges mean that many in Indian Country, particularly those 
living in remote areas, don't have reliable access to the medical care 
they need on a timely basis. This is healthcare that was promised by 
treaty and by our Constitution.
  Prior to the ACA, funding shortages meant that IHS was only able to 
provide people with the most basic services, so a lot of the care that 
people needed was simply not available. For example, prior to the 
passage of the Affordable Care Act, the Indian Health Service could not 
afford to provide vital services, including women's health screenings, 
like mammograms, or basic diabetes care. If you suffered from diabetes, 
you often had to wait until dialysis was required or limb amputation 
was needed before being able to receive care. That is just 
unconscionable. That is terrible. What is more, American Indians and 
Alaska Natives were more likely to be uninsured than non-Native 
populations, which meant that many people who needed care that wasn't 
covered by the IHS simply went without.
  The ACA helped change all of this for the better. First, the ACA gave 
States the option to expand their Medicaid Programs to include low-
income adults without dependent children. Thanks to Medicaid expansion, 
11 million Americans, including more than 290,000 American Indians and 
Alaska Natives, were able to get health insurance. The ACA's Medicaid 
expansion made it possible for an estimated 60 percent of uninsured 
American Indians and Alaska Natives to qualify for healthcare coverage.
  This expansion, coupled with other Medicaid policy reforms, such as 
those that simplified the enrollment process, helped increase the total 
number of people covered under the program. In fact, IHS reported 
earlier this year that 42 percent of patients receiving services--of 
those who receive the services--did so because they had coverage 
through Medicaid. That is what the Indian Health Service said. Forty-
two percent of those who received healthcare services did so because 
they are covered by Medicaid. In Grand Portage, which is a beautiful 
spot on the

[[Page S4045]]

northeastern corner of Minnesota, this meant that well over 20 more 
band members, many of them children, received coverage. We know from a 
recent report out of Georgetown University that, nationwide, 54 percent 
of children in American Indian and Alaska Native families were enrolled 
in Medicaid in 2015, compared to 39 percent of all children.
  This program has been a vital source of coverage, and, with health 
insurance coverage, people have finally been able to access the 
healthcare they need. That is what healthcare is really about. 
Healthcare is about having coverage so that you have routine visits for 
primary care. So if you are diabetic, you have routine visits. It is 
not about the emergency heroic event; healthcare is about the constancy 
of care. That is what improves people's health. That is what improves 
their lives.
  Another way the ACA helped improve healthcare for Native populations 
was by transitioning the IHS to be the payer of last resort. By 
establishing that Medicare, Medicaid, and private insurance would be 
the primary payers, the ACA ensured that there was more money going to 
provide a wider range of services that people needed, while 
simultaneously reducing the financial burden on the IHS.
  Yet there is more that we need to do to strengthen the Affordable 
Care Act and improve rates of coverage and access within Native 
communities. For example, we need to do more to address workforce 
shortages and lack of competition in insurance markets in rural areas. 
The Presiding Officer knows that. Also, it is imperative that we tackle 
the opioid epidemic in Indian Country. But recent Republican efforts to 
repeal the Affordable Care Act will do nothing to address these 
outstanding needs and would undermine the recent health and coverage 
gains Tribal communities have been able to achieve. I know the last 
bill had money targeted at opioid treatment, but it wasn't anywhere 
near what will be taken away when the Medicaid expansion and cuts to 
Medicaid are figured in.
  The Republicans' proposals would hurt Indian communities in a number 
of important ways.
  First, they would cause tens of millions of people, including many 
American Indians and Alaska Natives, to lose coverage, with between 15 
million and 18 million Americans losing coverage immediately. For 
example, Republican plans would end the Medicaid expansion, as I have 
said, which has been central to providing health coverage to many in 
Native communities.
  Second, they would jeopardize the sustainability and stability of the 
individual market, while giving huge tax breaks to powerful corporate 
interests.
  Finally, they would increase premiums and reduce subsidies that low-
income people receive to help pay for their healthcare, which would put 
private health coverage out of reach for so many.
  Efforts to repeal the Affordable Care Act are just bad for Native 
communities and bad for the country as a whole.
  As many of my colleagues know well, American Indians and Alaska 
Natives are twice as likely, as compared to non-Hispanic Whites, to be 
