[Congressional Record (Bound Edition), Volume 163 (2017), Part 8]
[Senate]
[Pages 11017-11025]
[From the U.S. Government Publishing Office, www.gpo.gov]




                           EXECUTIVE SESSION

                                 ______
                                 

                           EXECUTIVE CALENDAR

  The PRESIDING OFFICER. Under the previous order, the Senate will 
proceed to executive session to resume consideration of the Shanahan 
nomination, which the clerk will report.
  The legislative clerk read the nomination of Patrick M. Shanahan, of 
Washington, to be Deputy Secretary of Defense.
  The PRESIDING OFFICER (Mr. Flake). The Senator from New Hampshire.


                               Healthcare

  Mrs. SHAHEEN. Mr. President, the majority leader says that he will 
move forward this week with a vote on a straight repeal of the 
Affordable Care Act in its entirety. I don't believe that a majority of 
Senators are willing to support a reckless leap in the dark, which that 
vote would mean. It is a vote that would end protections for people 
with preexisting conditions. It would take healthcare coverage away 
from tens of millions of Americans and tens of thousands in New 
Hampshire. It would terminate the Medicaid expansion that has been 
critical to fighting the opioid epidemic in my State and so many States 
across this country.
  According to the nonpartisan Congressional Budget Office, a straight 
repeal of the Affordable Care Act would result in more than 32 million 
people losing their insurance coverage by 2026. Premiums would roughly 
double in the

[[Page 11018]]

individual marketplaces. I urge my Republican friends not to go forward 
with this misguided approach.
  The idea that they can repeal the healthcare bill now and give us a 
new bill in 2 years or whatever period of time is in the bill just 
doesn't pass the smell test. If we haven't seen an alternative to the 
Affordable Care Act in the last 7 years, there is no reason to believe 
that our Republican colleagues are going to be able to produce a bill 
in 2 years when there is chaos in the marketplaces.
  There is a better way forward for the Senate and for our country. 
During the Fourth of July recess, Majority Leader McConnell said that 
if he can't secure the votes to repeal the Affordable Care Act, he is 
prepared to work in a bipartisan way with Democrats on legislation to 
repair and strengthen the law.
  I believe that bipartisanship is the best way to get something done. 
That is what I tried to do when I was Governor of New Hampshire. I 
worked closely with our Republican legislature, and we got things done. 
It should not be a last resort for what we are doing; it should be the 
first resort. It should be what we do to build a foundation for policy 
in this country.
  I am hopeful that following the floor consideration of whatever the 
majority leader decides to do on healthcare--and, hopefully, it is 
going to get defeated--we will move forward with the majority leader's 
fallback plan, which I believe should be the starting position. We need 
to start fresh with regular order to craft bipartisan legislation that 
builds on the strengths of the Affordable Care Act, that builds on what 
is working and fixes what is not working. As we have been hearing at 
townhalls and in countless messages from our constituents, this is 
exactly what the American people want us to do.
  There is remarkable consensus in this country that the Republican 
leaders' bill is the wrong approach. An ABC/Washington Post poll on 
Sunday found that by a more than 2-to-1 margin, Americans prefer the 
Affordable Care Act to the Republican leaders' bill. Their bill is 
strongly opposed by hospital associations, by healthcare providers, by 
the health insurance industry, and by nearly every patient advocacy 
group, including the American Cancer Society and the American Heart 
Association. There is no reason to think that just repealing the 
Affordable Care Act is going to make that any better.
  On Saturday, the New Hampshire Hospital Association, the New 
Hampshire Medical Society--our physicians--and the New Hampshire AARP 
joined together in opposition to the bill. They noted that more than 
118,000 Granite Staters--nearly 1 in 10 people in New Hampshire--would 
lose healthcare coverage under the Republican bill, and that number is 
even greater if we just repeal the Affordable Care Act. Their joint 
statement urges Senators ``to start over and create a new version of 
legislation that protects coverage for those who have it and provides 
coverage for those who need it most.''
  Mr. President, I ask unanimous consent that the joint statement by 
these groups be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

               [From the Concord Monitor, July 15, 2017]

  Our Turn: Protecting Patients Must Be the First Goal of Health Care 
                              Legislation

           (By Todd C. Fahey, Stephen Ahnen and James Potter)

       The New Hampshire Hospital Association, New Hampshire 
     Medical Society and AARP New Hampshire have joined in 
     opposition to the Better Care Reconciliation Act currently 
     under consideration in the U.S. Senate.
       Our three organizations oppose the BCRA because it would 
     erode health protections for millions of Americans and expose 
     them to increased costs and health risks. We believe that any 
     health care legislation should have the goal of protecting 
     patients first.
       We are concerned that the BCRA would reduce funding for 
     Medicare by cutting nearly $59 billion over 10 years from the 
     Hospital Insurance trust fund, which would hasten Medicare's 
     insolvency and diminish the program's ability to pay for 
     services in the future. This would affect hospitals, doctors 
     and consumers by reducing revenue and making it more 
     difficult to provide services to Medicare patients. To put a 
     sharper point on the issue, New Hampshire hospitals are 
     projected to receive approximately $1.5 billion less in 
     Medicare reimbursements over the next decade, reductions that 
     were enacted as part of the Affordable Care Act to help pay 
     for the coverage expansions that have occurred. To maintain 
     those spending reductions while millions of people lose 
     health insurance coverage is simply not feasible.
       The BCRA threatens protection for people with employer-
     sponsored health coverage by weakening consumer protections 
     that ban insurance companies from capping how much they will 
     cover annually or over a person's lifetime--leaving people 
     vulnerable to costs that could be financially catastrophic 
     for them.
       In addition, the bill cuts more than $700 billion from 
     Medicaid by creating a capped financing structure in the 
     Medicaid program. This could lead to cuts in provider 
     payments, program eligibility, covered services or all three, 
     ultimately harming some of our nation's most vulnerable 
     citizens and dramatically impacting providers' ability to 
     serve patients and communities who depend on them every day. 
     It has been estimated that this would result in over $1.4 
     billion in reduced federal spending on Medicaid in New 
     Hampshire over the next decade. Where would New Hampshire 
     turn to find the resources necessary to care for our most 
     vulnerable citizens?
       According to the CBO, the BCRA will leave 22 million more 
     people uninsured, including more than 118,000 Granite State 
     residents who were able to secure vital health coverage 
     through the Affordable Care Act, making it more difficult for 
     our most vulnerable to receive the services they need to stay 
     in their homes. Without health coverage for, and therefore 
     access to, critical health services, patients will seek care 
     in emergency rooms, ultimately raising uncompensated care 
     costs for hospitals throughout New Hampshire and increasing 
     cost-shifting to New Hampshire businesses.
       We believe that the Better Care Reconciliation Act needs to 
     be viewed through the eyes of patients and the caregivers who 
     take care of them, and should make protecting health care 
     coverage for our most vulnerable citizens a higher priority. 
     We remain opposed to the BCRA and urge the Senate to start 
     over and create a new version of legislation that protects 
     coverage for those who have it and provides coverage for 
     those who need it most.
       We appreciate the efforts of both of our senators to 
     protect access to affordable health care for all Granite 
     Staters, and we urge them to continue to work toward 
     bipartisan solutions that will cover more people, not less, 
     and reduce health care costs, including insurance premiums 
     and the high cost of prescription drugs.

