[Congressional Record Volume 165, Number 115 (Wednesday, July 10, 2019)]
[Senate]
[Pages S4749-S4752]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]



                               Healthcare

  Mr. BARRASSO. Mr. President, I come to the floor because Democrats 
out on the campaign trail continue to spin their one-size-fits-all 
healthcare plan that they call Medicare for All. The name itself is 
misleading. I will state that as a doctor who has practiced medicine in 
Wyoming for 24 years.
  Even many Democrats in the first Presidential debate sounded confused 
about their own proposal. The candidates were asked a simple question. 
They were asked to raise their hands if they supported eliminating 
private health insurance. That is the health insurance people get from 
work. ``Just four arms went up over the two nights,'' but ``five 
candidates who kept their hands at their sides,'' the New York Times 
has now reported, ``have signed onto bills in [this] Congress that do 
exactly that''--take health insurance away from people who get it from 
work.
  On one point, though, they all raised their hands. That was on the 
question that was asked of all 10 Democrats in round 2 of the debate. 
They all endorsed taxpayer-funded healthcare for illegal immigrants. 
Every hand went up.
  It seems Democrats have actually been hiding their real, radical 
agenda. ``Most Americans don't realize how dramatically Medicare-for-
all would restructure the nation's health care system.'' That is not 
just me talking; that is according to the latest Kaiser Family 
Foundation poll. We need to set the record straight, and I am ready to 
do that right now.
  The fact is, Democrats have taken a hard left turn, and they want to 
take away your health insurance if you get it from work. The proposal 
abolishes private health insurance, the insurance people get from work. 
In its place, they would have one expensive, new government-run system. 
Still, Democrats know most of us would rather keep our own coverage 
that we get from work. Even the people on Medicare Advantage--20 
million people--would lose it under the Democrats' proposal. The Kaiser 
poll confirms Americans' top concern is, of course, lowering their 
costs or, as the Washington Post ``Health'' column put it, people 
simply want ``to pay less for their own health care.''
  That is what we are committed to on this side of the aisle.
  Many Democrats running for President continue to promote and support 
this radical scheme by Senator Sanders. The Sanders legislation would 
take away healthcare insurance from 180 million people who get their 
insurance through work, through their jobs. In addition, 20 million 
people who buy their insurance would lose coverage as well.
  You also need to know that the Democrats' proposal ends the current 
government healthcare programs. Medicare for seniors would be gone. 
Federal employees' health insurance would be gone. TRICARE for the 
military would be gone, and the children's health coverage also would 
be gone under this Democratic healthcare, one-size-fits-all plan. That 
is confirmed by the Congressional Research Service.
  The Congressional Research Service recently sent me a formal legal 
opinion. I requested it from them. It is a formal, legal opinion, 
stating: Medicare for All ``would . . . largely displace these existing 
federally funded health programs'' that I just mentioned--Medicare, 
Federal employees' health insurance, TRICARE, children's health 
coverage. It would largely displace these existing Federal health 
programs as well as private health insurance, the insurance people get 
from work.
  Mr. President, I ask unanimous consent to have printed in the Record 
the

[[Page S4750]]

Congressional Research Service memorandum, dated May 29, 2019.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                               Memorandum

     To: Senator John Barrasso, Attention: Jay Eberle.
     From: Wen S. Shen, Legislative Attorney.
     Subject: Effect of S. 1129 on Certain Federally Funded Health 
         Programs and Private Health Insurance.
       Pursuant to your request, this memorandum discusses the 
     legal effect of S. 1129, the Medicare for All Act of 2019 
     (MFAA or Act) on various public and private health care 
     programs or plans. Specifically, the memorandum analyzes 
     whether the MFAA would authorize the following programs or 
     plans to continue in their current form:
       Medicare (including Medicare Advantage and Part D);
       Medicaid (including the Children's Health Insurance 
     Program);
       TRICARE;
       Plans under the Employee Retirement Income Security Act; 
     and
       Individual, Small and Large Group Market Coverage.
       For reasons discussed in greater detail below, the Program 
     created by the MFAA would, following a phase-in period and 
     with some limited exceptions, largely displace these existing 
     federally funded health programs as well as private health 
     insurance. This memorandum begins with a description of the 
     key provisions of the MFAA before turning to its legal effect 
     on the programs and plans that are the subject of your 
     request.