overweight, obese, diagnosed with diabetes, and experience hopelessness 
and depression. In Minnesota, American Indian women are also more 
likely than Whites to be diagnosed with maternal opiate dependency 
during pregnancy, and more children are born opioid dependent. Reducing 
coverage and driving up healthcare costs is the last thing these 
communities need.
  Indian Tribes in Minnesota and in North Dakota and in all of our 
States are grappling with challenging and complex healthcare needs. 
They need our help. They don't need legislation that is hastily put 
together for ideological reasons. They don't need policies that 
undercut their care and livelihood.
  I believe we need to work together across partisan lines. I really 
hope that is what we are going to do.
  The Republican healthcare plans that have been put forward so far 
break the Federal Government's trust responsibility and undermine the 
very programs that are helping Indian communities. That is what I 
sincerely believe.
  I urge my colleagues to reject Republican efforts to repeal the 
Affordable Care Act and instead work with us on a bipartisan basis, in 
regular order, with hearings before our committees, to strengthen care 
options for our Native communities and for all Americans. I believe we 
can do that, and I believe we can work together. It is just the right 
thing to do.
  Thank you, Mr. President.
  I yield to the vice chairman of the Indian Affairs Committee, the 
Senator from New Mexico.
  The PRESIDING OFFICER. The Senator from New Mexico.
  Mr. UDALL. Mr. President, we have been joined by Senator Heitkamp of 
North Dakota. I appreciate her work on the subcommittee, her incredibly 
hard work and hard dedication that she has put in. She has been a 
champion for her Tribes in North Dakota, a champion for Native children 
and Native women, and a champion for Native Americans across the 
country.
  I yield to Senator Heitkamp.
  The PRESIDING OFFICER. The Senator from North Dakota.
  Ms. HEITKAMP. Mr. President, I think that anyone who picked up the 
Wall Street Journal over the last couple of weeks and read the stories 
about Indian health and what is happening, especially in our region of 
the world in the Great Plains--it shocked the conscience. It should 
have resulted in a prolonged level of outrage that would bring us all 
together.
  Unfortunately, we have seen this movie one too many times. Things 
happen where we see national stories about challenges in Indian 
Country, about the failure to fulfill commitments under treaty rights. 
We see despair. We see the incredible rates of poverty, the incredible 
rates of unemployment, even in a State like ours where unemployment 
rates are never the issue. We wonder, why isn't something being done? 
Guess who wasn't shocked. Those of us who serve on the Indian Affairs 
Committee.
  We on the committee spent a lot of time looking at this last year, 
trying to figure out how we could engage the bureaucracy to be more 
responsive and more responsible and how we could look at sourcing the 
dollars we needed to make sure that Indian health was supplemented and 
that the level of care we expect when we walk into our hospitals--that 
that is the level of care Native American people who go to the Indian 
Health Service on their reservations and who might go to an Indian run, 
a Tribal run facility, would expect. That is what we expect, and I 
think that is what the American public might think is actually going 
on, but those of us on the committee know differently.
  We held a roundtable today to talk about what those challenges are, 
what Native American leaders believe are those challenges, and to ask 
them a simple question: What has Medicaid expansion meant to your 
Tribes? What does access to Medicare and Medicaid mean for delivery of 
healthcare services?
  I want to start off by saying that they have a lot of great ideas, 
and I will run through some of these.
  Chairman Keplin from Turtle Mountain said: We need local doctors. It 
is hard to get people to live on the reservation if they are not from 
the reservation, so we need to figure out how we are going to get local 
folks to be trained, and we are willing to do that in our Tribal 
colleges. We need to build relationships with other healthcare 
providers, like Sanford, that can bring specialists. We need our cancer 
infusion center to be there so that people can get cancer treatment 
right at home. And we need to make sure we are doing everything we can 
to make sure we can treat diabetes right there at home.
  So the healthcare challenges were amazing, but the cost challenges 
were also amazing.
  Duane from Pueblo in New Mexico had some very interesting 
perspectives. Eighty percent of his patient load comes to the clinic. 
They speak their Native language. They have had stability in their 
workforce, but they are looking at transitioning to a Tribal facility. 
But those people don't want to transition because of Federal 
retirement. So is there something we can do to keep these treasured 
healthcare providers working for the Tribe and working for their 
people--the people who know the language and who are familiar with the 
case studies?

