Transcripts For CSPAN2 U.S. Senate Takes Up Nominations 20170718

Mr. Hatch mr. President. The presiding officer the president pro tempore. Mr. Hatch mr. President , the final pieces of obamacare care were signed into law a little over seven years ago. Since that time republicans not just in congress, but throughout the country have been united in their opposition to the law and our commitment to repeal it. This hasnt been simply a political or partisan endeavor. Were not just trying to take a notch out of president obamas win column. The simple truth is that obamacare is not working. The law was poorly written and the system it created was poorly designed. Even a number of obamacare supporters have come to acknowledge that it hasnt been working the way it was promised to work. As a result, millions of americans have suffered astronomical increases in their Health Insurance premiums, and fewer and fewer Insurance Options to choose from. That is obamacares great irony. The law requires people to buy Health Insurance while also making it impossible to do so. For . Efn and a half years for seven and a half years republicans fought to expose the failures of obamacare and have pledged time and time again to repeal it. Every single republican member of the senate has expressed support for repealing obamacare. Most of us have made promises to our constituents to do just that, and those promises coupled with the obvious failures of obamacare are a big reason why we now why we now find ourselves in control of both chambers of congress and the presidency. For the last six months republicans have worked in good faith to find a path forward to both repeal and replace obamacare. The released discussion drafts attempted to bridge the divide between our more conservative and moderate members, so the products were never going to be perfect. Such as the inherent nature of compromise. The draft released last week included editions to address member priorities that was likely the best chance we had at a compromise bill to repeal and replace obamacare with significant entitlement reform. But last night a handful of members said they would not support the compromise bill even though it would reform medicaid by putting it on a sustainable path for future generations and guarded the largest prolife protections and included the largest prolife protections on federal spending that ive ever seen. This, mr. President , was the opportunity we had been working toward. All we had to do was come together and compromise and seven and a half years of promises would have been much, much closer to being fulfilled. But last night we blinked. And, frankly, i think the members who opted to scuttle the compromise bill will eventually have to explain to their constituents why they left so many obamacare fixes on the table and walked away from this historic opportunity. So where does that leave us . The majority leader has announced his intention to shelve the effort to repeal and replace c obamacare with a single piece of legislation. Long story short, we have one more chance to do what weve all said we wanted to do. Im aware that some members have already expressed their skepticism, if not their opposition, to this approach. I would hope that they will take the time to reconsider. As senators contemplate this path, they should keep in mind that the upcoming voters upcoming vote is not about the next two years, nor is it about the past six months. Were not going to be voting to approve a specific process for drafting and enacting an obamacare replacement. And were not voting to approve the way this effort has moved forward during this congress. I know some of our colleagues have doubts about the path forward. Others have complaints about the path that got us here. But this vote, in my view, will simply be about whether we intend to live up to our promises. Do we want to repeal obamacare or are we fine with leaving it in place . Thats the question we have to ask ourselves. Keep in mind, mr. President , the vast majority of republican senators are already on record having voted two years ago in favor of a full Obamacare Repeal with a twoyear delay. Of course in 2015, we know we knew that the president would veto that legislation. We now know that the current occupant of the white house would surely sign it. Thats really the only difference between then and now. Was the vote in 2015 just a political stunt . Was it just pure partisanship . I know some of our democratic colleagues claim that that was the case. Were they right . I sure hope not. On the contrary, i sincerely hope that any member of the senate who voted for the 2015 bill and who spent the last seven and a half years pledging to repeal obamacare hasnt suddenly decided to change his or her position now that the vote has a chance to actually matter. If we vote to pass a full repeal, will we be solving all of our Health Care Problems with a single vote . Certainly not. But that was never going to be the case, mr. President. Anyone who thought repealing and replacing obamacare would be easy once we had the votes was likely not paying attention to the problems plaguing our Health Care System. However, if we act now to pass the full appeal, we will be full repeal, we will be taking significant steps towarding accomplishing our goal and keeping our promises. If we pass up yet another opportunity, if we cant muster the votes to pass something weve already passed, i have a hard time believing well get another shot to fulfill our promise and repeal this unworkable law any time soon. What does that mean . Among other things, it means a congressional bailout of failing Insurance Markets probably before the end of 2017. Frankly, that ship may have sailed on that one after last nights developments. Were probably looking at an insurance bailout one way or another. Those who will be interested in moving an insurance bailout later this year should be ready to explain how they want to pay for it. Failure would also mean premiums continue to skyrocket, and people will be left with few, if any, available Insurance Options even though they will still face penalties if they dont make a purchase. It would mean that the obamacare taxes and mandates remain in place, and it would keep Medicaid Expansion on the books indefinitely, most certainly creating a scenario for governors to advocate for the federal government to continue paying close to 100 of the share for ablebodied adults. Mr. President , we already know what happens if we leave obamacare in place. That