                      Medicare for All Act of 2019

       The MFAA aims to establish a national health insurance 
     program (Program) that would ``provide comprehensive 
     protection against the cost of health care and health-related 
     services'' in accordance with the standards set forth under 
     the Act. Specifically, under the Program, every resident of 
     the United States, after a four-year phase-in period 
     following the MFAA's enactment, would be entitled to have the 
     Secretary of Health and Human Services (Secretary) make 
     payments on their behalf to an eligible provider for services 
     and items in 13 benefits categories, provided they are 
     ``medically necessary or appropriate for the maintenance of 
     health or diagnosis, treatment or rehabilitation of a health 
     condition.'' Except for prescription drugs and biological 
     products, for which the Secretary may set a cost-sharing 
     schedule that would not exceed $200 annually per enrollee and 
     meet other statutory criteria, no enrollee would be 
     responsible for any cost-sharing for any other covered 
     benefits under the Program. The bill would direct the 
     Secretary to develop both a mechanism for enrolling existing 
     eligible individuals by the end of the phase-in period and a 
     mechanism for automatically enrolling newly eligible 
     individuals at birth or upon establishing residency in the 
     United States.
       All state-licensed health care providers who meet the 
     applicable state and federal provider standards may 
     participate in the Program, provided they file a 
     participation agreement with the Secretary that meets 
     specified statutory requirements. The Secretary would pay 
     participating providers pursuant to a fee schedule that would 
     be set in a manner consistent with the processes for 
     determining payments under the existing Medicare program. 
     Participating providers would be prohibited from balance 
     billing enrollees for any covered services paid under the 
     Program, but providers would be free to enter into private 
     contracts with enrollees to provide any item or service if no 
     claims for payment are submitted to the Secretary and the 
     contracts meet certain statutory requirements.
       With respect to payment for covered pharmaceuticals, 
     medical supplies, and medically necessary assistive 
     equipment, the Secretary would negotiate their payment rate 
     annually with the relevant manufacturers. The bill would 
     further direct the Secretary to establish a prescription drug 
     formulary system that would encourage best practices in 
     prescribing; discourage the use of ineffective, dangerous, or 
     excessively costly medications; and promote the use of 
     generic medications to the greatest extent possible. Off-
     formulary medications would be permitted under the Program, 
     but their use would be subject to further regulations the 
     Secretary issues.
       With respect to the Program's administration, the bill 
     would authorize the Secretary to develop the relevant 
     policies, procedures, guidelines, and requirements necessary 
     to carry out the Program. The Secretary would also establish 
     and maintain regional offices--by incorporating existing 
     regional offices of the Centers for Medicare & Medicaid 
     Services where possible--to assess annual state health care 
     needs, recommend changes in provider reimbursement, and 
     establish a quality assurance mechanism in the state aimed at 
     optimizing utilization and maintaining certain standards of 
     care.
       To fund the Program, the bill would create a Universal 
     Medicare Trust Fund. Funds currently appropriated to 
     Medicare, Medicaid, the Federal Employees Health Benefits 
     Program (FEHBP), TRICARE, and a number of other federally 
     funded health programs would be appropriated to the new fund.
       The MFAA also includes a number of other provisions related 
     to the administration of the Program, including an 
     enforcement provision aimed at preventing fraud and abuse, 
     provisions relating to quality assessment, and provisions 
     concerning budget and cost containment.