  Mrs. SHAHEEN. Mr. President, I strongly agree with these New 
Hampshire groups. After spending 6 months trying to pass the deeply 
unpopular, deeply flawed bill to repeal the law, shouldn't we welcome a 
bipartisan effort to improve the law? I believe the answer to that is 
yes, and the place to begin is by taking urgent action on a matter 
where most of us agree, and that is providing certainty to health 
insurance markets in order to hold down premium increases. In their 
2018 rate request filings, insurers say that large increases are 
necessary because of the uncertainty surrounding the repeal of the 
Affordable Care Act and because the Trump administration refuses to 
commit to making cost-sharing reduction payments--those payments that 
go to insurance companies so they can help their consumers with the 
cost of health insurance, making sure that more people can get health 
insurance. Well, we now have an opportunity to end this uncertainty by 
putting the repeal behind us and authorizing a simple bill to authorize 
regular appropriations for the cost-sharing reduction payments.
  The current instability in the ACA marketplaces is a manufactured 
crisis, and Congress can put a stop to it very quickly. That is why I 
have introduced the Marketplace Certainty Act, which is a bill to 
permanently appropriate funds to expand the funds for and to expand the 
cost-sharing repayments. It does two things: It guarantees that these 
payments are coming, and it is going to cover more people to help. I am 
pleased to be joined by 26 Senators who have already cosponsored this 
bill. We can end this artificial crisis. We can immediately restore 
certainty and stability to the insurance markets, and, in turn, we can 
get the time we need in order to come together in a bipartisan way to 
improve this law to build on what is working and to fix what is not.
  We have a number of these commonsense measures, and this is one that 
has been embraced, not just by Democrats but by key Republican leaders,

[[Page 11019]]

including Chairman Lamar Alexander and House Ways and Means Chairman 
Kevin Brady, who have urged that these payments be continued. As 
Chairman Brady put it, the payments are needed ``to help stabilize the 
[health] insurance market and help lower premiums for Americans.'' He 
added: ``Insurers have made clear the lack of certainty is causing 2018 
proposed premiums to rise significantly.''
  We have heard from our constituents at home. We have heard from 
doctors, nurses, hospitals, particularly rural hospitals, nursing 
homes, patient advocates, insurers, and those constituents who were in 
the statement I asked to be printed in the Record. They are pleading 
with us to set aside our partisan differences and work together to 
repair the Affordable Care Act.
  Again, we know what we can do. It is not just the Marketplace 
Certainty Act; there are other bills that have been introduced that can 
fix the uncertainty in the markets and allow us to address other issues 
with the law.
  Bipartisanship should be the Senate's first resort, not the last 
resort. An excellent place to start is by coming together right now to 
permanently appropriate funds for the cost-sharing reduction payments 
that keep health coverage affordable and to look at some of the other 
commonsense measures that are going to be talked about by my 
colleagues, like Senator Klobuchar, who will be coming to the floor. 
She has legislation that would help us deal with the high cost of 
prescription drugs, which is one of the things that is driving the 
increasing costs of healthcare. We need to pass these commonsense 
measures, and we need to do it now.
  Thank you.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Minnesota.
  Ms. KLOBUCHAR. Mr. President, I want to thank Senator Shaheen for her 
leadership, and I am proud to be one of the cosponsors of her bill with 
her commonsense approach--which I believe is the one that will rule the 
day--to work together on changes to the Affordable Care Act that will 
help the American people.
  I join my colleagues on the floor in sharing the concerns I have 
heard from so many people in my State and across the country about the 
bill that has been introduced by our colleagues. I also heard their 
desire to have us work together to bring down the costs of healthcare 
and to make fixes to the Affordable Care Act.
  Healthcare leaders in my State have come out strongly against the 
bill released last week because it would be devastating to the people 
of our State, especially in our rural areas--rural hospitals--and 
especially to our seniors who rely on Medicaid funding for nursing 
homes and assisted living.
  Last night we heard that we will not be proceeding to that bill, and, 
instead, the majority leader wants to bring up repealing big parts of 
the Affordable Care Act without a replacement. I just want to remind my 
colleagues that the Congressional Budget Office has already looked at 
this repeal without a replacement, and it is just as bad. Instead of 22 
million people losing their insurance by 2026, the CBO has estimated 
that about 32 million would lose insurance under the repeal approach, 
and premiums would double. So this repeal effort doesn't help the host 
of Minnesotans who, according to the Minnesota Medical Association, 
would be harmed by what they call draconian Medicaid cuts.
  It doesn't help our children's hospitals. I met with several last 
week, and they were very concerned that Medicaid cuts would wreck their 
ability to provide healthcare to our kids. This was something, by the 
way, that I heard repeatedly on the Fourth of July. During the parades, 
people would come out of the blue, out from the sides of the streets, 
mixed in with the hot dogs and American flags, and there were these 
families--predominantly families with kids with disabilities--and they 
would bring children over to meet me and would say how important this 
Medicaid funding is for their entire family. I remember that once, when 
the mom brought her child over with Down syndrome, all of the people on 
the parade route, on that block, cheered for that family.
  We know that we are all in this together, and we know that what 
happens to one family could, next year, happen to another family. You 
can have a child with a disability. You can suddenly have a disease 
that could be debilitating to your family's finances. Basically, we 
never know what is going to happen to our health or to the health of 
our family members. That is why we have health insurance, and we must 
make sure that it is affordable.
  In addition to that, we have had the CEOs of our healthcare system 
stand up and say that these approaches would lead to major job losses 
in our State. As I mentioned before, for seniors, AARP has said that, 
in my State, nearly half of all of the adults who receive tax credits 
under the Affordable Care Act are 50- to 64-year-olds and these 
subsidies would be eliminated under the repeal bill. This could make 
healthcare unaffordable, especially for the more than 350,000 people in 
my State who are aged 50 to 64 who have preexisting conditions.
  Now, it does not have to be this way, as Senator Shaheen has so 
articulately pointed out. I know that several of my Republican 
colleagues have said that they cannot support legislation that would 
take away insurance for tens of millions of Americans, and I agree. 
Instead of making these kinds of draconian cuts and moving backward, I 
think we have to move forward to actually help make healthcare in 
America better and more affordable.
  We can and we should make changes to the Affordable Care Act. The day 
it passed, I said this is the beginning and not the end. You simply 
cannot have a major piece of legislation like that and go for years 
without any significant changes. That is just not how it has worked 
with major legislation in the past, but every time we have tried to 
make changes, we have heard back that we have to repeal it. Maybe the 
result of all of this chaos in the last month has been that people have 
finally come to realize what the American people want, as Senator 
Shaheen has pointed out, as well as what is the best policy, and that 
is to make changes.
  I support Senator Shaheen's Marketplace Certainty Act because it 
would stabilize the individual market and protect and expand the vital 
program that reduces out-of-pocket healthcare costs for consumers. I 
also support the bill of Senator Kaine of Virginia, who is here with us 
today, and Senator Carper, which is the Individual Health Insurance 
Marketplace Improvement Act, which reestablishes a Federal reinsurance 
program. By the way, this idea of reinsurance is something that our 
Republican legislature in Minnesota just passed on a State basis and is 
supportive of. So I see these as not just some pie-in-the-sky ideas. I 
see these ideas as things that we can work on across the aisle.
  I just want to end by talking about some of my ideas, many of which 
have bipartisan support. Again, I throw them in a package of things 
that we could be working on. I have a bill that would harness the 
negotiating power of 41 million seniors who are on Medicare in order to 
bring drug prices down. Right now, by law, Medicare is banned from 
negotiating prices with all of those seniors. Think of the better 
bargain that those seniors could get if their marketing power were 
unleashed.
  Senator McCain, the Presiding Officer's colleague, and I have a bill 
to allow Americans to bring in safe, less expensive drugs from Canada, 
which is, by the way, very similar to the American market. As I have 
often noted, we can see Canada from our porch in Minnesota. We see 
right across the border the kinds of prices they are able to get. 
Senator McCain and I and several Republicans voted for a similar 
measure, and we think we should be allowed to bring in less expensive 
drugs from Canada and, perhaps, from other countries. You could also 
tie to it a trigger, if there is no competition or if prices have 
ballooned like they have for 4 of the top 10 selling drugs in this 
country.
  Senator Lee and I have a bill that would allow for the importation of 
safe drugs from other countries when there is not healthy competition.