scenario is playing out before our very eyes. That downward spiral of broken promises, one the American People have to deal with every day, is the reason we have all committed to repealing obamacare. Now, dont get me wrong, mr. President. I wish the path that got us to this point had been easier. With less melodrama and acrimony. To be honest, i wish we had simply moved to this full repeal strategy at the outset, because as i noted several times early in this year, it is probably the most feasible path forward if we want to achieve our goals. It would be nice if things had gone differently, but this is where we are with only 52 republicans in the senate and a minority that has from the beginning wanted no part of this process. Right now, we have essentially two choices we can keep talking about repealing obamacare and wishing for a better future, one with more republican votes or more democrats willing to acknowledge reality, or we can press forward with the numbers we have and make good on the commitment that we made to the American People. To quote the old scottish nursery rhyme, if wishes were horses, then beggars would ride. Translation were talking more talking and more wishing wont get us anywhere. We can either take a significant step forward to undo obamacares mandates and taxes that have collectively weakened or wreaked havoc on our Health Care System, or we can dither about them more and leave them in place for the foreseeable future. In my view, mr. President , the choice is an easy one. I urge all of my colleagues to once again vote with me to repeal obamacare. We have blown a number of opportunities already in recent weeks. Last night, we blew a big one. I hope we can avoid doing the same with this upcoming vote. If not, well have to answer to the American People and explain to them why we failed and why we failed. Mr. President , with that, i i suggest the absence of a quorum. A senator i would ask you to withdraw that, please. The presiding officer the senator from delaware. Mr. Carper mr. President , i see you and our friend from utah. I feel compelled just to go back in time, if i could, a question a lot of people say to me back home and around the country, where did obamacare come from . Well, the part where most people think of obamacare, they think of the exchanges that have been established in all 50 states where people who dont have Health Care Coverage can get coverage as part of a large group plan. That was an idea that came from romneycare. 2006, massachusetts, mayor romney was governor, running for president. They came up with a smart idea, said governor romney, you have a much better chance of being elected president if you do what no other governor has ever done and that is to cover everybody in your state for health care. You say well, thats an interesting idea. They looked around for ideas, and what did they come up with . They came up with an idea that was actually raised, suggested by the Heritage Foundation. The Heritage Foundation found its way to this body in 1993 in legislation introduced by republican senator john chafee from rhode island that called for doing five things. Number one, creating exchanges, marketplaces in every state where people who didnt have coverage could be part of a large group, and buy their coverage, get their coverage. Number two, the folks who bought their coverage on the exchange might be eligible for a sliding scale tax credit, lowincome people would get a better tax credit, reducing their premiums than people whose income was higher. Number three, the idea of an individual mandate, if people had to get their coverage, they would have to pay a fine. You cant force people to get coverage. Massachusetts, they say at least well find them. Maybe over time the fine will go up, and most people, including young, Healthy People would elect to get coverage and be part of a group to insure thats actually insurable, as opposed to people who are just sick or anxious to get an operation, needing to get an operation. The fourth principle was in the idea that underlaid the changing legislation, later to become romneycare was the idea that employers of a certain magnitude, certain number of employees had to cover their employees. And the fifth principle in that original idea brought to us from the Heritage Foundation, 23 republican senators and 93 in 1993 as an alternative by the way to hillarycare, later became romneycare. The fifth principle was the idea that if youre an Insurance Company and you were to deny coverage to people because they have a preexisting condition, you cant do that, cannot do that. But that was it. And when a number of us in this body worked on the Affordable Care act, we took the Heritage Foundation idea, the idea from those 23 republican senators who introduced it, cosponsored it, including senator hatch, including senator grassley. Some of the folks who are complaining the most about obamacare with the exchanges are the people who supported the original legislation introducing the idea. I dont know if that seems ironic to other people. It certainly does to me. I spent part of saturday invited up to providence, rhode island, to do something i used to do for eight years, meet with the National Governors association. For eight years as governor of delaware, i was privileged to be part of the National Governors association. At one time vice chair and later on the chairman of the they invited me to come back and talk about health care, Health Care Reform is what was going on here in this senate. I was happy to do that, and we made it work on my schedule. There to speak on behalf of the administration was the Vice President of the country, the secretary of health and Human Services. The o. M. B. Director and the director of the centers for medicare and medicaid, explaining to the governors why they should support the administrations position why they should support the republican position here in the senate. Today the republicans sent out a strong letter, not just republicans. Republican governors, democratic governors sent out a joint letter, bipartisan letter, saying to us, basically do these things, their advice to us. Hit the pause button. Stop what were doing. Number two, pivot and stabilize stop destabilizing the exchanges. This administration is trying to destabilize the exchanges, which is a republican idea and i think actually a good idea. The administration can stop destabilizing the exchanges, but through a variety of tricks that they are pulling. The third thing we should do