  Effect of the MFAA on Certain Federally Funded Health Programs and 
                        Private Health Insurance

     Federally Funded Health Programs
       The federal government currently funds a number of health 
     programs, including (1) Medicare, which generally provides 
     health insurance coverage to elderly and disabled enrollees, 
     (2) Medicaid, which is a federal-state cooperative program 
     wherein states receive federal funds to generally provide 
     health benefits to low-income enrollees, (3) the Children's 
     Health Insurance Program (CHIP), which is a federal-state 
     cooperative program that provides health benefits to certain 
     low-income children whose families earn too much to qualify 
     for Medicaid but cannot afford private insurance; (4) the 
     FEHBP, which generally provides health insurance coverage to 
     civilian federal employees, and (5) TRICARE, which provides 
     civilian health insurance coverage to dependents of active 
     military personnel and retirees of the military (and their 
     dependents). Following an initial phase-in period, the MFAA 
     would prohibit benefits from being made available under 
     Medicare, FEHBP, and TRICARE while also prohibiting payments 
     to the states for CHIP. These payment prohibitions would 
     effectively terminate these programs in their current form. 
     This reading is confirmed by Sec. 701(b)(2) of the MFAA, 
     which redirects funding for these programs to the national 
     Program.
       With respect to Medicaid, the MFAA would significantly 
     limit its scope. After the MFAA's effective date, Medicaid 
     would only continue to cover services that the new national 
     Program would not otherwise cover. Thus, Medicaid benefits 
     for institutional long-term care services (which are not 
     among the 13 categories of covered services under the MFAA) 
     and any other services furnished by a state that the Program 
     would not cover, would continue to be administered by the 
     states. The bill would direct the Secretary to coordinate 
     with the relevant state agencies to identify the services for 
     which Medicaid benefits would be preserved and to ensure 
     their continued availability under the applicable state 
     plans.


                        Private Health Insurance

       Currently, private health insurance in the United States 
     consists of (1) private sector employer-sponsored group 
     plans, which can be self-insured (i.e., funded directly by 
     the employer) or fully insured (i.e., purchased from 
     insurers), and (2) group or individual health plans sold 
     directly by insurers to the insured (both inside and outside 
     of health insurance exchanges established under Section 1311 
     of the Affordable Care Act). The MFAA would prohibit 
     employers from providing, and insurers from selling, any 
     health plans that would ``duplicate[]the benefits provided 
     under [the MFAA].'' Given that the benefits offered under 
     many existing private health plans would likely overlap 
     with--i.e., be the same as--at least some of the benefits 
     within the Program's 13 categories of covered benefits, those 
     existing health plans would likely ``duplicate'' the benefits 
     provided under the MFAA. Thus, this prohibition of duplicate 
     coverage would effectively eliminate those existing private 
     health plans. Employers and insurers, however, would be 
     allowed to offer as benefits or for sale supplemental 
     insurance coverage for any additional benefits not covered by 
     the Program. As a result, employers and insurers could offer, 
     for instance, coverage for institutional long-term care 
     services, which are not among the 13 categories of covered 
     services.

  Mr. BARRASSO. Mr. President, this report details how the bills cut 
off funding.
  The CRS memo concludes: These payment prohibitions would effectively 
terminate all of those programs I mentioned in their current form.
  The Congressional Research Service finds that Medicare for All 
actually terminates Medicare in this country. So Democrats want to turn 
Medicare, currently for 60 million seniors, into Medicare for None. It 
will become Medicare for None, not Medicare for All. Plus, 22 million 
people would lose Medicare Advantage. I know many of my patients who 
signed up for Medicare Advantage because there are advantages to doing 
it--coordinated care, working on preventive medicine. There are reasons 
for signing up for Medicare Advantage. That would all be gone under the 
one-size-fits-all approach that the Democrats are proposing.
  That is not all. This report says the Sanders bill ends Federal 
employee health insurance. There are more than 8 million Federal 
workers, families, and retirees who rely on this Federal Employee 
Health Benefits Program.
  The Congressional Research Service says that this bill, sponsored by 
over 100 Members who are Democrats in the House of Representatives and 
sponsored by a number of Democrats in this body, will abolish TRICARE, 
the insurance for the military. More than 9 million military members, 
their families,