[[Page 11020]]

  Senator Grassley and I have a bill to stop something called ``pay for 
delay,'' which is when big pharmaceutical companies pay off generics in 
order to keep their products off the market. It would be $3 billion in 
savings for the U.S. Government by just passing that, and I would 
challenge my colleagues to vote against something as simple as that.
  Lastly is the CREATES Act, and Senators Grassley, Leahy, Feinstein, 
Lee, and I have that bill, which makes sure that we get the samples so 
that we can get generics on the market, create more competition, and 
bring prices down.
  This debate is about the patients of a nurse practitioner who 
provides psychiatric care in my State.
  She wrote to me:

       Please, please, do all you can to prevent these people from 
     losing the health insurance coverage for medical and mental 
     healthcare that is so vital to their lives.

  In Minnesota, one-third--32 percent--of the funding for our State's 
mental health agencies comes from Medicaid, and across the country, 
Medicaid expansion has helped 1.3 million people receive treatment for 
mental health and substance abuse issues.
  This debate is about the mom in Minnesota who has private insurance 
and who has colon cancer. She is working full time, raising two school-
age boys and going to chemo every single week. She said she fears she 
will not be able to afford the care she needs to stay alive.
  This debate is about the rural constituents whom I noted come up to 
me at parades, like the Fourth of July, at nearly every other block, 
and tell me their stories of how they are concerned about their kids 
with disabilities and how they are concerned for their rural hospitals.
  We have things we can do to make this better, and now is the time 
when we must get them done. We have bipartisan support for these 
changes to the Affordable Care Act. Let's work together on them across 
the aisle, and let's remember that this is about one team, one country. 
We can get this done.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Virginia.
  Mr. KAINE. Mr. President, I also take to the floor to talk about 
healthcare. I appreciate my colleagues who are here, earnestly pleading 
with all of our colleagues to be about a process--Democrats and 
Republicans and the committee process that we have in the Senate--that 
does the work that we are supposed to be doing, which is listening to 
the American public and improving our healthcare system.
  Let me tell you about my first meeting of the day. It was an amazing 
one. I had a mom, Rebecca, and her 5-year-old daughter, Charlie, in my 
office. They had asked for the opportunity to meet with me to talk 
about healthcare. Here is their story.
  Charlie is just about 5 years old. She starts kindergarten in the 
Charlottesville public schools in September. She was born at 26 weeks, 
or about 14 weeks early. She weighed 1 pound and 11 ounces at birth. 
She went through the NICU and had great care. When she was released to 
go home, the doctors thought she would be fine, but within a couple of 
months, it was pretty clear that she had some significant challenges as 
she has the diagnosis of cerebral palsy, and she gets 80 percent of her 
food through a feeding tube. This family has many, many needs.
  Charlie, from a cognitive standpoint, is very, very sharp and is 
excited about starting school, but she has significant needs. Her 
mother Rebecca said that Charlie is like the case study for why a 
repeal of the ACA would be a disaster. Charlie has a preexisting 
condition because of the CP and her challenges. Charlie has already hit 
all of the lifetime caps that would have rendered her unable to get 
insurance pre-ACA.
  In the hospital, because of her dramatically low birth weight, 
Charlie was the recipient of Medicaid funds that would be cut under the 
current bill. Charlie is currently the recipient of a Medicaid waiver, 
which will help her afford supplies for her feeding tube. When she 
starts kindergarten in the Charlottesville public schools, Charlie will 
be given an individualized education plan under the Individuals with 
Disabilities Education Act, and some of those expenses are being 
compensated by Medicaid.
  The preexisting condition, lifetime caps, and Medicaid cuts all 
affect this dynamic, young 5-year-old, who is as entitled as any of us 
to try to be all she can be. If we persist on the path that we are on 
now with regard to the bill that is being proposed, we will hurt 
families like these, and we do not need to do that. Instead, we can 
help them.
  Before the passage of the Affordable Care Act, we know that 
Americans, like Charlie, who had preexisting conditions faced unfair 
barriers to accessing health coverage. There are challenges that we 
need to fix, but let's celebrate a few things. Since 2010, the rate of 
uninsured Americans has declined to a historic low. More than 20 
million people have gained access and have healthcare coverage--many 
for the first time in their lives. Another statistic that is 
interesting is that the number of bankruptcies in our Nation has been 
cut in half. Pre-ACA, medical costs had driven up bankruptcies, but the 
ACA has brought the bankruptcy rate down. We have to move forward to 
make healthcare stronger, not to destroy it.
  The Republican bill that is being discussed right now, because of its 
reductions of coverage, slashing Medicaid, and increases to premiums 
for seniors, would make the matter worse. The proposed amendment by the 
Senators from Texas and Utah has led insurance companies to come out 
and say that this will create a two-tiered system that will punish 
those with preexisting conditions. The latest plan, which was discussed 
this morning by the majority leader, would just be a straight repeal of 
the Affordable Care Act with a promise that we would fix it in a couple 
of years. It has been scored by the CBO, and the CBO says that it would 
cause 32 million Americans to lose their coverage and would 
dramatically increase premiums. Yet we do need to find improvements, 
and we should be working on that together.
  There have been some actions taken by this administration that have 
compounded challenges. In January, the President signed an Executive 
order that directed relevant agencies not to enforce key elements of 
the Affordable Care Act. They terminated components of outreach and 
enrollment spending. The administration has also threatened to end 
cost-sharing reduction payments. These actions and additional inactions 
have created such uncertainty in the individual marketplace that rates 
have been unstable, and, in some areas, companies are not writing 
individual policies. The amendment I discussed earlier, from the 
Senators from Texas and Utah, would make these problems even worse.
  There is a better way. There is a way forward, and I am here to just 
briefly reference a bill that Senator Carper and I have put on the 
table that we think will do a good job and should have strong 
bipartisan support. It is the Individual Health Insurance Marketplace 
Improvement Act.
  One of the ways to address uncertainty in the individual market is to 
establish a permanent reinsurance program that will stabilize premiums 
and will give insurance companies some stability so that they can stay 
in markets, but it will also enable those companies to write premiums 
at an average level and not have to take into account the high-cost 
claims. We think it could reduce premiums dramatically all over the 
country.
  Now, the idea of reinsurance should not be controversial. We use it 
in other programs--flood insurance, crop insurance, and Medicare Part 
D. A key part of Medicare that was achieved under the Bush 
administration includes a reinsurance provision. The Affordable Care 
Act had a reinsurance in its first 3 years, but it expired. That 
reinsurance helped to maintain stable premiums. This is an idea that is 
not a Democratic idea. It is an idea that is tested.
  Senator Carper and I introduced the bill to the Senators on the 
Finance Committee. I am on the HELP Committee. We are just waiting for 
the opportunity to be able to present it and

[[Page 11021]]