is stabilize the exchanges. And its not all that hard. Make it clear that the individual mandates are something or something very much like the individual mandate is going to be the law of the land, so that we end up with young, Healthy People in the exchanges. Not a lot of sick people and older people. Number two, reinsurance. One of the keys to the success of Medicare Part d, the drug Insurance Program for folks on medicare, one of the keys to his success there is reinsurance. And a number of us, led by senator tim kaine, myself and others, said why dont we take that tried and true idea and use it to help stabilize the exchanges . I spoke here earlier today on how that would actually work. Its not a democratic idea or a republican idea. Its just a good idea. The third thing we need to do to stabilize the exchanges, an idea actually suggested by a number of senators, including senator Jeanne Shaheen of New Hampshire, which is to say that were going to continue to fund and authorize something called c. S. R. s, costsharing reductions, which actually reduce the copays, the deductibles for lower income people who buy their coverage on the exchanges. Those three things were told by Health Insurance companies would reduce the cost of premiums in all of the states anywhere from 25 to 35 . It would stabilize the exchange, and it would get other Insurance Companies to say i dont know if i want to insure in ohio or delaware or utah. Insurance companies would say well, i think i can offer products there, Insurance Products there and not lose my shirt, and theyll get back into the exchange. Theyll offer coverage. And when more than one or two offer coverage, guess what happens . You have competition. And do you know what flows from competition . Better diversity of products to choose from, lower costs. So those are three things that we could do to stabilize the exchange, and, frankly, theyre not all that hard. The fourth thing that the governors suggested that we do is basically regular order. Around here, regular order means people is a good idea, they introduce it. Turn it in up here at the front desk, and the idea, legislative idea goes to the committee of jurisdiction. There is a discussion whether or not there should be a hearing about that particular bill. If its a good bill, there may well be hearings. You have sponsors, it could be bipartisan, but eventually the idea is to have a hearing in committee. Those who like that idea or those who dont like that idea have an idea to show up in daylight, light of day, and say heres why i like it, heres why i dont like it and let their voices be heard. On issues that are as important as health care, why were not fully involving the governors is beyond me. I just dont get it. Who runs the Medicaid Programs . Well, the governors and the states. Thats a big part of what were debating in this battle. Ill close with this. I said it before earlier today, mr. President. Im going to say it again. As i travel around delaware talking to people in my little state, i have a lot of democrats, a lot of republicans, a lot of independents. They speak to me with one voice, and heres what they say Work Together. Solve some problems together. Democrats, republicans, take off your hats and Work Together. Thats what they want us to do. And its not just delaware. There is a Kaiser Permanente National Survey released last week. 71 of the people in this country surveyed said we ought to Work Together. Get this done. And if were smart, we will come back here before we leave for an august recess, we will stabilize the exchanges were the three things that i talked about. And the administration, they just need to stand down and just be quiet on this point. If they dont like this republican idea of the exchanges, just be quiet. But come back here in september and we go to work, regular order. Hearings. Bipartisan hearings, bipartisan roundtables, the chance for us to debate legislation, in committees, in the house, in the senate, on this floor, to debate amendments. Thats the way we ought to do this. Any time in this country when we have done really big things Social Security comes to mind, g. I. Bill comes to mind, 1986 tax reform comes to mind we didnt do it with just democratic votes or republican votes. We did it together. And if we do that, well be stronger together. I will close with an old african proverb. It goes Something Like this. If you want to go fast, go alone. If you want to go far, go together. We need to go far, and if we do, we and the American People will get a lot further along toward the three things we sought forever since harry truman was president. One, cover everybody. Number two, Quality Health care. Number three, affordable price. Thats the holy grail, and we should strive to get there together. With that, i note the absence of a quorum. The presiding officer the clerk will call the roll. Quorum call quorum call countermr. President. The presiding officer the majority whip, the senator from texas. Mr. Cornyn mr. President , i ask unanimous consent that the quorum call be dispensed with. The presiding officer without objection. Mr. Cornyn mr. President , after weeks well, make that months make that years of discussions about the path forward to rescue the people from obamacare, we find ourselves at an important fork in the road. We have talked among ourselves about the necessity of keeping our promises to repeal and replace obamacare, but were coming down to the reality that without democrats being willing to participate in the process and giving the strictures of the reconciliation process, that its not going to be possible for us to do as much as we would like to do. But we continue to talk and my hope is that we will continue to make progress with some sort of consensus on how best to proceed. In the meantime, we do have a bill that 51 republicans voted for in 2015 to repeal obamacare and leave two years available for a transition on a bipartisan basis. But i have to tell you, mr. President , heres my concern under obamacare there is massive amounts of money being paid to Insurance Companies for something called cost sharing in order to try to help to bring the premiums down, in order to try to bring the deductibles down to make them affordable, but its pretty clear its not working given the 105 increase in premiums since 2013 alone under obamacare. But right now we know the individual market, which is the Insurance Market where individuals and where Small Businesses buy their Health Insurance, its in meltdown mode, and