[[Page S4751]]

and retirees rely on TRICARE for their healthcare.
  The report says the bill ends the Children's Health Insurance 
Program. Nine million of our Nation's children rely on the CHIP 
program.
  Interestingly, ObamaCare would end as well, according to the CRS 
report. After less than a decade, Democrats want to repeal and replace 
their failed ObamaCare healthcare law with a one-size-fits-all system.
  Again, the Congressional Research Service says the bill bans private 
health insurance. One hundred eighty million people get their insurance 
through work.
  To sum up, hundreds of millions of American citizens--American 
citizens--stand to lose their insurance, and I believe that is just the 
start of the pain for American families. In the new system, we would 
all be at the mercy of Washington bureaucrats. That means we would be 
paying more to wait longer for worse care--pay more to wait longer for 
worse care. The Democrats' massive plan is expected to cost $32 
trillion. That is trillion with a ``t.'' That is a 10-year pricetag.
  Guess who is going to pay for that mind-boggling bill--of course, 
every American taxpayer. Senator Sanders admitted in the Democratic 
debate the other night that his proposal would raise taxes on middle-
class families. His proposal will raise taxes, he said, on middle-class 
families.
  In fact, even doubling our taxes wouldn't cover the huge cost of what 
they are proposing. So Washington Democrats are planning to drastically 
cut payments to doctors, nurses, hospitals, and to people who are 
providing care. The bureaucrats would ration care, restrict care--the 
care you get that you need--and it would be restricted in terms of 
treatment as well as technology. People would lose the freedom to 
choose the hospital or doctor they want.
  As a doctor, I am especially concerned about the impact on patient 
care. Patients could wait weeks, even months, for urgently needed 
treatment. Keep in mind care delayed is often care denied. So the 
Democrats' grand healthcare vision is to force you to pay more to wait 
longer for worse care.
  As a Senator and a doctor, of course, I want to improve your care, 
make it less costly. You should get insurance that is appropriate for 
you and affordable. You should be free to make your own medical 
decisions. That is what it is like in America.
  No question, healthcare needs to be more affordable, and Republicans 
are working to lower costs without lowering standards. To me, that is 
the big difference. Democrats are proposing the reverse. Their plan 
would lower your standard of care and raise your costs. Democrats can 
keep campaigning hard left on healthcare. That is where they are 
headed.

  Republicans are going to stay focused on real reforms that promote 
more affordable healthcare, cheaper prescription drugs, protections for 
patients with preexisting conditions, and, of course, the end of 
surprise medical bills. President Trump recently took Executive action 
that increases price transparency to lower the costs that patients pay.
  You just need to know the facts about the Democrats' one-size-fits-
all healthcare. Don't let far-left Democrats fool you. Radical 
Democrats want to take away your current healthcare. There would be no 
more Medicare or private plans, just a one-size-fits-all Washington 
plan.
  Why pay more to wait longer for worse care? Instead, let's give 
patients the care they need from a doctor they choose at lower costs. 
That is our goal. That is our objective, and that is what we are going 
to accomplish.
  I yield the floor.
  The PRESIDING OFFICER (Mr. Romney). The Senator from Illinois.
  Mr. DURBIN. Mr. President, I ask unanimous consent to speak as in 
morning business.
  The PRESIDING OFFICER. Without objection, it is so ordered.


