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Congressional Record2017/7/18Senate | House | Extensions

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[Congressional Record Volume 163, Number 121 (Tuesday, July 18, 2017)]
[Pages S4031-S4038]
From the Congressional Record Online through GPO

                           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 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 [[Page S4032]] 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, 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 [[Page S4033]] 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.

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 [[Page S4034]] 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 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 [[Page S4035]] 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.

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 on in order to improve the Affordable Care Act. [[Page S4036]]

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 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. [[Page S4037]]

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.

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: [[Page S4038]] [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. ____________________

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