[[Page S4046]]

  Lincoln from Alaska said: One of our biggest problems is year-to-year 
funding. The VA has 2-year funding. We don't know what the money is 
going to be and when it is going to come. We also need to train local 
people.
  Sam said: We have a huge need to continue to build out our cultural 
resources and our attention to culture and prevention.
  Ron from Washington talked a lot about the recruitment of workforce. 
The employer mandate came up because so much of the employment on the 
reservations is in fact Tribal members. They are talking about that 
they are mandated to buy this health insurance, but these same members 
have a treaty right to that healthcare. Is there a way to help those 
stretched Tribal resources go a little further by taking a look at some 
relief from the employer mandate?
  The definition of what constitutes an Indian came up over and over.
  From Massachusetts, Cheryl talked about permanent reauthorization of 
Indian healthcare and more resources in diabetes, because that is a 
pervasive problem, and Indian employment, again, talking about that 
issue of buying health insurance.
  As to marketplace access for Native American enrollees who are not 
living on the reservation, how do they make sure they are able to get 
their treaty rights?
  Talking about mental well-being and talking about culture is 
prevention. One of my favorite lines that came out of this was when we 
asked about prevention, and Ashley said: Culture is prevention. We need 
better access to 1115 waivers. Take a look at the Canadian model, she 
suggested. They do more with cultural sensitivity.
  The list goes on and on of great ideas. Not one of these ideas said: 
Repeal the Affordable Care Act. Not one of them said: Let's get rid of 
Medicaid expansion; let's not look at what we can do.
  Let's just all acknowledge what we who serve on this committee know: 
We have challenges that far exceed many other populations. We have come 
to the floor to talk about how the repeal of the Affordable Care Act 
and how the Republican healthcare bill would hurt different 
populations. We have talked about the elderly. We have talked about 
children with disabilities. We have talked about rural communities. We 
have talked about many, many more folks. I think we haven't done enough 
to talk about what this means for Indian people.
  We have a special relationship with Indian people in my State because 
every Tribe in my State is, in fact, a treaty Tribe with a treaty right 
to healthcare.
  Last night, it obviously became clear that the bill, as it stands, 
wouldn't get enough votes to move forward. But we need to keep talking 
about this bill, and we need to keep talking about what the questions 
are. Instead of talking about this bill or that bill or all of the 
acronyms, let's start with healthcare. Let's have a conversation about 
healthcare that starts with healthcare. Where are we doing it right? 
Where are we doing it wrong? How can we reduce costs? Who is being left 
behind?
  It is clear to me that in the healthcare world--never mind the 
Affordable Care Act or the Better Care Act, whatever the Republican 
bill was called. That is a discussion for politics. That is not a 
discussion for healthcare. So let's talk about what Native Americans 
need. Let's talk about how we have failed.
  As I said earlier today, Senator Udall led a really important 
discussion about how we need to preserve Medicaid. When we look at the 
Indian Health Service, I think anyone who really looks at the numbers 
has to admit that it is chronically underfunded.
  Last year, I brought the former IHS Director to North Dakota to press 
her on maintaining quality care in our Tribal communities. This was 
especially important because of the severe challenges Indian healthcare 
has. We know that the lack of funding for Indian healthcare can be 
critically augmented by three main sources: Medicaid, Medicare, and 
private insurance. If every person walking in has the ability to pay, 
we are going to improve access to care, and we are going to improve the 
opportunity to recruit a workforce.
  I think some people may roll their eyes when they say: Don't get sick 
in June. My husband is a family physician and practices about 60 miles 
north of the Standing Rock Sioux Tribe. He can tell you that there have 
been times when people from the reservation have come to the clinic to 
see him because the clinic in Fort Yates is shuttered--no money that 
day, no opportunity for healthcare. So people come to get the 
healthcare they need, but they have to drive a long way. It is wrong. 
You see a new doctor whom you have never seen before and who may not, 
in fact, understand your condition.
  So the Turtle Mountain Band of Chippewa, who are represented today, 
have over 33,000 enrolled members, of which approximately 14,500 
actively receive treatment and benefits for services at the local IHS 
hospital. Thanks to Medicaid expansion and increased enrollment efforts 
by the Turtle Mountain Band of Chippewa in my State of North Dakota, 
their Indian Health Service hospital is now able to offer so much more 
in services to their people and increase their outreach and prevention.
  In June alone, Turtle Mountain's IHS clinic served nearly 13,000 
clinical patients and provided over 1,000 emergency room services. 
Third-party billing revenue has now allowed the Tribes to make 
renovations to their emergency room and their clinic, to purchase new 
medical equipment, including neonatal monitors, to recruit and hire 
additional staff, including licensed professionals, to increase staff 
training and education, to provide Wi-Fi throughout the hospital, and 
to expand their behavioral healthcare facility to serve more patients.
  Since the Medicaid expansion, they have had a 9-percent increase in 
the number of individuals they have served. Their hospital is also 
experiencing a decrease in the number of uninsured patients--still too 
high, in my opinion, at 39 percent. We can get that lower if we get 
more people to take advantage of Medicaid expansion.
  But, unfortunately, a Republican healthcare plan that would eliminate 
cost-sharing subsidies is making that private health insurance less 
affordable and less successful.
  So let's be honest about how we are affecting our Native American 
population and talk about the multiple times this expansion has been so 
important to our Native families.
  In North Dakota, the Republican bill would cause an estimated 984 
Native Americans to lose cost-sharing reduction subsidies. The Senate 
Republican healthcare bill would also get rid of the Medicaid expansion 
and cap the amount of Federal funding States can get to cover those on 
traditional Medicaid. As a result, it would drastically reduce the 
amount of Medicaid funding going to the States. This would push the 
remaining costs to the States and counties that can't afford it.
  The American Hospital Association estimates that North Dakota 
Medicaid would lose $1.2 billion. I will say that again. North Dakota 
Medicaid would lose $1.2 billion through 2026.
  Right now, 9,000 North Dakota children and individuals with 
disabilities--Native Americans, seniors, and low-income families--rely 
on Medicaid for affordable, quality care, but this bill would rip it 
away in so many wrong ways.
  The uninsured rate for Native Americans has fallen nationally from 24 
percent to 15 percent, largely due to Medicaid expansion.
  We go on and on. Currently, Medicaid accounts for 24 percent of the 
Indian Health Service workforce. The Senate Republican bill would strip 
away $772 billion from Medicaid, and the White House proposes cutting 
an already underfunded Indian Health Service budget by 6 percent.
  We already know that the per-patient cost in the Indian healthcare 
system is greatly below that of Medicaid reimbursement cost, on 
average. So if we take away Medicaid reimbursement, we are hurting not 
only the providers, but we are once again making healthcare less 
affordable.
  This is a crisis. I can't begin to tell the Members of this body what 
a crisis Indian healthcare is in. We have known it on the committee for 
many, many years. In fact, Senator Dorgan was the first one to really 
sound the alarm of the crisis in the Great Plains area,

[[Page S4047]]