thats after seven years of obamacare. Our friends across the aisle would like to convince you in the six months or to President Trump has been in office that he is the cause of that, its just not true. Its just not true. Now, many of us, me included, would love to see us stabilize the individual Insurance Market while we get some important reforms done to try to help bring premiums down in order to reassure people that were going to protect preexisting conditions and why we do some additional important work on medicaid reform. But id be lying if i said this was easy, but, frankly, people didnt send us here just to do easy stuff. They sent us here to do the hard stuff, and we need to continue to use our best efforts to keep our commitments and to deliver Something Better than the broken status quo of obamacare. My concern is if we are unsuccessful in doing that weve already seen, for example, our friend, the distinguished senator from New Hampshire propose some additional mandatory cost sharing for Insurance Companies. Now, according to the kaiser foundation, these are direct payments from taxpayers to Insurance Companies. So rather than working with us to try to make a course correction in obamacare and to put it on a sustainable path, our friends across the aisle want none of us none of that. What they want is the cash. They want the billions of dollars that go to Insurance Companies and want no reform. Well, i personally find that to be an unacceptable alternative. We do need to do something to protect people who are being hurt right now from the skyhigh premiums and the deductibles that render their Health Insurance unaffordable. And my concern is, to be absolutely candid with you, right now the president is authorizing, on a month to month basis, costsharing payments which are sustaining the market as it currently is, not well enough, but at least keeping some Insurance Companies available in most places, although not all. My concern is unless we pass Something Like the better care act, were left with an untenable alternative. The president s statement that he may just decide not to make the costsharing payments, which would provoke an immediate crisis in the marketplace which would force us to act. Now, i dont think thats inherently bad, but i want to make sure that we act in a constructive way and that were not throwing billions of dollars at a broken system but implement the right reforms to put it on the right path. I know here in Washington People tend to think of republicans and democrats and this is all about obama, this is about trump, this is about personalties. Its not. Its not even about politics. It shouldnt be ultimately. This should be about the people we represent in our states and the people we represent across the country and how can we do the best job given the difficult hand weve been given to try to help make things better . Now this is not going to be the end of the process. This is just another step along the journey toward making health care more affordable and more accessible. Theres a lot of great work that has been done. As the presiding officer knows, hes been at the forefront of trying to make sure that we address things like the Opioid Crisis which has been devastating communities across the country. I was here showing a chart yesterday that the presiding officer has seen, showing hiv deaths going way down, thanks to modern drugs, but car wrecks still in the 30,000range, but deaths as a result of overdoses up to 52,000 a year i think is a rough number. That is a Public Health crisis. We need for do everything we can to make sure were delivering services to people who need is the most who are suffering. But if all we do is bail out Insurance Companies, we will not have done our job, especially toward the communities hurt by the Opioid Crisis. So were going to continue to work. At some point were going to have to vote. And, yes, people are going to have to be put on record. Were all grownups. Most of us have held Political Office for a fair time now. We know how to explain our votes to the voters back home to whom we are accountable, but if you dont vote, then nobody is accountable. And everybody can blame each other for the outcome. But i really do worry that unless we redouble our efforts to come up with meaningful reforms of the broken obamacare system, that we will be left with an untenable choice, either an Insurance Company bailout of the same flawed structure of obamacare or an immediate crisis thats going to force us to act and do the bailout with any without any reforms. So the other thing i would want to point out in the closing minutes i want to speak is the process by which our democratic friends have dragged that irheels to the point of almost bringing their heels to the point of almost bringing this place to a halt, particularly when it comes to a new president getting votes on his nominees for cabinet positions and subcabinet positions. Theyre the first to criticize the president for not getting things done that he said he wants to get done, but when they sabotage his ability to try to populate these important positions in the cabinet and subcommittee positions by dragging their heels on nominations, they are causing a large part of the problem. To put this in perspective, in 2009, 90 of president obamas nominations happened by voice vote. Thats without a recorded vote. Thats without 30 hours expiring after closing off the debate. This was just essentially an agreement in 90 of the cases. But democrats in the senate under the Trump Administration have allowed only 10 of his nominees to be voice voted. We allowed 90 for president obama. We didnt agree with president obama on a lot of things. But we agreed he won the election. That he was entitled to populate his cabinet and subcabinet with people of his choice, assuming they werent disqualified for some other reason. Well, this week we weve considered Patrick Shanahan nominated to be defense secretary of the department of defense which is a roll vitally important to the department as it works through readiness, modernization, and of Course Service to our men and women in uniform providing them the tools and the equipment and the training they need in order to protect the country. But in order to accomplish that, the Defense Department needs a full team. We spend more than 600 billion a year on National Defense and yet the president cant get his full team put in place on a timely basis because of partisan foot dragging. Well, it serves another purpose, i