get a hearing for it. We ought to be able to work together on 
reinsurance, on the cost-sharing guarantees that Senator Shaheen has 
proposed, and on a variety of other ideas. Senators Cassidy and Collins 
have a bill in that uses auto enrollment, which is an interesting 
concept that we should be tackling.
  I am just going to conclude and tell you how naive I am.
  I was a mayor and a Governor before I got here to the Senate. When 
you are a mayor and a Governor, what you know is education and 
healthcare. We have a Governor here and a Governor here and a Governor 
here. We have four former Governors who are sitting on the floor. What 
you know is education, which was your biggest line item, and your 
second biggest line item is Medicaid--healthcare. I tried to get on the 
committee when I got to the Senate, and I was not put on the committee. 
I was very disappointed. For 4 years I tried to get on the HELP 
Committee. I got on it on January 3. I was so excited. Finally, I am 
working on something that I know about.
  I got a group together of 13 Democratic Senators. Within 48 hours of 
getting on that committee, on January 5, I wrote a letter to my 
committee chair, Senator Alexander, a great committee chair, as well as 
to the Finance chair, Senator Hatch, and to the majority leader, 
Senator McConnell: If you want to fix healthcare, we are here to sit 
down with you right now and fix it. I was naive enough to think that, 
because I was on the HELP Committee, I might be included in a 
discussion about healthcare. We have had hearings in our committee--
many hearings--on nominees, on pensions, on higher ed, on the FDA, but 
there has been one taboo topic on the HELP Committee since I got on it 
in January. We are not allowed to have a hearing about healthcare. We 
haven't had a hearing about the House bill. We haven't had a hearing 
about Senate proposals. We are being told that we are not going to have 
a hearing, that we are just going to rush whatever we do to the floor 
either on a House proposal, a Senate proposal, or a Senate repeal. We 
are going to completely skip the committee.
  Now, you know a little bit about this committee. We have a doctor on 
the committee, Senator Cassidy from Louisiana. Our chair of the 
committee, Senator Alexander, was a Governor. He had a Medicaid 
Program. He was the president of the University of Tennessee. He had a 
hospital. He had a medical school. He had physician practice groups. 
There are people on the HELP Committee who know something about 
healthcare. There are people on the Finance Committee, which covers 
Medicaid and Medicare, who know something about healthcare, but we have 
not been allowed to have a hearing about this. When you have a hearing, 
you bring people up to the witness table, patients like Charlie, who 
was in my office this morning, and doctors and hospitals. You ask them 
what works, what doesn't work, and what can be fixed. We haven't had 
the opportunity to hear from folks.
  So why wouldn't we do exactly what Senator McCain said yesterday? 
Senator McCain said: We have gone about this the wrong way. We should 
be the U.S. Senate. We should take advantage of the Senate procedures 
and the expertise on the Senate committees, including staff expertise, 
and we should assign these various bills to the relevant committees and 
have hearings and then come forward with a proposal that will actually 
improve healthcare for this country.
  I am completely confident that if we let the committees do the work 
they are supposed to do, we will find improvements that can get 
bipartisan support and that will help Virginians and help Americans. 
That doesn't seem too much to ask. I hope my colleagues will consider 
that, and I hope we will be engaged in those discussions soon.
  With that, I yield the floor.
  The PRESIDING OFFICER. The Senator from Delaware.
  Mr. CARPER. Mr. President, I want to preface my remarks today by 
asking that you convey to your wingman, Senator John McCain, our 
colleague, our best wishes and our hope that he is on his way to a 
speedy recovery and will be back here because we need him. We need his 
wisdom.
  I want to thank Tim Kaine for the leadership that he and Senator 
Shaheen are showing to help us try to stabilize the marketplaces. 
Senator Hassan and I have talked a lot about this.
  What do we do now? I think this is an opportunity. This is an 
opportunity here. I realize there is a fair amount of confusion as to 
which path to take and which way to go. I hope we don't waste this 
opportunity.
  I sent a message to the new chairman of the National Governors 
Association and to the new vice chairman of the National Governors 
Association. Brian Sandoval from Nevada is the new chair and the 
Governor from Nevada, previously the vice chair, and Steve Bullock from 
Montana is the vice chair. One is a Republican, and the other is a 
Democrat. I sent them a message this morning saying that it would be 
good to hear from the Governors. They have been working on a bipartisan 
letter--they have been working on it for a while--and this is really 
the time it could make a positive impact.
  We have three people sitting here--four of us--who used to be part of 
the National Governors Association. I loved it, and I am sure Senator 
Kaine, Senator Hassan, and Senator Shaheen loved it as well. Here is 
what I suggested that the Governors may want to consider in their 
message:
  No. 1, urge us to hit the pause button. Hit the pause button. Let's 
just stop in place for a moment.
  No. 2, pivot soon--not in September, not in August, but now, like 
this week, pivot to stabilizing the exchanges.
  No. 3, return to regular order. Senator Kaine has already mentioned 
this. When I talked with Senator McCain last week a couple of times 
briefly, we both talked about the need for regular order. People have 
good ideas on healthcare; introduce them. Committees with jurisdiction, 
hold hearings. Witnesses, including Governors, should come before the 
committees of jurisdiction--a couple of committees in the House and in 
the Senate--and let's hear from the experts, and let's certainly hear 
from the Governors, who have to run these Medicaid Programs and have a 
lot of expertise in this area to offer us.
  Then I would say, after the August recess, if we can actually do 
something real in stabilizing the exchanges, what a confidence builder 
that would be among us and, I think, around the country. It would be a 
great confidence builder.
  The other thing I would mention is that when we come back after the 
August recess, don't just muck around and wonder what we are going to 
do; we should pull together in a bipartisan way--something we talked 
about doing a lot, but we don't often do it--to really do maybe a 
couple of things.
  Let's figure out what we need to fix in the Affordable Care Act. 
Republicans believe that Democrats feel it is perfect and nothing 
should be changed. Well, I don't feel that way. My guess is that most 
of our Democrats don't, either. No bill I have ever worked on was 
perfect. It can always be done better. The same is true with big 
programs like Medicare and Social Security, veterans programs, and so 
on. They can all be done better, and this is certainly the case as 
well. Let's fix the parts of the ACA that need to be fixed, and let's 
preserve the parts that ought to be preserved.
  I would reiterate, speaking on behalf of some recovering Governors, 
including me, the Governors need to be heavily involved in this. I 
suspect that all of the former Governors who are on the floor with me 
today, when we were part of the NGA, we weren't on the floor--actually, 
I was on this floor any number of times because Governors had access to 
the floor--but we had many opportunities, many invitations to testify 
before Senate committees and House committees on a wide range of 
issues. I think we brought value, and we need to hear from them today.
  I want to go back and talk about how we go about stabilizing the 
exchanges. The first thing that would help would be for the 
administration to stop destabilizing them. That would be a big help.

[[Page 11022]]