thinking that a report that was so damaging would result in change. 
Guess what. It didn't. It didn't result in change. But the one thing we 
can point to that is a bright shining light has been access to Medicaid 
dollars. It has given them access to capital expenditure, and it has 
given them access to workforce. It has given a more consistent way for 
people who don't live on the reservations to get healthcare.
  I have said this many, many times: We need to not go backward; we 
need to go forward. When people say: We are going to take a step back, 
we are going to reduce actual appropriations by 6 percent for Indian 
health, and we are going to eliminate Medicaid expansion, I say: You 
had better look before you take a step backward because you might be 
off the cliff. That is how dire it is in Indian Country.
  The one thing I am going to conclude with is that for many, many 
years in healthcare we have not done what we need to do to consult with 
Tribal people: Here is the facility; this is what we are going to 
provide. Good luck. One size fits all.
  What we need to do and what Medicaid has allowed is that flexibility 
for Tribes to engage, for Tribal people to engage in what their needs 
are, and to take a look at those community health models that do dental 
care, eye care, and mental health and addiction counseling. All of this 
needs to be wrapped up. When people say there is no hope, there 
certainly is no hope without help.
  There is an old saying: When you have your health, you have 
everything. I can tell you from personal experience that it is 
absolutely true. You could be the richest man in the world, but if you 
don't have good health, your quality of life is not what it could be.
  When we look across the indicators of what has happened in Indian 
health with indigenous people throughout our country, when we know this 
is our obligation--this is that treaty obligation, the treaty right 
that has been bargained for--shame on us.
  Medicaid can be that bridge. It can be the bridge to better 
healthcare. That is why it is so critical, Mr. President and my vice 
chairman, that we be out here speaking for our communities, speaking 
for these unique groups of folks who depend so much on Medicaid 
expansion but who also depend on us to do a better job, to be better 
stewards of that relationship, to be better citizens as it relates to 
living up to the obligations that our ancestors negotiated.
  I ask everybody who hasn't really been exposed to this issue to read 
the articles in the Wall Street Journal. But don't just read them and 
wring your hands and say: This is horrible. Take a step to change the 
outcome. Don't just read them and say: Boy, that is horrible. Take 
responsibility for what you read. Every one of us in the Senate and in 
the Congress is responsible for fulfilling the obligations of these 
treaties. When we aren't doing it, it is a failure on every one of us, 
and it is a failure to protect some of the most vulnerable people in 
our country--and that is Native American children.
  I yield the floor and turn it back to my vice chairman, Senator 
Udall.
  The PRESIDING OFFICER. The Senator from New Mexico.
  Mr. UDALL. Mr. President, I know Senator Durbin is on the floor so I 
am going to wrap up very quickly. I first want to thank Senator 
Franken, who came down here and advocated for his State and for Native 
Americans across the country. I thank Senator Heitkamp for her 
passionate speech about Native Americans and Native children. I have 
known her almost 30 years, as the State attorney general, when she was 
doing the same things, and she has made real progress.
  You can see from this roundtable today--and I really appreciate 
Senator Heitkamp coming and helping me chair that. I had to slip out to 
Foreign Relations, but she spent a significant amount of time chairing 
that roundtable. I think it really made a difference to all of the 
Tribal leaders there.
  I want to finish with what one of those Tribal leaders said to us.
  Senator Heitkamp, you said something very similar.
  This Tribal leader reminded us, he said: Decades ago, Tribes made a 
downpayment on the healthcare they receive. We are not asking for a 
handout. We made a downpayment.
  What was he talking about?
  We made a downpayment with our land, with our water, and with large 
areas of what were then either territories or the United States--that 
they considered their homelands. How sad it is to see that we are not 
fulfilling the promises of these sacred treaties they entered into.
  With that, I would conclude--as Senator Franken did and I believe it 
was the same thrust of what Senator Heitkamp was saying--with this. We 
have hit a wall on healthcare. We have come up to the point where you 
don't know where to go. The best thing to do when you hit a wall is to 
get back to the regular order, work on a bipartisan basis, go into 
committee, let people put proposals forward, have amendments, open up 
the process.
  That is where we need to go at this point. I would urge the 
Republican leadership to take a look at the regular order. That may 
help us find our way out to improve the healthcare situation for not 
only Native Americans but all Americans, which is what we face with 
this TrumpCare, which is taking us in the wrong direction.
  With that, I yield the floor.
  The PRESIDING OFFICER (Mr. Daines). The Senator from Illinois.
  Mr. DURBIN. Mr. President, let me thank my colleagues for coming to 
the floor and speaking on behalf of Native Americans and the Indian 
Health Service, its shortcomings and challenges that it creates for us.
  I don't have an Indian reservation in my State, but I certainly have 
visited these Indian reservations in other States and believe we have 
an ongoing responsibility--social and moral responsibility--to those 
who were in this country long before many of our ancestors and who have 
not been treated fairly many, many times when it comes to the poverty 
they face in this country and the challenges they face.
  It is as bad as or worse than any other group in America. We can do 
better, and we need to start with the Indian Health Service and health 
services. I thank my colleagues for raising that issue.
  Mr. President, it is interesting, this is a historic week in the 
Senate because we have been engaged in a debate for weeks about what to 
do about healthcare in America. The Senate, of course, is under the 
majority control of the Republicans, as the House of Representatives 
is, and, of course, with a Republican President. They all came to 
Washington at the beginning of this year and said: The first thing we 
want to do is to repeal ObamaCare. We have said it for 6 years. We are 
finally going to do it. We are going to get rid of ObamaCare, the 
Affordable Care Act, once and for all.
  They set out to do it in a variety of ways. President Trump's first 
Executive order to the agencies of the Federal Government said: Do 
everything you can to discourage ObamaCare. He turned around and did 
just that. His agency stopped advertising for people to sign up for 
ObamaCare. They were determined to put an end to it.
  In the House of Representatives, they took a step beyond that. They 
introduced legislation to repeal it and replace it. What they replaced 
it with was a disaster. The Congressional Budget Office took a look at 
the Republican repeal plan in the House and said 24 million people will 
lose their health insurance.
  Beyond that, they talked about the changes that would take place in 
health insurance policies with the Republican repeal plan. It passed 
the House by four votes, which meant that if two Republican Members--
and only Republicans voted for it--had voted the other way, it wouldn't 
have passed. It was that close.
  Then it was sent to the Senate, and it was up to the Senate 
Republicans to decide what they would do with this bill and what they 
would do with the repeal of ObamaCare. They spent many weeks in 
conversation and discussion about what they might do. Thirteen Members, 
Republican Senators, sat in private rooms and talked about what they 
would do to replace ObamaCare.
  Finally, they reported a bill. It turns out their bill was an 
improvement over the House bill. The House bill eliminated health 
insurance for 24 million Americans. The Senate bill eliminated health 
insurance for 23 million Americans. Still, when you look at it, it is a 
horrible thing.

[[Page S4048]]