suppose, because the more were tied up on legislation, excuse me, on nominations, the less time we have to deal with legislation. Well, these kind of tactics remind me of the former majority leader harry reid whose political schemes caused his party a 60vote filibusterproof majority. I know the distinguished senator from new york, my friend, the democratic leader, remembers that when members of his own party cant bring back home any record of accomplishment for what theyve done during their time here in washington, its pretty hard to make the case you should be reelected. And after harry reid blocked participation not just from the minority but also from the majority so that they couldnt go back home and demonstrate that they had fought and accomplished things for their constituents, their party suffered a very tough political price. So i would urge our colleagues to end this perpetual obstruction on nominations and legislations and everything else. Noncontroversial nominees should not require days to get confirmed or judges for that matter, require a 30hour postcloture vote in order to get confirmed by more than 90 votes. That indicates its not a controversial vote so why burn up the time except out of spite or desire to slow down this administration or this congress in terms of getting things done. The American People sorely want leaders at every level of our government. Theyre hungry for us to lead and to demonstrate we are listening to them and doing what we believe to be in their best interest. And they deserve a senate that fulfills one of their most fundamental responsibilities, our most fundamental responsibilities which is to consider and vote on president ial nominees. Mr. President , i yield the floor. Id note the absence of a quorum. The presiding officer the clerk will call the roll. Quorum call quorum call mr. Udall mr. President. The presiding officer the senator from new mexico. Mr. Udall mr. President , i would ask to vitiate the quorum call. The presiding officer without objection. Mr. Udall thank you, mr. President. Thank you for your recognition. Let me just say at the beginning, i want to thank you for the bipartisanship that we both worked together on the Indian Affairs committee, and very much appreciate that. And were down here with a few members. I rise today with my colleagues from the Senate Committee on Indian Affairs. I thank senator heitkamp and senator franken and maybe others will join us. I rise with them to remind the congress of its duties to tribes and to stand up for the health care of American Indians and alaska natives across Indian Country. Most of us are aware of the Health Disparities facing native communities. Weve seen the news about the failings of the Indian Health service, and many of us have heard directly from tribal leaders and native constituents about the barriers to Health Care Access on reservations, on pueblos and villages. But the members of the senate on the Indian Affairs committee are uniquely aware of the complex ways the Tribal Health care system works and how those systems will be catastrophically disrupted by trumpcare and the repeal of the Affordable Care act. The United States government has a trust responsibility to provide American Indians and alaska natives with comprehensive Quality Health care. The u. S. Constitution, treaties and longsettled Legal Precedents are the basis for this responsibility. The Indian Health service is the primary agency for fulfilling this obligation. But our trust responsibilities do not end there. The medicaid and medicare program, planned parenthood, and other Public Health services all play key roles in the delivery of native health care. And because i. H. S. Is so consistently and severely underfunded, the a. C. A. Has made a huge difference. Each fiscal year i. H. S. Receives a finite allocation of funding, discretionary funding that it must stretch to meet the Health Care Needs of 2. 2 million native americans. That leaves i. H. S. With just over 3,500 per person, less than onethird of the National Average for health care spending. As a result, without additional resources, i. H. S. Is forced to ration care, limiting native families to hospitals and clinics that can only provide life or limb emergency medical services. Basic Preventive Care like wellness visits and mammograms have frequently been unavailable to most i. H. S. Patients. Dont get sick after june, the unofficial motto given to the Indian Health service on many reservations, has tragically become the epitaph of too many tribal members whose cancer grew undetected, whose diabetes went untreated, and whose highrisk pregnancies went unnoticed. Seeing this catastrophic need for health care dollars, congress enacted a series of laws that supplement i. H. S. Resources. The Affordable Care act is the most recent and now the most significant. Nearly 287,000 American Indians and alaska natives from 492 tribes almost 90 have benefited from the a. C. A. s Medicaid Expansion. Another 30,000 individual native americans have private insurance, thanks to the a. C. A. s individual marketplace and the native costsharing subsidies. In my home state of new mexico alone, Medicaid Expansion has ensured an additional 45,600 native americans. Thanks to the Medicaid Expansion and increased access to the individual Insurance Market, 63 of i. H. S. Patients have Health Care Coverage that allows them to receive care above and beyond the level of life and limb. Because of a. C. A. , i. H. S. Now receives almost 1 billion to supplement its health care delivery, and that is an increase of 21 . We can see the results. Not only are people healthier, but they are more productive. Health insurance has allowed native americans to finish school, to return to work, and lead Productive Lives instead of worrying that their next illness could lead to an i. H. S. Referral denial or ruin them financially. And it has improved the economy in Indian Country. The a. C. A. Has created new Health Care Jobs and led to the construction of new medical facilities. It has also meant dialysis clinics on new mexico pueblos, new hospitals for the choctaw in mississippi and thousands of jobs for montanas black feet reservation. These are just a few examples of a nationwide trend. Trumpcare would undo this progress. It will undo the newly expanded access to care. It will shut down those new health care facilities. It will freeze the economic progress of those areas. These arent just numbers and statistics. Were talking about peoples lives. Individuals will