                        prescription drug costs

  Mr. DURBIN. Mr. President, just a few minutes ago, four young people 
from the State of Illinois visited my office. They were a variety of 
different ages, from 10 years of age to the age of 17. They all came 
because they had a similar life experience, and they wanted to share it 
with me. Each one of them had been diagnosed with type 1 diabetes.
  Ten-year-old Owen from Deerfield told a story--the cutest little kid; 
great reader; read me a presentation that he put together--and the 
young women who were with him all talked about how their lives changed 
when they learned at the age of 7 or 8 that they had type 1 diabetes. 
For each one of them, from that point forward, insulin became a 
lifeline. They had to have access to insulin, and they had to have it 
sometimes many times a day, in the middle of the night. It reached a 
point where, through technology, they had continuous glucose monitoring 
devices and pumps that were keeping them alive, but every minute of 
every day was a test to them as to whether they were going to get sick 
and need help.
  It was a great presentation by these young people, whose lives were 
transformed, and their parents, who were hanging on every word as they 
told me their life stories.
  They brought up two points that I want to share on the floor this 
afternoon. The first is the importance of medical research. As one 
young woman said--she is about 17 now. She has lived with this for 8 or 
9 years. She said she is a twin, and her brother told her when she was 
diagnosed that he hated the thought that, as an old woman, she would 
still be worried about her insulin every single day. She said: I told 
my brother ``We are going to find a cure before I am an old woman.''
  Well, I certainly hope that young girl is right, but she will be 
right only if we do our part here on the floor of the Senate and not 
just give speeches. What we have to do is appropriate money to the 
National Institutes of Health. It is the premier medical research 
agency in the world.
  We have had good luck in the last 4 years. I want to salute two of my 
Republican colleagues and one of my Democratic colleagues for their 
special efforts. For the last 4 years, Senator Roy Blunt, Republican of 
Missouri; Senator Lamar Alexander, Republican of Tennessee; and Senator 
Patty Murray, Democrat of Washington, have joined forces--I have been 
part of that team too--to encourage an increase in medical research 
funding every single year, and we have done it.
  The increase that Dr. Collins at NIH asked for was 5 percent real 
growth a year. That is 5 percent over inflation. Do you know what we 
have done in 4 years? NIH has gone up from $30 billion to $39 billion. 
Dramatic. A 30-percent increase in NIH research funding.
  We are going to have a tough time with this coming budget, as we have 
in the past, but I hope we really reach a bottom line, as Democrats and 
Republicans, that we are committed to 5 percent real growth in medical 
research every single year so that we can answer these young people who 
come in dealing with diabetes, those who are suffering from cancer, 
heart disease, Alzheimer's, Parkinson's--the list goes on and on--that 
we are doing our part here in the Senate; that despite all the 
political battles and differences, there are things that bring us 
together, and that should be one.
  The second point they raised--one of the young girls there, Morgan of 
Jerseyville, started telling me a story about the cost of insulin. As 
she was telling the story about the sacrifices being made by her family 
to keep her alive, she broke down and cried. What she was telling me--
her personal experience, her family experience--was something that 
every family with diabetes knows: The cost of insulin--charged by the 
pharmaceutical companies--has gone up dramatically, without 
justification, over the last 20 years.
  In 1999, one of the major insulin drugs--called Humalog, made by Eli 
Lilly--was selling for $21 a vial. That was 20 years ago. In 1999, it 
was $21 a vial. The price today is $329 a vial. What has caused this 
dramatic increase? There is nothing that has happened with this drug. 
It is the same drug. And, I might add, Eli Lilly of Indianapolis, IN, 
is selling the same insulin product--Humalog--in Canada for $39. So it 
costs $329 in the United States and $39 in Canada.
  These families told me they were lucky to have health insurance that 
covered prescription drugs. That sounds good, except they each had 
large copays--$8,000 a year. And what it meant was that for this young 
girl, this beautiful little girl who was in my office and who has 
juvenile diabetes,

[[Page S4752]]

they would spend $8,000 a year at the beginning of the year for 3 
months of insulin before the health insurance kicked in and started 
paying for it. Of course, there are families who aren't so lucky--they 
don't have health insurance to pay for their drugs.
  So what are we going to do about it? It happens to be something the 
Senate is supposed to take up. We are supposed to debate these things 
and decide the policy for this country. We will see. Very soon, we will 
have a chance. A bill is coming out of the Health, Education, Labor, 
and Pensions Committee, and we will have a chance to amend it on the 
floor and to deal with the cost of prescription drugs. I will have an 
amendment ready if my colleagues want to join me--I hope they will--on 
the cost of insulin, and we will have a chance if Senator McConnell, 
the Republican leader, will allow us--it is his decision. We will have 
a chance to decide whether these kids and their families are going to 
get ripped off by these pharmaceutical companies for years to come.

  It isn't just insulin; it is so many other products. It is time for 
us to stand up for these families and their kids, to put money into 
medical research, and to tell pharma once and for all: Enough is 
enough. Insulin was discovered almost 100 years ago. What you are doing 
in terms of increasing the cost of it for these families is 
unacceptable and unconscionable.