  Senator Kaine has led on legislation--and he has mentioned it, and I 
want to drill down on it just a little bit--that would provide 
reinsurance, much as we do in other ways in terms of the Medicare Part 
D drug program. Using reinsurance is a very common tool, and we can use 
it to help stabilize the exchanges.
  How would it be used in our proposal? If this lady standing right in 
front of me were getting healthcare and her healthcare needs were 
expensive, under our reinsurance plan starting in 2018, 2019, 2020, the 
first $50,000 in her healthcare that she used in year one, 2018, the 
Federal Government--well, the insurance companies themselves actually 
would be on the hook for the first $50,000 of care she got. Between 
$50,000 and $500,000, under our proposal, the Federal Government would 
pay for 80 percent of that cost--80 percent of that cost. Between 
$50,000 and $500,000 would be on the Federal Government. Anything above 
$500,000 would be back on the insurance company. That is what we would 
do for the next 3 years.
  Starting in 2021 and going forward, the first $100,000 would be on 
the insurance company for the costs borne--created by an individual, 
and then between $100,000 and $500,000, 80 percent of that would be on 
the Federal Government, and after that, the rest of it is back again on 
the insurance company to pay for.
  That is our proposal. We have a bunch of cosponsors on it, and we 
need some Republican cosponsors as well. It is not a Democratic idea. 
It is not a Republican idea. It is just a good idea that deserves 
bipartisan support.
  Another thing we ought to do to stabilize the exchanges is what 
Senator Shaheen has proposed; that is, we have these CSRs, cost-sharing 
reductions. I think of them as subsidies to help subsidize people whose 
income is under a certain level; I think it is 250 percent of poverty. 
Folks who are in the exchanges getting healthcare coverage and whose 
income is under 250 percent of poverty currently receive some subsidies 
to help buy down and reduce the cost of their copays and their 
deductibles. It is not really clear whether that is authorized. It is 
not really clear whether that is being funded, but it has been done for 
a number of years.
  The current administration has been saying: Well, we don't know if we 
are going to continue to do that.
  There have been some States that want to go to court and say: You 
can't do that.
  We need to pass a law and say that we are going to have these cost-
sharing reductions and that the subsidies will continue to be offered.
  The last thing we need to do is to make clear that the individual 
mandate or something as good as or at least as effective as the 
individual mandate is going to be around. For the administration to 
say: Well, we don't know if we are going to enforce the individual 
mandate--it just encourages young, healthy people not to get coverage.
  We have to make it clear that the individual mandate or something as 
good as--it could be a proxy for it or maybe several things that work 
together that could be as effective as the individual mandate. If they 
don't work, maybe we could just have a default position that would be 
the individual mandate again.
  We ought to have hearings on these kinds of things and discuss them 
and hear from all kinds of folks.
  The other thing I want to mention is just that when I go around my 
State, my Lord, I have never heard people so interested in encouraging 
us. I think I am regarded in my State--along with Senator Coons and our 
Congresswoman, Lisa Blunt Rochester--I think we are regarded as 
bipartisan people. We are Democrats and proud to be Democrats. We would 
like to work with Republicans, too, and I think that is part of being a 
recovering Governor. But on this subject, on healthcare reform, going 
forward, the people in my State don't want a Democratic victory. They 
don't want a Republican victory. Frankly, they don't want a Trump 
victory. They want a victory for our country. That is what they want. 
They want a victory for our country. And so do I, and I think so do 
most Democrats in this Chamber and most Republicans.
  So let me say again, if I could make this suggestion, let's hit the 
pause button. Let's stop in place for right now. Let's pivot and figure 
out how we can stabilize the exchanges. Let's return to regular order. 
Let's hold bipartisan hearings, have expert witnesses, including folks 
from all walks of life who know about healthcare coverage, who know a 
lot about healthcare. After the August recess, let's launch a real, 
bipartisan effort to fix the things in the ACA that need to be fixed 
and retain, preserve those aspects that should be retained. As I said 
before, we need Governors at the table, not just recovering Governors. 
We need Governors at the table and a bunch of other folks as well who 
have a lot to contribute.
  If we do those things, we will, in the words of--paraphrasing Mark 
Twain--Mark Twain used to say: When in doubt, tell the truth. You will 
confound your enemies and delight your friends. I think that is what he 
used to say. In this case, I would just say, paraphrasing Mark Twain, 
when in doubt, do what is right. When in doubt, do what is right. We 
will confound our enemies and delight our friends.
  With that, I yield the floor.
  The PRESIDING OFFICER. The Senator from New Hampshire.
  Ms. HASSAN. Mr. President, I am honored to join my colleagues here 
today. I thank Senator Carper for his excellent suggestions and 
leadership in terms of reaching out to both the current and former 
Governors as we proceed on this issue. I am very grateful to my 
colleague Senator Kaine for his leadership on the HELP Committee and 
what he brings as a former mayor and Governor.
  I rise today to join my colleague from New Hampshire in supporting 
her efforts to help lower healthcare premiums for middle-class 
Americans and to stabilize the insurance marketplace.
  The Trump administration has been working to sabotage the individual 
market by playing games with cost-sharing reductions. Those cost-
sharing reductions help lower out-of-pocket expenses, such as 
deductibles and copays, for individuals with health insurance plans in 
the marketplace. This legislation from Senator Shaheen is a commonsense 
measure that would work to prevent the instability and chaos being 
pushed by the administration.
  I also join my colleagues in making clear that we are ready and 
willing to work across the aisle on priorities that will improve and 
build on the Affordable Care Act and bring down costs for people in New 
Hampshire and across the country.
  Over the course of the last several months, we have seen that the 
partisan process Republican leadership has pushed with TrumpCare simply 
won't work. It is going to take a bipartisan approach in order to make 
progress, not a senseless repeal bill that would pull the rug out from 
millions of Americans.
  I have seen firsthand that it is possible for Democrats and 
Republicans to come together in order to improve our healthcare system. 
As Governor of New Hampshire, I worked across party lines to pass a 
bipartisan Medicaid expansion plan that delivered quality, affordable 
insurance to over 50,000 hard-working Granite Staters. Expansion has 
truly made a difference for communities across my State, particularly 
for people impacted by the heroin, fentanyl, and opioid crisis.
  Just last week, I visited Goodwin Community Health in Somersworth and 
heard from a woman named Elizabeth. At one point in her life, as a 
result of a substance use disorder, Elizabeth was homeless, and she 
lost custody of her son. But Elizabeth is now in recovery, and she 
works at the SOS Recovery Community Organization in Rochester, helping 
others get the support they need. She said she owes her recovery to the 
insurance she has received through the Medicaid expansion and the 
Affordable Care Act.
  Elizabeth's story is a great example of the power of what is possible 
when we come together on bipartisan solutions to help improve the 
health of our people. This is the same approach we need to take in the 
Senate, and I believe there are areas for bipartisan cooperation that 
we should be working

[[Page 11023]]

on in order to improve the Affordable Care Act.
  In addition to Senator Shaheen's legislation to stabilize the 
individual market and in addition to the legislation we have heard 
discussed by Senator Kaine and Senator Carper, there are other things 
we can do.
  I believe it is critical that we take on Big Pharma and bring down 
the cost of prescription drug prices, including allowing importing safe 
and affordable drugs and allowing Medicare to negotiate drug prices, 
and I believe we should eliminate the existing income cliff in the 
Affordable Care Act which blocks many middle-class individuals from 
receiving premium assistance.
  These are commonsense measures we should be taking now. People across 
our Nation have made clear, they don't want Congress to do a wholesale 
repeal of the Affordable Care Act because it would have devastating 
impacts for them and their families.
  I urge my colleagues to put the partisan gamesmanship aside. I join 
Senator Kaine, as a member of the HELP Committee, in asking for a 
hearing at the very committee which is supposed to set healthcare 
policy in this body so we can listen to the voices of constituents, of 
providers, of other stakeholders. We need to come to the table ready to 
work on bipartisan solutions in order to improve our healthcare system. 
All of our people deserve to have access to quality, affordable care so 
they can be healthy. That makes our country healthy, productive, and 
strong too.
  The PRESIDING OFFICER. The Senator from New Hampshire.