be harmed by trumpcare and the evisceration of medicaid. Let me tell you about rachel, justin, and their two children. Adalie and jude. They are one native family whose lives have been changed for the better under the Affordable Care act and the Medicaid Expansion. Rachel and justin are from the pueblo lagoona in new mexico. Heres a photo of them right after jude was born in august 2015. And before the a. C. A. And the ask Medicaid Expansion, rachel received hitormiss care from the i. H. S. But when she enrolled at the university of new mexico, she was able to qualify for medicaid because of the expansion. This meant that when rachel and justin decided to start a family, rachel have access to preventive services, including prenatal and maternity care. Rachel was able to get care she needed when she became pregnant question adely. Her care became even more important when they decided to add to their family while rachel was at graduate school at u. N. M. That pritions pregnancy had serious complications. The doctors figured out rachel didnt have enough amniotic fluid to support jude and she had to have a csection. She was allowed to complete her College Education and get a masters in Public Education without worrying about health care for her and her children. Medicaid expansion meant rachel was able to get the Preventive Care she needed to make sure she and jude were healthy. Rachel recently got a job offer to work in her chosen field. But now that shes able to come off medicaid, shes worried that the Republican Health care proposals will make Insurance Coverage ineffective or unaffordable. Even though she lives near her tribes i. H. S. Facility in the albuquerque yeah, albuquerque yeah, she cant defend on i. H. S. To depend on Critical Care if insurance premiums become unaffordable. Once again rachel is worried about the future of her familys health care. Rachel is one of the thousands of native americans whose lives have been dramatically helped by the Affordable Care act and who is scared that trumpcare will leave them unable to get the health care their families need in the future. If this bill becomes law, tribal communities will be forced back to a system of health care rationing. If the president and the Republican Leadership eviscerate the Medicaid Program and federal support for Public Health programs, native american lives will be lost, no doubt about it. Let me say this plain and simple, trumpcare would devastate Indian Country and must be stopped. Just this morning, as vice chair of the Indian Affairs committee, i held a round table with tribal leaders and native Health Experts to hear more about how Republican Health care proposals would impact tribes. And i want to thank the leaders who came in to talk with me and my colleagues on the committee, on the committee. Senator franken was there. Senator heitkamp was there. Senator tester, senator cantwell; all came to hear these native leaders. Their insight into the damage this bill could do to native communities was profound. The Turtle Mountain chairman from north dakota reported that dont get sick after june is no longer true on his reservation because of the a. C. A. And Medicaid Expansion. Panelists warned that the rollback of medicaid would be devastating to tribal members. And a representative from san phillipe pueblo reminded us that Indian Health is not an entitlement. Its an obligation. But now the republican leader and the president are moving in an even more dangerous direction. Theyre pushing to repeal the a. C. A. With no replacement, which would strip health care from over 30 million americans. It would devastate anyone who is sick today, anyone who relies on insurance, they get through the Medicaid Expansion or the Affordable Care act. And it sets up a disaster for anyone who might get sick after repeal because it would destabilize Insurance Markets and would throw our economy into turmoil, killing up to 50,000 jobs in new mexico alone. And as often happens with policies that hurt the most vulnerable, Indian Country would be hit the hardest. Traditionally the senate has worked on a bipartisan basis to address native american issues. That tradition must continue now. We must Work Together to find a sustainable solution so native americans can get affordable Quality Health care when they need it. Mr. President , i will end by asking that a copy of all the tribal letters on trumpcare shared with the Indian Affairs Committee Office be entered into the record. The presiding officer without objection. Mr. Udall thank you, mr. President. While this small effort cannot fully replace the necessary governmenttogovernment consultation we owe tribes on this issue, i hope it reminds us of our federal obligations to tribes and to all native americans. Trumpcare would turn back the clock. It would violate our trust responsibilities. It would endanger the lives of native families. We cannot let that happen. Mr. President , i would now yield the floor. I yield the floor to my colleague and friend from the great state of minnesota, senator franken. Senator franken has been such an advocate on the Indian Affairs committee for tribes from his state and across the nation. All of us have worked extensively to try to improve a situation that many times we hear from tribal members is despairing. And i just really, really appreciate his effort. And thank you for coming to the floor today and participating in this discussion about Indian Health care and what these Medicaid Expansions mean. I yield to senator franken. The presiding officer the senator from minnesota. Mr. Franken thank you, mr. President. I want to thank my vice chairman of the Indian Affairs committee and thank the presiding officer who chairs that committee. Im honored to serve under both of you. Im speaking today to discuss the devastating effects that various Republican Health care proposals that have been made would have on Indian Country. Republicans are now considering a straight repeal of the Affordable Care act with no replacement. This policy, like others that have come before it, would have a devastating effect on native communities. Today i want to describe some of the Health Care Challenges that these communities face, and how the Affordable Care act helped address some of those challenges and how repealing the Affordable Care act would undermine these gains and further jeopardize health care for an already vulnerable population. Ive served on the Indian Affairs committee for the past eight years, and i am continually shocked by