[Congressional Record Volume 163, Number 151 (Tuesday, September 19, 2017)]
[Senate]
[Pages S5836-S5840]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]



                               Healthcare

  Mr. CARDIN. Mr. President, there are reports that we may be having a 
vote next week, under reconciliation, dealing with the healthcare 
system of this country. We know that colleagues have filed a new bill, 
but it is basically the same bill we have seen in the past but this 
time even more consequential to our healthcare system and the people of 
this country.
  I mention first the process because this bill has not gone through 
any regular order. It has not been referred to a committee for 
consideration. It has not been marked up or debated in our committees. 
It is going to supposedly be

[[Page S5837]]

brought up as an amendment but with us returning to reconciliation.
  Let me first explain what that means. That means there will be no 
chance for us to offer amendments to the legislation. That means there 
will be no opportunity in our committees to mark up legislation or to 
get the cost of the legislation or the technical help to do any bill, 
let alone a bill that affects a large part of our economy.
  The Presiding Officer and I both serve on the Finance Committee, 
which has jurisdiction over healthcare. We are not going to get the 
opportunity to get the expertise and help from our staff to look at the 
consequences of the Cassidy bill and have a chance to work on it to 
make it work. Instead, what is going to happen if the game plan goes 
forward is that this bill is likely to be on the floor next week during 
budget reconciliation, where a simple majority will be able to pass it. 
There will be no chance for debate on the floor because it is what is 
known as a vote-arama, and it will affect one-sixth of our economy. 
That is not the way we should be operating.
  I am also told that it will be done without a Congressional Budget 
Office score. That is unconscionable. We know from previous 
Congressional Budget Office scores on the other proposals that have 
been brought out that tens of millions of Americans would lose their 
health insurance coverage. Premiums would increase by, in some cases, 
20 to 25 percent. It was certainly information from our objective staff 
that caused many of us to say: What are we doing? But at least we had 
that information before we voted.
  We are now being told that we may get a one-liner from the 
Congressional Budget Office giving us the bottom-line impact on the 
deficit but not the specific information as to how many millions of 
Americans are going to lose their coverage and what is going to happen, 
for those of us who currently have insurance, with our premium 
increases.
  This is not the way we should be proceeding. It retreats from the 
progress we have made against the abusive practices of the insurance 
industry.
  Under the Cassidy bill, as I understand it, each State could 
basically set up its own rules for how they wish to have coverage. The 
entire Medicaid system of this country would be block-granted and would 
be capped. So the Federal Government could be getting out of the 
Medicaid business. The States would be given greater flexibility on how 
to operate the exchanges in their State and would no longer be subject 
to the same national requirements.
  We all pride ourselves that we eliminated preexisting conditions. 
But, in reality, if the State determines what benefits are going to be 
covered and under what conditions, preexisting conditions come back. 
That is something we should not ever allow to happen. Yet, under the 
Cassidy bill, we are going to be telling people that we may not be 
covering their mental health needs. We may not be covering the opioid 
addiction problems. We may not be covering maternity benefits. We may 
not be covering pediatric dental coverage.
  We don't know what plans will be offered. Today we know that under 
the Affordable Care Act we have the national protections so that 
everyone is on a level playing field. So a State could design a plan 
that would be totally unaffordable for people who need the coverage 
because they isolate the group into such a small number. That is not 
what we should be doing. That strategy would provide inadequate 
coverage.
  Let me explain what I mean. I have a young family that came to me and 
told me about the circumstance of their child being born prematurely 
with significant challenges. They said that, if that child had been 
born before the Affordable Care Act, the parents' policy would have 
reached their lifetime cap within the first year. Then, the family 
would have had to make some horrendous decisions on how to take care of 
their child. That is why we passed the protection against annual 
lifetime caps. That could return again under the bill that could be 
brought to the floor next week.
  I know circumstances where families have been able to get preventive 
healthcare and discover cancer at an early stage. That coverage wasn't 
there before the Affordable Care Act. There is no guarantee that 
coverage will be there afterwards.