                   Unanimous Consent Request--S. 1462

  Mrs. SHAHEEN. Mr. President, I am really pleased to have been joined 
by my colleagues to talk about the importance of addressing healthcare 
for all Americans, especially my colleague from New Hampshire. She and 
I have been touring the State for months now, talking with people in 
hospitals, with patients, with physicians, with providers, with people 
with substance use disorders, with providers who are providing 
treatment for people with substance use disorders, with people all over 
New Hampshire about what we can do to make sure people get healthcare 
when they need it.
  That should be the goal of this body. It should not be throwing 
people off their healthcare, which a repeal of the Affordable Care Act 
would do. It would throw 32 million people off their healthcare.
  We can address the instability in the marketplaces. We can do that 
pretty quickly. Senators Kaine and Carper talked about reinsurance, 
something which has worked very well for the first 3 years of the 
Affordable Care Act, and the reason it doesn't work now is because they 
have stopped. That is why we are seeing some of these rate increases.
  We can address the uncertainty by being clear that we are not going 
to repeal the Affordable Care Act, by addressing those cost-sharing 
reduction payments. The ACA already stipulates that CSR--those payments 
which reduce the costs of copays and deductibles--are to be made 
pursuant to 31 U.S.C. 1324.
  My bill provides for payments to be made jointly from a permanent 
appropriation rather than subject to the year-to-year whims of the 
annual appropriations process. The Marketplace Certainty Act removes 
all bases for any further questions about what is already clear from a 
fair reading of the Affordable Care Act as a whole; that both those CSR 
payments and the advanced premium tax credit subsidies are to be funded 
from the same permanent appropriation.
  I see my colleague from Texas on the floor, and I am sure he is going 
to object to the unanimous consent request I am going to be proposing 
in a couple of minutes. He objected last Thursday when I asked for 
unanimous consent to pass the Marketplace Certainty Act, and he 
justified the objection by asserting that the cost-sharing reduction 
payments are--I think he called it a bailout of the insurance 
companies. That is an inflammatory term, and I think we ought to be 
careful with how we use it because the truth is, the cost-sharing 
reduction payments are in no way, shape, or form a bailout. They are 
orderly payments built into the law to go directly to keep premiums, 
copays, and deductibles affordable for lower income Americans. In fact, 
those same payments were included in the bill Majority Leader McConnell 
just said he is not going to go forward with, the Republican bill. It 
included those very same cost-sharing reduction payments. I think they 
were included because there was a recognition that these are important 
to help address the cost of healthcare for all Americans.
  As I said earlier, we have had statements by the chairman of the 
Health, Education, Labor, and Pensions Committee, Lamar Alexander, 
talking about that these payments should be continued. We have heard 
from House Ways and Means Chairman Kevin Brady, who said we need to 
continue these payments to help stabilize the insurance market. It is 
the uncertainty that is causing the current problem, and we could 
address that today--this week--if people were willing to work together.
  As Democrats, we have come to the floor to say we want to work 
together. We think we can address the challenges we face with the 
Affordable Care Act. We can do it in a bipartisan way. I know we can 
because Tim Scott and I have done it. We passed a bill several years 
ago by unanimous consent, which basically gave States the ability to 
control group size for people and for companies in the marketplaces so 
I know it can be done, and I know we could do it today if there were a 
willingness on the part of all of our colleagues to work together. That 
is what the American people want. They don't want 32 million people 
thrown off their health insurance. We don't want rural hospitals to 
close in New Hampshire. We don't want nursing homes to close. We don't 
want people to be thrown out of their nursing homes.
  I was up in northern New Hampshire at a nursing home over the 
weekend, where I talked to a group of women in their eighties and 
older. One woman said to me: You know, I worked my whole life. I paid 
my taxes. I did everything I was supposed to do. I sold my house so I 
could get into this nursing home so I could qualify under Medicaid. I 
got rid of all my assets. Now they are telling me I am going to get 
thrown out? She said: What would I do? I have no place to go. I have no 
family to help me.
  People don't want that. What they want is for us to work together, to 
help fix healthcare so people can get what they need when they need it.
  Mr. President, I ask unanimous consent that the Committee on Health, 
Education, Labor, and Pensions be discharged from further consideration 
of S. 1462; that the Senate proceed to its immediate consideration; 
that the bill be considered read a third time and passed, and the 
motion to reconsider be considered made and laid upon the table with no 
intervening action or debate.
  The PRESIDING OFFICER. Is there objection?
  The Senator from Texas.
  Mr. CORNYN. Mr. President, reserving the right to object.
  The Senator from New Hampshire has acknowledged that she had made 
this previous request last week. The Kaiser Family Foundation, among 
other publications, has clearly stated that the cost-sharing reductions 
she is asking for are paid directly by the Federal Government to 
insurance companies. Thus, when I call this an insurance company 
bailout, I believe that is literally true.
  The Congressional Budget Office estimates the cost of these payments 
at $7 billion in 2017, $10 billion in 2018, and $16 billion by 2027.
  So what my friend, the Senator from New Hampshire, is proposing is an 
insurance company bailout in the tens of billions of dollars with no 
reform, throwing more money at a broken Affordable Care Act, which has 
been in existence 7 years now.
  I know they would like to blame this on President Trump, who has been 
in office just a short time--about a half a year--but this is built 
into the very structure of the Affordable Care Act, and it isn't 
working.
  I, personally, will not be part of any bailout of insurance companies 
without

[[Page 11024]]

