[Congressional Record Volume 163, Number 156 (Thursday, September 28, 2017)]
[Senate]
[Pages S6209-S6211]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]



                               Healthcare

  Mr. President, I would like to say one thing about the fellows who 
serve in our office. I know many of us are privileged to have fellows 
who get assigned to us. Arnold Solamillos has been assigned to my 
office and has helped us in so many different areas. His expertise from 
the Social Security Administration is a valuable service. I, 
personally, thank him for the contributions he has made not just to my 
Senate office but to the work we do in the U.S. Congress.
  Mr. President, I want to comment about the status of healthcare. We 
had expected that the majority leader might have brought up this week 
the Graham-Cassidy bill as part of budget reconciliation. I can tell 
you I am relieved he did not, but I hope this Chamber will consider 
healthcare legislation not 6 months from now, not a year from now, but 
there is important work we need to do now in regard to healthcare, and 
we need to work together, Democrats and Republicans.
  One of the urgent issues is to reauthorize the Children's Health 
Insurance Program, CHIP. That program, as I am sure the Presiding 
Officer knows, expires in the next 2 days. We need to make sure there 
is predictability for our States to continue this extremely important 
program that protects the health of our children.
  It was created as a bipartisan program, enjoyed bipartisan support. I 
certainly compliment Chairman Hatch and Ranking Member Wyden for their 
work together to reach an agreement on the reauthorization of this 
program. I hope we can consider that very shortly.
  I also would like to point out that we have very important healthcare 
policies that have time limits on it and expire, and we need to pass 
what is known as extenders in health. Some of these policies expire in 
the next 2 days.
  I am going to just mention one. There are many others I could 
mention, but I want to mention one that I have been involved with ever 
since Congress made the mistake of placing a limit known as the therapy 
cap on rehab services. This limit makes absolutely no sense. It made no 
sense 20 years ago when it was imposed. It was put in there to reach a 
budget number and reconciliation and had nothing to do with policy.
  Today, those who have the most serious needs of therapy services are 
the ones who are the most at risk. So I would urge my colleagues that 
we need to take up these medical extenders, and we need to do it now. 
We need to do it quickly. We don't want to leave the uncertainty out 
there. Every day we leave the uncertainty, there is a question in the 
minds of individuals who need these services and those who are 
providing these services whether, in fact, Congress will extend the 
policies.
  Let me talk a little bit about the broader issue of the Affordable 
Care Act. We had, I thought, a very informative hearing before the 
Senate Finance Committee on the Graham-Cassidy amendment to the 
Reconciliation Act. We had that hearing on Monday, and I thought it was 
a very informative hearing for the members of our committee and the 
American public. We had the opportunity to have one of the members of 
our committee on the panel of witnesses. Senator Cassidy was a witness 
at the witness table. During the questioning, I said to him that he had 
mentioned many examples of individuals who are facing very high premium 
increases or they don't have the ability to pay the premiums and the 
out-of-pocket costs. He was using those examples, as some of my other 
colleagues were using, as to why we have to deal with a change in the 
Affordable Care Act.
  I had the opportunity to question what individuals he was talking 
about. He identified the group. The group is those who are in the 
individual marketplace. These are not the families who have policies 
through their employers or in the group plans, these are individuals 
who have no other opportunity but to go into the individual market in 
order to buy their health insurance. Secondly, these are individuals 
who don't qualify for subsidies because their income is too high.
  So I asked Mrs. Miller, who was on the panel who is the insurance 
commissioner from Pennsylvania, whether my estimate of the number of 
people who fall into this category is correct. She confirmed it is 
somewhere between 1 to 2 percent of the population that fall in the 
individual marketplace and incomes are too high for subsidies.

[[Page S6210]]

  That is a significant number of Americans, and we need to deal with 
their concerns. Let me sort of spell out what that is all about. In my 
State of Maryland, the average cost--capital cost--of healthcare is 
somewhere around $8,600 a year. If you don't have an employer helping 
to contribute to your healthcare insurance or cost or you don't qualify 
for any subsidies and you are a husband or wife with two children, then 
your average costs are going to be in excess of $34,000. That is if you 
buy insurance so you are not exposed to the unexpected costs. A lot of 
families just can't afford that.
  The problem is, the individual marketplace is not stable. There are 
too many uncertainties, and those premium costs can become unaffordable 
for those families whose incomes are too high to receive subsidies. It 
is an important group, but let's keep in mind it is 1 to 2 percent, so 
let's not jeopardize the healthcare of 98 to 99 percent of Americans in 
an effort to say we are doing something for the 1 or 2 percent.
  Here is the rub. The Graham-Cassidy bill didn't help that 1 to 2 
percent. In fact, it made it worse. It made it less likely that they 
would be able to get affordable coverage so they didn't deal with the 
problem that was identified for the reason for the reform. Instead, 
what the Graham-Cassidy bill did was basically to block grant the 
Medicaid Program to the States. They had a complicated formula, where 
many States, like Maryland, would lose a lot of money because we used 
our State resources to expand Medicaid, and now we are being penalized 
for it. The bottom line was every State was going to have a cap as to 
how much money the Federal Government was going to make available, and 
that cap became tighter and tighter every year.