  In my State of Illinois, a million people in my State would have lost 
health insurance with either the House or Senate Republican bills. It 
is the reason there has been resistance in my State to this Republican 
effort from the start.
  You would expect it on a political basis. Sure, the Democrats will 
oppose the Republicans on issues, but this went beyond it. There wasn't 
a single medical advocacy group in the United States that supported 
what the Republicans were doing, not one. The hospital associations 
across America, the medical society of doctors, the nurses, the 
pediatricians, they all opposed what the Republicans set out to do.
  When it looked like there were problems in passing one version of the 
Senate Republican repeal bill, they sat down to rewrite it. As they sat 
down to rewrite it, they got into deeper water and bigger problems.
  Senator Cruz, the junior Senator from Texas, said: Well, one way to 
bring down the cost of health insurance is to take out some of the 
protections of a health insurance policy. We can get premiums down 
pretty low if we take away the protections of a health insurance policy 
that are in the Affordable Care Act.
  That was his proposal.
  Just this weekend, Blue Cross Blue Shield and the major health 
insurance industry said that this will be a disaster. If you have some 
people buying real insurance and real protection and others paying 
rock-bottom premiums for little or no coverage, you are going to create 
two classes of Americans, and you are going to see premiums going 
through the roof for those who are buying full-coverage policies. They 
came out against the Cruz proposal.
  This week, we returned to face the votes. We were supposed to be 
voting today, a vote on whether to repeal ObamaCare. As of last night, 
things started changing. Two Republican Senators joined two others and 
said they were opposing the effort, and so the Republican majority did 
not have the votes it needed to go forward.
  They said: Well, at least we will vote on repealing ObamaCare.
  Three Republican Senators have announced, as of today, that voting 
for simple repeal is something they will not do. Many of them make the 
argument that just repealing ObamaCare without replacing it is 
irresponsible. They are right.
  If you don't like the current system, I believe you are duty-bound, 
as a Senator or Congressman, to come up with a better idea, something 
that serves America better. They have been unable to reach that point.
  Where are we? At this moment, we are at a standstill. The Republican 
efforts to repeal and replace have stopped as of this moment. There may 
be a vote, an official vote this week. I don't know. That is up to 
Senator McConnell as the Republican leader, but it appears there is no 
plan coming out of the Republican side to replace the Affordable Care 
Act.
  I am proud to have voted for it. I voted for it for very simple 
reasons. When it comes to health insurance, I believe that is one of 
the basics in life. I am one of those politicians who believes 
healthcare is a right, just like police and fire protection. It should 
be part of who we are in America. I don't believe it is a question of 
how rich you are or how lucky you are as to whether you have health 
insurance in this country.
  We can do better as a nation. The Affordable Care Act set out to do 
that. We reduced the number of uninsured Americans with ObamaCare when 
we passed it 6 years ago by 50 percent. We reduced by half the 
uninsured people living in my State of Illinois. Many of them went to 
the insurance exchanges, bought private health insurance. If they had 
lower incomes, they got subsidies to help pay the premiums. Others 
picked up Medicaid coverage as their health insurance. It was 
significant.
  I ran into people all across my State, from Chicago to downstate, who 
had never had health insurance 1 day in their lives. These are not lazy 
people. These are hard-working people who happen to have the kind of 
jobs that didn't offer health insurance.
  Ray Romanowski, big Polish fellow, guitarist and musician in Chicago 
said: Senator, I have never had health insurance. I am a musician. 
Nobody was ever going to provide me with health insurance.
  He said: Lucky I have it now because I have been diagnosed with 
diabetes. I am in my sixties, and I have, through the Affordable Care 
Act, health insurance through Medicaid.
  Similar story, almost identical story in deep Southern Illinois. 
Judy, who works as a hospitality hostess in a local motel--she is the 
one who greets you with a smile when you come in for that free 
breakfast. Judy is 62 years of age. She never had health insurance 1 
day in her life. She holds down two and three jobs at a time. The only 
health insurance she ever had is what she has now under Medicaid.
  What is going to happen to those people if we eliminate Medicaid 
coverage--which the proposals before us suggested--if Medicaid coverage 
is cut back dramatically?
  Those two people, Ray and Judy, are still going to face health 
challenges. They are still going to get sick and go to the hospital, 
but if they don't have health insurance, will the hospital treat them? 
Yes. What will happen to their bills? Their costs will be passed on to 
everyone else. That is the way it used to be done.
  What we have learned this week in Washington, in this national 
healthcare debate, is there are of course concerns about whether the 
current healthcare system is what it should be, and I think it can be 
improved, but we have learned one basic thing. We are not going back. 
We are not going back to the days when health insurance companies could 
deny coverage to you or your family because of a preexisting condition. 
We are not going back to the days where they put a limit on how much 
they would pay on your health insurance plan.
  Remember when you first realized that a $100,000 limit was not worth 
that much if you had a serious diagnosis or a serious accident? We are 
not going back to the days when that health insurance plan literally 
expired in coverage, forcing you and your family into bankruptcy over 
medical bills.
  We are not going back to the day when families couldn't cover their 
kids coming out of college. The Affordable Care Act said you can keep 
your child on your health insurance plan as a family until they reach 
the age of 26.
  Those of us who have had kids who have graduated college realize they 
don't always get a great job right off the bat. Some of them start as 
interns or part-time workers, and they don't have health insurance. 
They now know they have the peace of mind of the family health 
insurance plan.
  We want to make sure we protect that. We are not going back to the 
day when those young people had no coverage at a critical moment in 
their lives. We are not going back to the day when we allow these 
insurance companies to charge whatever premiums they wish.
  We put provisions in the law that limit the premiums that can be 
charged on Americans, that limit the profits that are taken out of 
health insurance companies. Those were moves that had to be made to 
protect innocent American families who, unfortunately, were struggling 
with medical bills before this law passed and now at least have some 
chance of paying for them.
  What we learned in the course of this national debate is significant. 
We learned that if you put up a proposal, as the Republicans did in the 
House and the Senate, that takes health insurance away from over 20 
million Americans, you have a problem. People are going to push back 
and say that it isn't fair to take away health insurance and the 
protection and peace of mind that come with it. If you come up with a 
plan that ends up dramatically cutting back on Medicaid, you are going 
to get a lot of people who are concerned about it.