  We could return again to bankruptcies. Healthcare costs were the 
leading cause of bankruptcy before we passed the Affordable Care Act. 
Now we are going to say that because of inadequate coverage and lack of 
coverage, American families are going to be faced with taking care of 
their family, running up bills, and ultimately facing bankruptcy.
  We are going to be affecting people's lives. Make no mistake about 
it.
  But the real tragedy of this proposal, and why it is so different 
from some others, is that it is an abandonment by the Federal 
Government of the Medicaid system. It would institute draconian cuts to 
the Medicaid system, to the extent that it would cripple it and make it 
ineffective. The States would be unable to respond.
  It is interesting that we just got a letter from 10 Governors in our 
country--five Democrats and five Republicans. All of these Governors 
said: No, don't do this. We can't do what you are asking us to do. We 
would have to make horrible decisions on whether we are going to 
continue to provide long-term care to our seniors, whether we are going 
to expand coverage, whether we are going to narrow benefits, whether we 
are going to cover prescription drugs, or whether we are going to cut 
providers who may not be able to treat Medicaid patients. These are 
decisions the States are going to have to make if this bill ever 
becomes law.
  It affects so many. Some of the things that maybe are misunderstood 
about the Medicaid system is that 1.75 million veterans are in the 
Medicaid system. Quite frankly, their coverage has never been enough, 
and the Medicaid system has helped fill the gap. That is going to cause 
a problem for our veterans.
  I will just give one example. We pride ourselves on federalism, and 
federalism, to me, is very important. I served for several years in the 
State legislature. I am the former speaker of the Maryland General 
Assembly. I take pride in the fact that Maryland has been an innovator 
in healthcare. They have been able to do that because of the 
partnership between the Federal Government and the States. That is 
federalism. It has worked.
  If this bill were to become law--the Cassidy bill--it would prevent 
the States from innovating. It is not giving them more flexibility if 
you don't give them the resources and tools to deal with this because 
you can't.
  For example, in Maryland we have what is known as an all-payer rate 
structure for hospital costs, regardless of who covers your insurance. 
Whether you are Medicare, Medicaid, or private insurance, or you pay on 
your own, you pay the same rate in my State for hospital care at the 
same hospital. It is an all-payer structure. We don't have cost-
shifting, and we don't have charity hospitals. Therefore, we have 
hospitals that are located in all of our communities. It saves the 
Federal Government money, it saves the State government money, and it 
has proven to be more cost-effective. The State experimented and it 
worked, and the Federal Government has partnered with us.
  Can we continue that program if we get these draconian cuts in 
Medicaid? The answer is no. Can we continue this program if we see the 
uninsured rates go up in Maryland because of people losing their health 
coverage under this bill? The answer is no. You can't do this if the 
uninsured rates go from 6 percent to 12 percent to 15 percent of 
uncompensated care in our hospitals. That is what is at risk with the 
Cassidy bill.
  To me, it really is also an affront to federalism in that you are 
creating States versus States. I am in a State that did Medicaid 
expansion. As the Cassidy bill has been scored, it will cost my State 
$2.1 billion. I know that our legislature doesn't have that money. I 
know the Governor doesn't have it. He just recently went to the 
Maryland Board of Public Works and reduced the State budget because 
they were running a deficit and they are not allowed to run a deficit. 
They can't possibly cover the $2.1 billion.
  Here is another tragedy of this bill. The tragedy is that some States 
do much worse than other States. Why? Because Maryland expanded 
Medicaid,

[[Page S5838]]

as did many other States and, therefore, we got more Federal funds 
because we had more people in the program. That seems fair. We are 
covering more people. But the Cassidy bill takes away from those States 
that expanded coverage, and we lose more.
  I thought this was the United States. I thought we were all in this 
together. The people of Maryland are proud to help the people of Texas 
or Florida because of the hurricane, and now you are coming back and 
saying you are going to hurt the people in Maryland because we did the 
right thing on Medicaid.
  Is that what this country is all about? Is that the United States? Is 
this body going to condone that type of discrimination against States? 
I hope that is not the case.