  So I asked one of the witnesses on our panel on Monday: How would you 
deal with that?
  The witness who is responsible in his State said: Well, you manage to 
the cap. Those were his exact words: ``You manage to the cap.''
  So I said to Mrs. Miller, the insurance commissioner from 
Pennsylvania: What does that mean, managing to the cap?
  She said: Well, it means that in order to make the cap, you either 
knock people off the rolls and change the eligibility so fewer people 
have coverage in our State--and let me remind my colleagues the 
Congressional Budget Office, although they didn't give us a finite 
score, did say there would be millions of people who would lose their 
coverage under the Graham-Cassidy bill--so that is one way. Also, the 
bill eliminated the expansion of Medicaid, which was part of the 
Affordable Care Act and was responsible for tens of millions getting 
healthcare coverage. So there would be millions of people who would 
lose their benefits because the States have to manage to this cap that 
was in the bill.
  The second way Mrs. Miller said you can manage to the cap is to 
reduce benefits, and many States have done that. They can impose caps. 
Caps means that if--I had so many people who wrote me letters, and I am 
sure the Presiding Officer got letters from people in his State--but 
the ones who really got to you was when you heard from a young husband 
and wife who have a child with special needs and that person indicated 
that within the first couple of months, they would have exceeded the 
cap that was in the insurance policies before the passage of the 
Affordable Care Act.
  What are we supposed to do? If the State, in order to save money to 
manage to the cap, imposes a cap on how much the coverage is and you 
have a child with special needs, what do you do about that?
  Well, the answer, quite frankly, is you either sell everything you 
have, mortgage everything you have, or go into a bankruptcy in order to 
take care of your child because you just can't do it.
  So that is what was at risk.
  There was a third way to manage to the cap, and Mrs. Miller said: We 
could cut provider fees, and States have done that. Cutting provider 
fees means that in areas where there is a large Medicaid population, 
you are going to have a hard time finding a hospital or a doctor that 
will be willing to treat the lack of access to care. We saw that over 
and over again, where people may have coverage, but they can't get a 
provider. That is not access to care.
  So, for all of these reasons, what would have been done under the 
Graham-Cassidy bill would not have dealt with the 1 to 2 percent where 
we do have an issue and we need to work on it, it would have created 
significant problems for millions of others, and I haven't even gotten 
to the fact that it eliminated the Patients' Bill of Rights and 
insurance protections that we put into law against preexisting 
conditions and things like that. So I was glad to see we are not 
considering that amendment this week. That, to me, was the right 
decision.
  I know we are now going to end this fiscal year in the next 2 days 
and that next week we are likely to see come out of the Budget 
Committee another budget document so that we are back on fiscal year 
2018 rather than fiscal year 2017. We don't know whether that will deal 
with taxes or with healthcare, but there will come a time that we may 
be getting back to this debate. I would hope we don't need a budget 
resolution to do it. I hope we can move in a bipartisan manner and get 
some things done now to improve and stabilize the Affordable Care Act.
  I have been participating, under the leadership of Senator Alexander, 
the chairman of the HELP Committee, and Senator Murray, the ranking 
Democrat on the committee--who have been conducting hearings over the 
last several weeks, and we have invited Members who are not on that 
committee to join them. We were able to ask the witnesses questions. We 
were able to find out whether there were some common areas where we 
could in fact help stabilize the market that includes the 1 to 2 
percent I have already talked about who are the ones who have issues 
here.
  I have met with our insurance carriers in Maryland in reference to 
why we were having large increases in the individual marketplaces, and 
we went over the various reasons. The three principal reasons were all 
talked about in this bipartisan group. Quite frankly, Senator Alexander 
said: Look, we are trying to see whether we can't come together with 
some legislation, perhaps to pass as early as this month, which gave a 
lot of us confidence that at long last we are coming back to work, 
Democrats and Republicans.
  I was criticized by some of my constituents during this debate who 
asked: Where is your proposal? How are you going to fix it? So several 
months ago I filed legislation, and I was pleased to see that a couple 
of the issues I included in my legislation were consensus proposals in 
this bipartisan group that has been meeting for the last couple of 
weeks.