what i hear almost every week from tribal leaders and other witnesses about the challenges facing native communities. One of the Biggest Challenges is that the federal government consistently falls short of its responsibilities to indian communities. There is a lack of attention to the concerns of native communities. There is a dysfunctional bureaucracy and a congress that doesnt adequately fund indian programs. And this can create a vicious cycle. When programs dont have adequate funding, they dont work as they should, and some of my colleagues who failed to provide Indian Country with the funds they need have said this is a justification for continuing to cut and underfund critical programs. This that just doesnt make sense to me. Health care has fallen prey to this this vicious cycle even though the federal government has a trust responsibility to provide health care to tribes and to their members. Medicaid and the Indian Health service are both part of this trust responsibility. Now, over the year Indian Health services has suffered from lack of resources, poor staffing, and other challenges. The vice chairman was right, dont get sick after june because, unfortunately, something that is you hear over and over again, said with some irony and but also hurt on Indian Country because the funding really runs out then. And these challenges means that many in Indian Country, particularly those living in remote areas, dont have reliable access to the medical care they need on a timely basis and this is health care that has been promised by treaty and by our constitution. Prior to the a. C. A. , funding shortages meant that i. H. S. Was only able to provide people with the most basic services, and so a lot of the care the people needed was not available. For example, prior to the passage of the Affordable Care act, the Indian Health service could not afford to provide vital services, including Womens Health screenings like mammograms or basic diabetes care. If you suffered from diabetes, you often had to wait until dialysis was required or limb amputation was needed before being able to receive care. That is just unconscionable. S that terrible. That is terrible. Indians and alaskan natives were more unlikely to be insured. Those who were not covered by the i. H. S. Simply went without. The a. C. A. Helped to change all of this for the better. First, the a. C. A. Gave states the option to expand their Medicaid Programs to include lowincome adults without dependent children. Thanks to Medicaid Expansion, 11 million americans, including more than 290,000 American Indians and alaskan natives were able to get Health Insurance. The a. C. A. s Medicaid Expansion made it possible for an estimated 60 of uninsured American Indians and alaska natives to qualify for Health Care Coverage. This expansion, coupled with other medicaid policy reforms, such as those that simplify the enrollment process, helped increase the total number of people covered under the program. In fact, i. H. S. Reported earlier this year that 42 of patients received services of those who received services did so because they had coverage through medicaid. Thats what the Indian Health services said, 42 of those who received Health Care Services did so because they are covered by medicaid. In grand portage, located in its a beautiful, beautiful spot on the northeastern corner of minnesota. This meant that well over 20 more 20 more band members, many of them children, received coverage. We know from a recent report from georgetown university, that nationwide, 54 of American Indian and alaska native were enrolled in medicaid. This program has been a vital source of coverage, and with Health Insurance coverage people have finally been able to access the health care they need. Thats what health care is really about. Health care is about having coverage and so that you have the routine visits for primary care. So if you are diabetic, you have routine visits. Its not about the emergency heroic event. Health care is about the constance is about the constant care. Thats what improves peoples health. Thats what improves their lives. Another way the a. C. A. Helped improve health care for native populations was by transitioning the i. H. S. To be the payer of last resort. By establishing medicare and medicaid would be the primary payers, the a. C. A. Ensured that there was more money going to provide a wider range of services that people needed whiebl simultaneously while simultaneously reducing the financial burden on the i. H. S. Yet, there is more that we need to do to strengthen the Affordable Care act and improve rates of coverage and something s. And access within native communities. For example, we need to do more to address the shortages and lack of Insurance Markets in rural areas. The presiding officer knows that. It is imperative that we tackle the Opioid Epidemic in indian coverage. The recent efforts to repeal the Affordable Care act would do nothing to address these needs and would undermined the recent Health Coverage gains that tribal communities have been able to achieve. I know the last bill had money targeted at opioid treatment, but it wasnt anywhere near what would be taken away when Medicaid Expansion and cuts to medicaid are figured in. The republicans proposals would hurt indian communities in a number of important ways. First, they would cause tens of millions of people, including many American Indians and alaska natives, to lose coverage, with 15 million and 18 million americans losing coverage immediately. For example, republican coverage would end the Medicaid Expansion, as i said, which has been essential to providing Health Care Coverage to millions in the indian community. It would jeopardize the stability of the individual market while giving huge tax breaks to powerful corporate interest. Finally, they would increase premiums and reduce subsidies that lowincome people receive to help pay for health care. , which would put health care, which would put private Health Care Coverage out of reach for so many. Efforts to repeal the Affordable Care act are just bad for native communities and bad for the country as a whole. As many of you know well, American Indians and alaska natives are twice as likely, as compared to nonhispanic whites, to be overweight and diagnosed with diabetes and experience depression. In minnesota American Indian women are also more likely than whites to be to have opioid dependency snd more and more children are likely to have opioid dependency. Driving up