  So I hope, for many reasons, on substance and on process, that this 
bill is not brought up. Let's return to regular order. I heard Senator 
McCain say that so eloquently on the floor of the Senate.
  For the last two weeks I have been working with my Republican and 
Democratic colleagues to come up with bipartisan ways to improve our 
healthcare system. We have made progress. We have some good ideas that 
stabilize the individual marketplace and bring down the cost of 
healthcare, working together. Guess what. If we succeed in regular 
order and bipartisanship, we will not only do the right thing so people 
have stronger protections, but we will also have policy that will stand 
the test of time and give predictability to the healthcare system of 
this country. That is what we should be doing, in the best tradition of 
the Senate.
  So I urge my colleagues: Let's work together, and let's reject this 
proposal. Let's not bring it up. Let's continue our work on a 
bipartisan basis. Certainly, don't use reconciliation. Let's work 
together for the people of this country.
  With that, I suggest the absence of a quorum.
  The PRESIDING OFFICER (Mr. Hoeven). 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. Mr. President, my colleagues have been here on the 
floor over the last few minutes, last night, this morning, and this 
afternoon to talk about our distress about people trying again to push 
the repeal of the Affordable Care Act without a successful strategy to 
move our Nation forward with more affordability.
  We just received a letter from 10 Governors basically telling us the 
same thing, to slow down and work on a bipartisan basis. They are 
basically telling us the proposal people are trying to rush through 
without regular order is not the kind of thing which will help us in 
making the necessary reforms.
  I think these bipartisan Governors--from the Governor of Colorado to 
the Governor of Ohio, to the Governor of Alaska, the spectrum of 
Democrats, Republican, and Independents is something people in the 
United States of America should listen to because it is important we 
get this right because the affordability of healthcare is so important.
  What I don't like about the proposal now being pushed by my 
colleagues--even though they want the States to have some flexibility 
and play a larger role--is that it basically ends the 52-year State-
Federal partnership we know as Medicaid today; that is, it changes the 
dynamic in saying that the States and the Federal Government are in 
business together to take care of a population that is the most 
vulnerable of citizens in our country and that giving them affordable 
access to healthcare is a priority because it actually reduces 
everybody's healthcare costs.
  When people think about the expense in healthcare, ask any provider, 
and they will tell you that 1 in 5 dollars spent on the Federal system 
drives the cost of everybody's insurance. If you leave people 
uninsured, they go to the hospital, they raise the cost to everybody. 
It is not a good strategy. We have seen States that have covered people 
on Medicaid actually raise people out of poverty, help their economies, 
and reduce the costs at individual hospitals, thereby driving down the 
cost of private insurance.
  Why would we want to destroy that by authorizing in legislation the 
end of this 52-year relationship between the Federal Government and 
States, trying to make sure our populations are covered; that if a 
State spends a dollar, they can count on the Federal Government to 
spend that dollar as well and to continue the partnership that works 
cost-effectively.
  What I also don't like is it sunsets Medicaid for 15 million people. 
If you are going to sunset Medicaid for these 15 million people, when 
are you going to sunset Medicaid for the rest of the Medicaid 
population? When are you going to try, by legislative action, to 
curtail the opportunities for millions of Americans who use Medicaid as 
a stabilizing force for health insurance in America? In our State, 
600,000 people--most of whom were previously uninsured--would be in 
that sunset of Medicaid.
  The legislation my colleagues are pushing would basically end the 
funding for this block grant program in 2027, which would leave States 
with an unfunded bill for those individuals of about $300 billion. I 
doubt States have the money. I doubt the individual market is going to 
take care of those individuals as cost-effectively as we are taking 
care of them through Medicaid. States will then cost shift these 
resources back to the public, raising everybody's rates again.
  Our job has to be about affordability. It has to be about driving 
down costs. It has to be about driving down costs in the individual 
market and driving down costs of the delivery system overall. There is 
nothing innovative about kicking 15 million people off Medicaid and 
sunsetting it in this bill.
  I also object to the notion, in this bill, of literally advocating 
the privatization of Medicaid. They are advocating that what you do 
with this population is take them off the current program and shift 
them onto the private individual market.