  Across America, the Medicaid Program as we know it does many 
significant things. One-half of the babies born in my State of Illinois 
are covered by Medicaid. Mom and her prenatal care, the delivery of the 
baby, and the caring for mom and the child afterward are covered by 
Medicaid. If you make a cut in the reimbursement for Medicaid, you will 
endanger the basic treatment needed to have a healthy baby.
  The second thing we know is that Medicaid is critical for people with 
disabilities. I met a mother in Champagne, IL, and she came up and told 
me

[[Page S4049]]

she has a 23-year-old autistic son. It has been a struggle for her and 
her family, but now he has a somewhat independent life. She said: 
Senator, if you take away Medicaid insurance from him, I will have to 
put him in some institutional program that I cannot afford. There is 
nowhere to turn.
  I also want to remind people that Medicaid pays school districts to 
take care of kids with special education needs, transportation, 
counselors, even feeding tubes for the severely disabled. That is an 
important part of Medicaid.
  I haven't touched on the most expensive part of the Medicaid Program 
in America. The most expensive part is for those who are in nursing 
homes, those who are older Americans and need Medicaid to get by. They 
have Social Security and they have Medicare, but they need Medicaid. If 
you cut back on Medicaid as proposed by the Republicans in both the 
House and the Senate, who will take care of these elderly folks who are 
in a situation where they have exhausted their savings? Do they move 
back in with the family? Sometimes that is not even possible, but that 
is one of the prospects faced.
  What we need to do is to accept the obvious. We have reached an 
important political milestone here where the Republicans don't have the 
votes to move forward, but we still have the challenge of the current 
system. I was proud to vote for it, but it is far from perfect. The 
current healthcare system in America, the Affordable Care Act, needs 
help, needs changes. We need to do it. We ought to just surprise the 
heck out of America by working together, both political parties, to 
solve the problems.
  Let's identify a few of the most obvious problems.
  No. 1, the Affordable Care Act in America today does not address the 
cost of prescription drugs. You ask a health insurance company: What is 
driving the cost of premiums? Prescription drugs.
  Did you ever notice that when you turn on the television at certain 
times of the day, it is all about drugs? It is all about new drugs, 
things you can hardly pronounce. These new drugs are being advertised 
on television time and again. And then there is a 2- or 3-minute 
disclaimer: Be careful. If you take this drug, you might die. Be sure 
and tell your doctor if you have ever had a liver transplant.
  I listen to all these warnings, and I am thinking, this is being sold 
in advertising for the general population? Did you know that there are 
only three countries in the world that allow television advertising of 
prescription drugs--the United States, New Zealand, and Brazil?
  Why do the pharmaceutical companies advertise drugs on television? 
Certainly if you want to inform a doctor about a new drug, you wouldn't 
buy a television ad, would you? The reason they are on television is so 
that we, as individual consumers and patients, will walk into the 
doctor's office and say: Doctor, it took me five times, but I finally 
figured out how to spell ``Xarelto,'' and I want Xarelto as my blood 
thinner.
  The doctor has a choice: He or she can explain to you that you may 
not need Xarelto, that there is a cheaper version of blood thinner or 
that this isn't the one that really fits your needs in this 
circumstance. Doctors don't do that. Many of them just write out the 
prescription. That is why the television advertising is taking place--
to convince the consumer, who asks the doctor and who ends up with the 
high-priced drug being scripted for them. That is the reality of why 
the costs of healthcare keep going up.
  What does the Affordable Care Act do about that? Nothing. It does 
nothing when it comes to the cost of prescription drugs. I want these 
drug companies to make a profit, don't get me wrong. If they are 
profitable while looking for new cures, that is the way it should be. 
But when they charge through the roof and double and triple the cost of 
these pharmaceutical drugs, that is not fair. It is not fair to 
consumers, and it is not fair to taxpayers.
  Think about the fact that many of exactly the same drugs made in the 
United States are sold in other countries for a fraction of what they 
cost in the United States. Even in Canada, they charge about one-half 
or one-third for many of the most popular drugs because the Canadian 
Government said to the drug companies in America: We are drawing the 
line. We are not going to let you charge anything you want to charge.
  Why don't we do something in America to protect consumers? Why don't 
we at least inform people when pharmaceutical companies are 
overcharging so that we can put some pressure on them to stop? That is 
part of the change to the Affordable Care Act that I think will save us 
money and at the same time deal with an issue most Americans really are 
concerned about.
  We also should be concerned about the fact that when it comes to the 
individual health insurance market, that is where most of the problems 
are. Six percent of the American population buying health insurance 
through the exchanges--half of them have to pay the full premiums, and 
some of those premiums go through the roof. Why? Because the people who 
are buying this insurance are usually people with a medical history or 
they are older folks and they want to have the peace of mind of 
coverage. The healthy, younger folks aren't buying it. As a result, the 
insurance risk pool gets pretty expensive when it comes to premiums. We 
need to fix that, and we can fix that. That is another thing on which 
we should come together as Democrats and Republicans to try to achieve.
  For those who say: Well, I promised my entire political career that I 
couldn't wait for the day to come forward and vote to repeal ObamaCare, 
I just want to tell them that they should be aware that when the 
Congressional Budget Office looked at the impact of just repealing the 
Affordable Care Act and not replacing it, they said the following: This 
would force more insurance companies to leave the market immediately. 
It would increase premiums by 20 percent a year and double the price of 
premiums over 10 years, and it would take health insurance away from 32 
million people.
  So taking that vote to repeal the Affordable Care Act may earn you a 
cheer at some political rally, but it is not responsible. It is not 
good. It will raise the cost of health insurance for families across 
our country if we just repeal and don't replace, and it will take 
health insurance away from over 30 million people, according to the 
Congressional Budget Office. It is better that we replace it with 
something responsible, better that we take the current system and make 
it stronger.
  This has been an interesting debate. I have learned a lot in the 
course of this debate because I went and visited the hospitals in 
Illinois. The Illinois Hospital Association opposed the Republican plan 
in the House and opposed the proposal in the Senate. They said it would 
cost us 60 to 80,000 jobs in Illinois and it would close down some 
hospitals we need in rural parts of our State, smalltown hospitals that 
are critically important. I don't want to see that happen, the people 
who live there don't want to see that happen, and you won't be able to 
keep and attract good employers and good jobs if that does happen. So I 
have worked with these hospital administrators and want to move forward 
with them on an alternative.
  I will close by saying this: It is interesting how many people say 
``I can't wait until I reach age 65 because I will qualify for 
Medicare.'' Medicare doesn't discriminate based on preexisting 
conditions and provides good health insurance for millions of 
Americans. It is an illustration and a lesson for us that if you have 
something that isn't driven by the profit motive, that people trust, 
that has provided basic, good care for Americans, good hospitals and 
good doctors, that is what people are looking for. Why shouldn't they? 
That should be part of the American dream. It should be part of our 
right as Americans.
  Mr. President, I yield the floor.
  I suggest the absence of a quorum.
  The PRESIDING OFFICER (Mr. Johnson). The clerk will call the roll.
  The assistant bill clerk proceeded to call the roll.
  Mr. ENZI. Mr. President, I ask unanimous consent that the order for 
the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. ENZI. Mr. President, in our job, we get a lot of books, probably 
two or three a week at least, and for the last year most of those have 
been on