reforms. That is why we were trying to structure something under the 
Better Care Act, which unfortunately we haven't been successful with so 
far. We are going to keep on trying, but this is not the answer.
  I object.
  The PRESIDING OFFICER. Objection is heard.
  Mrs. SHAHEEN. Mr. President, I am disappointed but not surprised that 
my colleague has objected. I don't believe he objected because of the 
effort to help pay these subsidies, which are passthroughs to insurance 
companies.
  Reforming how we do those, I am certainly happy to sit down and talk 
about that, but the fact is, that is not the issue right now. The issue 
is, this is a way we could address the current uncertainty in the 
marketplaces in a way that will be good for maintaining stability of 
healthcare for all Americans. I am disappointed there isn't a 
willingness to work together to do that.
  I hope, as this debate continues, we will finally see people come 
together to get something done to address, not just healthcare for 
Americans but to address the one-sixth of the economy that depends on 
the healthcare industry.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Rhode Island.
  Mr. REED. Mr. President, I rise to discuss the nomination of Mr. 
Patrick Shanahan to serve as the 33rd Deputy Secretary of Defense. The 
Senate Armed Services Committee held a hearing on his nomination on 
June 20, and he was voted out of committee by voice vote.
  Mr. Shanahan was born and raised in the State of Washington. He 
received his undergraduate degree from the University of Washington and 
then a master's degree and MBA from the Massachusetts Institute of 
Technology. Mr. Shanahan then embarked on a 30-year career at the 
Boeing Company, where he rose to the most senior echelons of 
management, working on both the company's defense and commercial 
programs. Most recently, Mr. Shanahan served as the senior vice 
president for supply chain & operations.
  The Deputy Secretary of Defense is one of the most important 
positions within the entire national security system. The Deputy serves 
as the number 2 official at the Department of Defense, as well as the 
Department's Chief Management Officer. As the second in command to the 
Secretary of Defense, the Deputy oftentimes is assigned a broad 
spectrum of responsibilities which require strong management skills.
  The Department currently faces challenges on multiple fronts. For 
more than 16 years, our military has been consumed by two prolonged 
wars against violent extremist groups like ISIS. As a result, the 
military has faced a generational fight which has sapped readiness and 
precluded our military personnel from training for full spectrum 
operations. However, violent extremist groups are only one of the many 
challenges facing our country.
  The past several years have seen the rise of near-peer competitors, 
most notably Russia and China. Russia has been a resurgent force bent 
on disrupting Europe and undercutting our own Nation and our 
Presidential election process. China continues its saber-rattling in 
the Asia-Pacific region by undermining the freedom of navigation and 
using economic coercion of its smaller, more vulnerable neighbors. When 
we factor in the destabilizing actions of North Korea and the long 
shadow of Iran, it becomes urgently clear that we need strong 
leadership at the Department of Defense. If Mr. Shanahan is confirmed, 
he will need to contend with all these challenges. It will not be easy 
and hard decisions on policy and strategy will need to be made.
  Perhaps one of the hardest decisions facing the Deputy Secretary of 
Defense is the allocation of budget resources within the Department. In 
an ideal world, a cogent defense strategy that takes into consideration 
the multitude of concerns facing our Nation would inform how the 
Department invests resources in weapons platforms and advanced 
technologies to confront these challenges. However, the reality is that 
the spending caps imposed by the Budget Control Act determine the level 
of funding for most of these budget decisions.
  The current budgetary crisis is compounded by the fact that the 
President's most recent budget request adds much needed funding to 
defense activities, but it shortchanges nondefense spending accounts in 
order to increase spending for our military. Furthermore, the budget 
request fails to recognize that the BCA budget caps are law. If these 
spending levels are enacted, the President's budget request would 
trigger sequestration, effectively wiping out increased defense 
spending with mandatory across-the-board cuts.
  This would be the worst of all worlds. Not only would we be giving 
the money on the one hand and taking it back with the other hand, but 
it would not be in any systematic way. We would be making cuts to 
readiness. We would be making cuts to personnel. We would make cuts to 
all sorts of things which are much more valuable than some programs 
which would receive an additional cut.