  Some people who are following this might say: Well, wait. Then they 
can go to the private market--and, yes, there is support to make sure 
we have affordable health insurance. No, because the legislation also 
says you stop that support by 2027. So this is just one more sneak 
attack by our colleagues at kicking people off Medicaid. To start the 
process and agree to privatize Medicaid, where is it going to end?
  I am the first to say we can improve our delivery system, that we can 
save money. I have advocated I think one of the most cost-effective 
ideas of the Affordable Care Act; that is, to move the population of 
our citizens who need care in the later years of their life off nursing 
home care and into community-based care. It is one-third the cost. Our 
State, the State of Washington, saved more than $2 billion doing this 
over a 15-year period of time. If other States would do this, we could 
save $100 billion or more by having States give people the opportunity 
to age at home and have a long-term care delivery system which works in 
our communities. It is one-third the cost.
  That is innovation. Those are cost savings. That is improvement on 
our current delivery system, hopefully covering an aging baby boomer 
population that will reach retirement and a population of Americans who 
are going to live longer.
  There is nothing innovative about just privatizing Social Security, 
privatizing Medicaid, and kicking people off by shifting them over to 
an exchange and then cutting the resources for the exchange. I hope our 
colleagues will stop the notion that somehow this is innovation. It is 
not innovation. It is sunsetting, it is privatization, and it is 
cutting people off care. That is why we have heard from these Governors 
and others about why it is so important not to take this bait.
  We need to make sure we are continuing our bipartisan discussions, 
continuing to work together about what will drive affordability into 
the market. Bundling up a population and giving them clout to negotiate 
on rates and giving a State the ability to negotiate on rates--either 
on drug costs or on insurance--yes, this can save dollars. It is being 
done right now in New York and Minnesota, and it can be done in other 
places.
  Cost-shifting to the States this $300 billion or then making States 
make

[[Page S5839]]

the draconian decision of, ``Wait. I already shifted that population 
onto the exchange. Oh, my gosh. The Federal Government just cut the 
funds we are going to get,'' and the next thing you know, this 
population is left without care.
  Privatizing Medicaid is not the way to go. I hope our colleagues will 
continue to discuss, on a bipartisan basis, the aspects of the 
Affordable Care Act that could be expanded to drive down costs and 
increase affordability. I hope they will continue to make sure things 
like basic health--the essential elements of what should be covered in 
a basic plan--are there for our consumers; that we are not going to 
take the bait in thinking that by cutting essential services to people, 
somehow that is the way to get a private insurance plan.
  We have the ability to work together. My colleagues and I have been 
working and discussing these ideas. My colleagues Senator Murray and 
Senator Alexander are working on various ideas in their HELP Committee, 
as we are working in the Finance Committee, in making sure we expand 
and fund the affordability of insurance for children and their families 
under the Children's Health Insurance or CHIP program.
  Let's not make this worse. Let us not end this 52-year relationship 
that has successfully covered a population of America, and let's not 
fall for the bait and think that somehow this is going to save the 
American taxpayer money. It is not. It is going to cost shift right 
back to the private individual, raise individual rates, and we can't 
afford it. Let's not privatize Medicaid. Let's fight to make it a more 
cost-effective program for the future.
  Mr. President, I yield the floor.
  The PRESIDING OFFICER. The Senator from Maine.
  (The remarks of Ms. Collins pertaining to the introduction of S. 1835 
are printed in today's Record under ``Statements on Introduced Bills 
and Joint Resolutions.'')
  Ms. COLLINS. Mr. President, I yield the floor.
  The PRESIDING OFFICER. The Senator from Wyoming.
  Mr. BARRASSO. Mr. President, last week, the junior Senator from 
Vermont and a group of other Democrats unveiled a proposal to have 
Washington take over healthcare for everyone in America. Some refer to 
it as BernieCare. They intend to do this on the backs of American 
seniors, which is of grave concern to me as a doctor who has taken care 
of many senior citizens--many people on Medicaid--as part of my 
practice as an orthopedic surgeon. Their idea is to put everyone in 
this country on a new program that operates like Medicare. That is 
about 250 million Americans who would be added on to the Medicare 
Program, which is already being strained.