[[Page S4050]]

healthcare and healthcare reform. A book I received recently is one 
called ``Demystifying ObamaCare,'' by David G. Brown, who is a doctor. 
It was helpful enough to me that I thought I would share a part of it 
with anybody listening. It always fascinates me when we are here 
talking and maybe somebody is listening.
  Page 7 starts out by talking about, ``How Does ObamaCare Look After 
Seven Years?'' Incidentally, this one is all well documented and 
footnoted, which is one of the unusual things about this book. It is 
not just speculation on his part--it is a lot of research that he has 
done and shared. He says:

       ObamaCare actually reduces insurance market competition by 
     strict rules, regulations, and mandates.
       ObamaCare significantly increases healthcare cost by the 
     way it attempts to assist those who cannot afford coverage.
       ObamaCare does not tackle the underlying causes of 
     increased costs. Instead, it worsens the factors that drive 
     up the cost of healthcare with the addition of mandates, 
     regulations, and taxes. ObamaCare does nothing to decrease 
     the factors that increase costs.
       ObamaCare has increased the total number of healthcare 
     spending. The cost is not $938 billion dollars, but now is 
     $2.6 trillion dollars over 10 years, or almost 3 times the 
     original figure.
       ObamaCare increases cost for families, businesses, and 
     individuals for their healthcare. This includes not simply 
     ObamaCare exchanges but health insurance across the board. 
     Associated with this, there has been a marked increase in 
     healthcare premiums, costs for medications, deductibles, and 
     copays.
       There has been reduction of access to care in ObamaCare 
     plans, i.e. ObamaCare exchanges (insurance does not equal 
     access).
       ObamaCare, to some extent, has reduced the number of 
     uninsured but not handled the problem of the uninsured 
     population.
       ObamaCare does not effectively address the problems of the 
     safety net system, i.e. putting new people into Medicaid has 
     exacerbated the problems for Medicaid, and removes its 
     original safety net function.
       ObamaCare has reduced funding and thus care for programs 
     for the elderly, Medicare.
       ObamaCare has taken the decision making process out of the 
     hands of patients and their families. It has done so by 
     removing their freedom to make those decisions.

  This is from the book, ``Demystifying ObamaCare,'' by David Brown, 
who is a doctor.
  It goes on later to say:

       The individual mandate was instituted as a way to force 
     patients into having health insurance or else pay a financial 
     penalty for not having it. The employer mandate, which was 
     just instituted in 2016 after several delays, was intended to 
     move those with employer-based insurance into the government 
     sector. Additionally, the HHS required all individual and 
     small group policies to meet the ``essential health benefit'' 
     requirements. These benefits were determined by the secretary 
     of the HHS and required involvement of not simply government, 
     but also non-government plans. The individual and small group 
     policies then had to be sold at a more significant cost to 
     the consumer.
       How is the Employer-Based System changed so employees could 
     be moved into a government system?
       Businesses with 50 or more full-time employees had to 
     provide health insurance approved by HHS or be financially 
     penalized.
       The cost for businesses for the penalties for not providing 
     insurance was less than the cost of the insurance.
       ObamaCare exchanges were there to take in anyone who needed 
     to have insurance. Employer based mandates were a way of 
     moving employees out of the employee-based marketplace into a 
     government program. It is the back door way of having a 
     government based healthcare system. It was ingenious but 
     fortunately, for the American people it was flawed.
       Yes, Americans in the individual market lost their 
     insurance (5 million Americans) but the employer-based 
     mandate was postponed through the efforts of Congress. Many 
     of the larger companies have self-insured their employees. 
     The ObamaCare exchange program has been very expensive for 
     the consumers. It has also significantly limited access to 
     care i.e. narrowed networks of providers, (doctors and 
     hospitals). ObamaCare has increased the numbers in Medicaid 
     but this program itself has severe flaws.

  Again, in ``Demystifying ObamaCare'' by David Brown, a doctor, going 
to page 18, ``What Are the Facts About Medicaid and Medicaid 
Expansion?''

       Costs of Medicaid (total federal and state spending) will 
     more than double i.e. more than $427 billion to $896 billion 
     between 2014 and 2024. The costs of this will be borne by the 
     taxpayers.
       The cost of Medicaid to the states has a tremendous impact 
     on other services. It is often the second most expensive 
     budgetary item. With Medicaid expansion, there are increased 
     costs to the states, even in those states, which have 
     accepted Medicaid expansion and increased federal funding for 
     it. Other state services may have to be reduced even in 
     states who have not accepted Medicaid expansion.
       Medicaid is actually a safety net for the poorest and most 
     vulnerable Americans but expansion changes this. It reduces 
     the access to care for others who are already in the system. 
     The single adult able-bodied American is competing for care 
     with those who need the care as a safety net.
       It severely underpays doctors and hospitals, and the number 
     of Medicaid providers are declining. It compensates doctors 
     an average of 50% less than private insurance. By CBO 
     estimates, by the time of full implementation of ObamaCare, 
     one out of every six hospitals will be in the red because of 
     severe underpayment from Medicaid and Medicare.
       Medicaid expansion does not reduce inappropriate 
     utilization of emergency rooms. A recent study showed 
     Medicaid patients utilize the emergency rooms for their 
     routine care 40% more than those who are uninsured.
       Medicaid has the worst clinical outcomes compared with any 
     other medical program. There are worse outcomes including 
     conditions such as heart disease, cancer, complications from 
     major surgery, transplants, and AIDS. These outcomes are 
     independent of patient factors and reflect the program 
     itself. It may be no better than having no insurance at all. 
     A recent study comparing Medicaid patients with those who are 
     uninsured showed no difference in blood pressure, glucose, 
     and cholesterol levels after two years of observation.
       In short Medicaid expansion reduces access to care, 
     increases cost of care and places people within the program 
     that has the worst possible outcomes to care.