  Unless we resolve ourselves to act--which is going to take a 
bipartisan effort to repeal the BCA--we can't effectively fund not only 
the Department of Defense but every other Federal department. That is 
one of the great challenges Mr. Shanahan will face. Indeed, these 
multiple challenges will require strong leadership and the ability to 
make tough decisions. Mr. Shanahan has developed a strong reputation 
during his tenure at Boeing as someone capable of taking on challenging 
programs, fixing problems, and turning them into successes.
  When I met with Mr. Shanahan to discuss his nomination, he emphasized 
that the public sector needed to work closer with the private sector to 
get more cost-effective results while ensuring our warfighters have the 
best equipment at their disposal. It is that kind of leadership that 
the Department of Defense needs as our Nation faces as diverse an array 
of threats and challenges to our national security as at any point in 
our history.
  Based on Mr. Shanahan's qualifications and experience, as well as his 
testimony before the Senate Armed Services Committee, I believe he is 
fully qualified for the job. Therefore, I will vote in favor of his 
nomination to be the next Deputy Secretary of Defense, and I trust he 
will do his best to lead the men and women who ably and courageously 
serve this Nation.
  On a final note, if confirmed, Mr. Shanahan will be relieving Bob 
Work, who has served this Nation ably and selflessly for most of his 
life. Bob Work served in the U.S. Marine Corps for 27 years, rising to 
the rank of colonel. In 2009, he was confirmed as Undersecretary of the 
Navy, where he shepherded the service through many challenges for the 
next 4 years.
  He tried to return to the private sector, but in 2014 he was then 
nominated and confirmed as Deputy Secretary of Defense. Bob Work was 
the continuity in the Defense Department through three Secretaries of 
Defense. He stayed more than 6 months into the new administration in 
order to aid Secretary Mattis. There is no task, no matter how 
difficult or how big or small, that Bob Work would not devote all of 
his energy to until it was resolved. Bob Work personifies his name. He 
works, tirelessly. Our Nation owes him a great debt of gratitude, and I 
hope he takes some well-deserved vacation time and enjoys the company 
of his wife and daughter.
  I yield the floor.
  I suggest the absence of a quorum.
  The PRESIDING OFFICER (Mr. Cruz). The clerk will call the roll.
  The bill clerk proceeded to call the roll.
  Mr. ALEXANDER. Mr. President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Under the previous order, all time has expired.
  The question is, Will the Senate advise and consent to the Shanahan 
nomination?
  Mr. ALEXANDER. Mr. President, I ask for the yeas and nays.

[[Page 11025]]

  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be a sufficient second.
  The clerk will call the roll.
  The bill clerk called the roll.
  Mr. CORNYN. The following Senator is necessarily absent: the Senator 
from Arizona (Mr. McCain).
  Further, if present and voting, the Senator from Arizona (Mr. McCain) 
would have voted ``yea''.
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 92, nays 7, as follows:

                      [Rollcall Vote No. 162 Ex.]

                                YEAS--92

     Alexander
     Baldwin
     Barrasso
     Bennet
     Blumenthal
     Blunt
     Boozman
     Brown
     Burr
     Cantwell
     Capito
     Cardin
     Carper
     Casey
     Cassidy
     Cochran
     Collins
     Coons
     Corker
     Cornyn
     Cortez Masto
     Cotton
     Crapo
     Cruz
     Daines
     Donnelly
     Durbin
     Enzi
     Ernst
     Feinstein
     Fischer
     Flake
     Franken
     Gardner
     Graham
     Grassley
     Hassan
     Hatch
     Heinrich
     Heitkamp
     Heller
     Hirono
     Hoeven
     Inhofe
     Isakson
     Johnson
     Kaine
     Kennedy
     King
     Klobuchar
     Lankford
     Leahy
     Lee
     Manchin
     McCaskill
     McConnell
     Menendez
     Merkley
     Moran
     Murkowski
     Murphy
     Murray
     Nelson
     Paul
     Perdue
     Peters
     Portman
     Reed
     Risch
     Roberts
     Rounds
     Rubio
     Sasse
     Schatz
     Schumer
     Scott
     Shaheen
     Shelby
     Stabenow
     Strange
     Sullivan
     Tester
     Thune
     Tillis
     Toomey
     Udall
     Van Hollen
     Warner
     Whitehouse
     Wicker
     Wyden
     Young

                                NAYS--7

     Booker
     Duckworth
     Gillibrand
     Harris
     Markey
     Sanders
     Warren

                             NOT VOTING--1

       
     McCain
       
  The nomination was confirmed.
  The PRESIDING OFFICER. Under the previous order, the motion to 
reconsider is considered made and laid upon the table and the President 
will be immediately notified of the Senate's action.

                          ____________________