  One of those that is in my legislation and that is in conversation is 
to have predictable funding for the cost sharing. As we know, President 
Trump has raised a question as to whether he is going to continue to 
pay the insurance companies for keeping the copays and deductibles and 
premiums low for low-income families. He is doing it on a month-to-
month basis. If we could make that a predictable payment, as was 
anticipated under the Affordable Care Act, that could affect a 
significant part of the premium increase that has been sought in the 
individual marketplace. That was what was told to me in Maryland, and 
that was confirmed by a wide network of groups from many States in the 
discussions with Senator Alexander and Senator Murray. That is 
something we could do right now. We anticipated that would be done. We 
can do that, and then we can help those people whose examples were 
given for reasons why we need to address the Affordable Care Act.
  A second issue that is included in my legislation that was very much 
included in this discussion is, let's make it easier for States to 
implement a reinsurance program. A reinsurance program takes the high 
risks and spreads them over so an insurance company doesn't have to 
impose higher premiums because they have unknown risks. It is a pretty 
simple process, to use reinsurance. The State Senate used reinsurance 
and it has worked. It was in the original Affordable Care Act.
  The problem is, the States' budgets have already been put to rest. In 
order to do a reinsurance program, you have to put some money upfront 
in order to save money. The States just don't have those funds. So 
let's look for ways we can make it easier for States to implement the 
reinsurance program, and

[[Page S6211]]

part of that is to deal with the waivers that are in the Affordable 
Care Act. We have guardrails to make sure States use waivers but do not 
compromise the protections that are in the statute. So let's make it 
easier for States to implement a reinsurance program which could also 
bring down rates. Quite frankly, I didn't see anyone object to those 
two suggestions that were made, which would certainly help.
  There are other things I hope we can do. The three main reasons given 
by the insurance carriers in Maryland for the premium increases are, 
No. 1, the uncertainty of the cost-sharing payments; No. 2, the 
reinsurance program; and, No. 3, that we are not enforcing the 
requirement that everybody be in the pool. We don't do that. You get 
those that are at the highest risk who are going to come in, but those 
who feel like they are not going to be using the policies stay out, and 
then we have adverse risk selection and therefore higher premiums than 
there should be.
  So we really need to do a better job to try to get people into the 
plans. That is why many of us have been urging our appropriators to 
provide the funds so we can inform people about the advantages of 
having healthcare coverage and we can get a broader market in there. I 
certainly hope a law is passed by Congress that requires the coverage 
would be enforced. These are things I think we all could do.
  There are other issues I hope we can deal with that I think will help 
all people, in addition to the 1 to 2 percent who need immediate help, 
as well as bring down the entirety of our healthcare costs. Part of 
that is to bring down healthcare costs generally. We all know 
prescription drugs are too expensive in this country. We pay twice what 
other countries pay. One simple way is to get the same discounts for 
Medicare as we get for Medicaid. My understanding is that saves 
billions of dollars. It was in my legislation, just one simple way. I 
think that if you can collect the bargaining power of the Medicare 
marketplace, we can certainly get better prices than we get by using a 
divided market.
  So there are things we can do. We can have a better delivery system 
for providing healthcare to people in this country. I have talked about 
this many times--collaborative and integrative care models. In 
Maryland, we have Mosaic, which is a behavioral health facility, 
working with Sheppard Pratt, a mental health hospital. They worked 
together in order to have a more efficient delivery system. We need to 
encourage those types of models that use integrative care to bring down 
healthcare costs.
  Lastly, we need more competition. Yes, I have always supported a 
public option under the exchanges. I think that makes sense.
  We have a lot of other proposals that have been given. Let's sit down 
and talk about these proposals to see if we can't find ways to make our 
system better.
  We have, once again, reached a situation where the majority has 
pulled the budget reconciliation, this time permanently, from the 
fiscal year 2017 calendar year. Let us start the new year that begins 
on October 1--the new fiscal year--with a commitment from Democrats and 
Republicans to work together, to share our best ideas, to make sure our 
children are protected by the extension of the CHIP program, to make 
sure policies that are currently in place that protect our constituents 
such as the therapy cap relief are extended.
  Let's join together so the Affordable Care Act can be made stronger, 
particularly in stabilizing the problems in the individual marketplace, 
and help bring down the growth rate of healthcare costs. That is what 
we should be working on now, and I encourage my colleagues to do just 
that.
  With that, I yield the floor.
  I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The senior assistant legislative clerk proceeded to call the roll.
  Mr. MERKLEY. Mr. President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The PRESIDING OFFICER (Mr. Cassidy). Without objection, it is so 
ordered.