  Going on in ``Demystifying ObamaCare,'' by David Brown, page 25, 
``Medicaid Expansion Update: How Does It Stand Today?''

       Thirty-one states and the District of Columbia have adopted 
     Medicaid expansion. Three states have considered it but 
     rejected Medicaid expansion. The other sixteen states have 
     refused to participate in it.
       Medicaid expansion has increased the Medicaid number from 
     58 million to approximately 70 million people, 20% of the 
     uninsured population. It has caused overall expansion of the 
     number of people in the program.
       ObamaCare has increased the number of individuals insured 
     by allowing them to participate in the existing Medicaid 
     program. In order to do so, the inclusion criteria for their 
     enrollments have changed. Medicaid expansion is now based on 
     age and financial criteria. That includes both the able-
     bodied individuals who are able to work and chose not to and 
     those who were previously involved in the Medicaid safety 
     net. For example, the lower income mother with children.
       It was thought that the states that accepted Medicaid 
     expansion would have ``free money'' if they participated with 
     this Federal program. 100% of the costs of adding new 
     patients were picked up by the federal government with that 
     figure gradually being reduced to 90% of the cost starting in 
     2017.
       This was for new patients added to Medicaid and not the 
     existing patient population. States however found that their 
     Medicaid programs were flooded with new enrollees, many of 
     which had met the criteria for Medicaid before the ``woodwork 
     effect.''
       The overall expansion of Medicaid with increasing numbers 
     of enrollees has led to marked increase in spending on 
     Medicaid and marked increase in total costs for Medicaid.

  It goes on with a lot of numbers which have a lot of significance to 
accountants, but I will skip over those and continue on with his last 
two points.

       Medicaid is associated with the worst possible clinical 
     success rate across the board for all medical and surgical 
     illnesses. It is worse than any other program, including any 
     government programs such as Medicare or any private program. 
     In certain studies, it has shown to have worse clinical 
     outcomes than having no insurance at all. No data has 
     developed during the course of Medicaid expansion to change 
     these findings.
       Medicaid expansion is associated with a huge financial 
     burden on the states and the cost to the states with Medicaid 
     expansion has increased dramatically.

  Again, at the end of the chapter it shows a lot of references for 
where he got this information.
  Continuing with ``Demystifying ObamaCare'' and moving on to page 31 
is ``What are ObamaCare Insurance Exchanges?''

       ObamaCare insurance exchanges are federally constructed and 
     state run markets where individuals and families can purchase 
     insurance plans. Private healthcare insurance companies 
     participate but the insurance companies are only able to sell 
     plans that are acceptable to the Secretary of the HHS. Many 
     individuals and families then could receive subsidies 
     provided by the government, (i.e. taxpayers funded 
     subsidies). The subsidies are [to] be on a sliding scale, 
     families whose income is up to 400% of the federal poverty 
     level can be in the ObamaCare exchange ($97,000 dollars a 
     year for a family of four). The program is tightly regulated 
     by the Federal Government. The choice is limited to four 
     plans (bronze, silver, gold, and platinum.) Each state was 
     required to set up their own insurance exchanges and then 
     regulate them. If a state

[[Page S4051]]

     did not set up such an exchange, the Federal Government did 
     that for them.

  ``What Effects These Policies Have on Those Inside and Outside the 
Exchanges?''

       The public must know that the exchanges dramatically 
     restrict patient care by restricting access to care. 
     Exchanges decrease access by reducing access to doctors and 
     hospitals. This includes access to some of the most important 
     specialized care. The exchanges have a limited network of 
     providers.
       The public must understand that they do [not have] 
     protection from fraud. Some of the most sensitive information 
     is given to navigators to help enroll people in the 
     exchanges. The enrollees then become ``fair game.''
       The ObamaCare website, ``Healthcare.gov'' does not 
     automatically verify enrollee's eligibility, i.e., whether 
     they legally qualify for subsidies. Various sources indicate 
     that at least 2 million enrollees (some estimates are 
     significantly higher) are receiving subsidies that they did 
     not legally qualify for. Douglas Holtz-Eakins, former 
     director of the CBO, estimates that over the first 10 years 
     of ObamaCare, overpayments and inappropriate payments could 
     add up to $152 billion dollars. Who pays the bill? The 
     American taxpayer. The website, ``Healthcare.gov'' cost 
     taxpayers $1.4 billion dollars in 2014.

  He goes on to explain how that increases the costs for all taxpayers.
  I will continue with some of the other lessons in this book at 
another time. The leader is coming to the floor to speak in a few 
moments.
  What we are trying to do is to find some solutions for the American 
people so they have access to healthcare--and more extensively than 
now. I recommend for reading this book called ``Demystifying 
ObamaCare'' by David Brown. It is very eye-opening. There is a section 
I will cover later that covers some of the solutions that will be 
useful.
  I yield the floor.
  I suggest the absence of a quorum.
  The PRESIDING OFFICER (Mr. Rubio). The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. McCONNELL. Mr. President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.