  One-third of the Democrats in the Senate have signed on to this plan. 
It seems to be the litmus test for the liberal left. Several of them 
came to the floor last night to criticize efforts by the Republican 
Party to save America's failing healthcare system. Problems with the 
American healthcare system, as a result of ObamaCare, continue to get 
worse, and the impacts, such as those that I hear every weekend in 
Wyoming, including this past weekend.
  From what I heard from the Democrats, they seem to want to let the 
system collapse in a way that they can then impose a complete 
Washington takeover of healthcare in America. To me, this plan they are 
proposing is going to be devastating to people currently on Medicare. 
These are the seniors who rely on Medicare today. What the Democrats 
are proposing is going to, in my opinion, undermine the stability, the 
integrity, and the certainty of the Medicare Program on which our 
seniors rely, and for them, it is truly their lives that depend upon 
it.
  Remember when President Obama promised that if people liked their 
insurance, they could keep their insurance, and that if they liked 
their plan, they could keep their plan? Well, people realize that is 
not exactly what happened. Many people lost their plan. They lost their 
insurance. It got more expensive, harder to afford, and millions ended 
up paying a fine, a fee, or a tax--whatever you want to call it--
because they weren't able to afford the premiums for the plan that 
President Obama said they had to buy, and they lost their own plans. 
Well, now it seems that if Democrats have their way, millions of 
seniors will find out that they are not going to be able to keep the 
insurance that they have right now that they depend upon and that they 
use on a daily basis.
  The Sanders plan will get rid of Medicare Advantage plans. We have 17 
million seniors in this country who are on a Medicare Advantage plan. 
The reason they sign up for Medicare Advantage is that for them 
personally, when they study it, there are advantages to Medicare 
Advantage for them in terms of preventive care and coordinated care. 
That would all go away under BernieCare.
  It is interesting to watch this whole process unfold because one in 
three people who are currently on Medicare have chosen to go outside 
the system the Democrats want to put them into. They want to put 
everyone into it, but a third of the people on Medicare have chosen a 
different way.
  What happens to these 17 million Americans who are currently on 
Medicare Advantage with the scheme that Senator Sanders and other 
Democrats have come up with? They don't say. Did the Democrats who came 
to the floor last night have anything to say about these 17 million 
seniors who would lose their Medicare, seniors who are on Medicare 
today? What is going to happen to them? They are going to lose what 
they have today.
  A lot of seniors are probably going to lose access to their doctors 
as well because when their plans change, their doctors change. That is 
because there are going to be doctors who won't be able to take care of 
these new Medicare patients whom ObamaCare has caused to have problems, 
but it is made worse with what is being proposed by Senator Sanders.
  Right now, it can be tough for a senior to find a doctor. These are 
seniors on Medicare. That is because today about one in four doctors 
doesn't take new Medicare patients or take any Medicare patients. But 
certainly as more and more people--and 10,000 baby boomers a day are 
turning 65 and going on Medicare. There are more and more people on 
Medicare without an expansion of the number of doctors to take care of 
them.
  Since the reimbursement is lower, what doctors and hospitals are paid 
to take care of Medicare patients is lower than what those doctors or 
hospitals get paid for patients with private insurance. Their priority, 
when they are already crowded and loaded in their office and very busy 
taking care of patients, with waiting rooms full--their choice, of 
course, is to choose patients who pay them more than what they get from 
the government.
  You say: Why is that? Is that right?
  Well, having practiced medicine for 24 years and having run an 
office, there are issues related to paying nurses, healthcare 
personnel, rent, electricity--all the costs of running an office, let 
alone the high cost of medical malpractice insurance. We know the huge 
cost of that. A physician who wants to be able to pay his or her bills 
needs to take all those things into consideration. And with Medicare 
paying less than the current going rate for care at hospitals and with 
doctors, the concern is, Will Medicare patients be able to find a 
doctor in the first place?
  The Democrats' solution is to cram more people onto Medicare when we 
already have 10,000 people a day joining the ranks of Medicare and 
Social Security. If a doctor has a lot of Medicare patients, he or she 
has to make sure they have enough other patients who have insurance to 
make up for the lower rates Washington pays. Well, under the Democratic 
plan, doctors won't have the backup of private insurance companies 
because that is all going to go away.
  All those things will be lost to people who want to buy private 
insurance. Under the plan the Democrats are now--and it is not just 
Democrats in the Senate; a majority of the Democrats in the House of 
Representatives have cosponsored legislation by Representative Conyers 
that does exactly the same thing: puts everyone on a Medicare Program--
a government takeover of healthcare.
  When the Democrats came to the floor last night, I didn't hear them 
say anything about that. How are they going to guarantee that seniors 
will keep their doctors? Seniors are not going to be able to keep their 
doctors

[[Page S5840]]

under the Sanders liberal-left plan that is being proposed and 
cosponsored by over half of the Democrats who are in the House of 
Representatives.
  We are already facing a shortage of doctors in this country. The 
Association of American Medical Colleges, which helps oversee the 
training of doctors, says that the shortfall could be as many as 
100,000 doctors across the country within the next decade. If we have 
fewer doctors and more people trying to get appointments, that means 
less access for seniors.
  It is not even clear if Washington can afford to add every man, 
woman, and child on to a government program like Medicare because 
Washington has done a terrible job in running Medicare as it is. The 
Medicare trust fund is supposed to be exhausted at the end of the 
2020s. That is what the Medicare trustees are telling us. In 12 years, 
they say, there will only be enough money coming in to fund about 8 or 
9 cents on the dollar of what the benefits for Medicare are supposed to 
be paying out. The program is going to have to start doing something--
either raising taxes or cutting benefits. From what I have seen 
proposed by Senator Sanders, it would be raising taxes a lot. The 
Medicare trustees say the program needs significant reform. They say it 
is already unsustainable. The Democrats' plan does nothing to change 
any of that. It does nothing to reform the program. All it does is 
crowd more people into a system that is already struggling financially.
  My concern is that the Democrats' plan is going to undermine the 
stability of the Medicare Program that our seniors desperately need. We 
should be taking steps now to shore up, to strengthen Medicare so that 
it is able to keep the promises that we made to our seniors. My goal is 
to save, to strengthen, and to simplify Medicare. That is not what we 
are seeing here.
  A few years ago, we knew the Medicaid Program needed help. Democrats 
just threw more people into the system with ObamaCare. That is what 
they did. With the expansion of ObamaCare, the majority of people who 
have new coverage under ObamaCare didn't get it through private 
insurance; they were put in to the Medicaid Program, which has 
significantly strained Medicaid and made it much harder for people on 
Medicaid, the people for whom it was originally designed--low-income, 
women, children, people with disabilities. It was designed to help 
them. It made it harder for them to get care because all these 
individuals who were working-age adults were put on in addition.
  Now it looks as though the Democrats want to do the same thing they 
did to hurt Medicaid--make it harder for our patients on Medicare. It 
won't work. An insurance card does not equal accessible, available 
access to care. The people who suffer the most are going to be the 
seniors who have no other options. These are seniors who are relying on 
Medicare today. They were promised that Medicare would be there for 
them. We need to keep that promise.
  Instead of protecting seniors today, however, Democrats are trying to 
give Medicare to everyone else. So 17 million seniors are going to lose 
access to the plans that they have chosen, that work for them, and that 
they want to keep.
  Seniors are going to lose access to the doctors that Democrats push 
out of the system as they continue to put more and more people on 
Medicare. Democrats should not be building their takeover of the 
American healthcare system on the backs of our seniors.
  Thank you.
  I yield the floor.
  I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The assistant bill 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.
  Mr. McCONNELL. Mr. President, I ask unanimous consent that 
notwithstanding rule XXII, at 4 p.m. today, there be 2 minutes of 
debate, equally divided between the managers or their designees, and 
that following the use or yielding back of that time, the Senate vote 
on the motion to invoke cloture on the Emanuel nomination.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  The Senator from New Hampshire.