medicaid costs is the last thing these communities need. Indian tribes in minnesota and north dakota, and in all of our states, are grappling with challenging and complex Health Care Needs. They need our help. They dont need legislation that is hastily put together for ideological reasons. They dont need policies that undercut their care and livelihood. I believe that we need to Work Together across partisan lines. I really hope that thats what were going to do. The Republican Health care plans that have been put forward so far, break the federal governments trus responsibility and trust responsibility and undermined the programs helping indian communities. This is what i sincerely believe. I ask that republicans work with us on a bipartisan basis in regular order with reargs before our with hearings before our committees. The strength and care options for our native communities and for all americans. I believe we can do that and i believe we can Work Together. And its just the right thing to do. Thank you, mr. President , and i would throw it back to the senator from the vice chairman of the Indian Affairs committee and the senator from new mexico. Mr. Udall thank you. Mr. President. The presiding officer the senator from new mexico. Mr. Udall mr. President , we have been joined by senator heitkamp of north dakota. I really appreciate her work on the subcommittee just incredibly hard work and hard dedication that she has put in. She has been a champion for her tribes in north dakota, a champion for native women and native children and a champion for native americans across the country. I yield to senator height hamp. The presiding officer the senator to senator heitkamp. The presiding officer the senator from north dakota. Ms. Heitkamp i think anyone who picked up the wall street journal and read the stories on Indian Health and especially in our region of the world and in the great plains, it shocked the conscience. It should have resulted in a prolonged level of outrage that would bring us all together. Unfortunately, we have seen this moving one too many times. Things happen where we see National Stories about challenges in Indian Country, about failure to fulfill commitments under tree rights, we see despair, we see the incredible rates of poverty, the incredible rates of unemployment. Even in a state like ours where unemployment rates are never the issue. We wonder, why isnt something being done . Guess who wasnt shocked . Those of us who serve on Indian Affairs who spent a lot of time looking at this last year and trying to find how we could have the committee be more responsible and how to look at resources and dollars to make sure that Indian Health was supplemented and that level of care that we expect when we walk into our hospitals, that thats ale level of care that native American People who go to Indian Health services on their reservations and also who who might go to an indianrun tribalrun facility might expect. I think thats what the American Public might think is actually going on, but those of us on the committee know differently. We held a roundtable today to talk about what those challenges are, what native american leaders believed were those challenges and to ask, what has Medicaid Expansion meant to your tribes . What has access to medicaid and medicare meant for delivery of Health Care Services . I wanted to start out by saying they had a lot of really great ideas. I want to run through some of these. Chairman keplan said we need local doctors. Its hard to get people to live on the reservation if they are not from the s. Res. Radification. We node from the reservation. We need to look at how we can get folks to be trained. We ned to build relationships with other Health Care Providers like sanford who can bring specialists. We need our Cancer Infusion Center to be there so people can get Cancer Treatment right at home. We need to make sure that were doing everything that we can to make sure that we can treat diabetes right there at home. So the Health Care Challenges were amazing, but the cost challenges were also amazing. Dewayne from a pueblo in new mexico, he had some really interesting perspectives. 80 of his patient load come to the clinic. They speak their native language, and they have had stability in their workforce but theyre looking at transitioning to a tribal facility. But those people dont want to transition because of federal retirement. And so is there something we can do to keep these treasured Health Care Providers working for the tribe and working for their people, the people who know the language, who are familiar with the case study . Lincoln from alaska said you know what one of our biggest problems is yeartoyear funding. V. A. Has twoyear funding. We dont know what the money is going to be and when its going to come. We also need to train local people. Sam said we have a huge need to continue to build out our Cultural Resources and our attention to culture and prevention. Washington washington, ron talked a lot about recruitment of workforce. The employer mandate came up because so many of the so much of the employment on the reservations is in fact tribal members, and theyre talking about theyre mandated to buy this Health Insurance but yet these same members have a treaty right to that health care. Is there a way to help those very, you know, those stretched tribal resources go a little further by taking a look at some leave from the employer mandate . Definition of what constitutes an indian came up over and over again. Massachusetts, cheryl talked about permanent reauthorization of Indian Health care. More and more resources in diabetes, because that is a pervasive problem. Indian employment, again talking about that issue of buying Health Insurance. Marketplace access for native american enrollees who are not living on the reservation. How do they make sure that theyre able to get their treaty rights . Talked about mental wellbeing. Talking about culture is prevention. One of my favorite lines that came out of this, ashley said when we asked about prevention, she said culture is prevention. We need better access to 1115 waivers. And take a look at the canadian model, she suggested, that they do more with culturally sensitive and the list goes on and on and on of great ideas. And i will tell you, not one of these ideas, mr. President , not one of these ideas said repeal the the Affordable Care act. Not one of them said lets get rid of Medicaid Expansion. Lets not look at what we can do. I inadvertently and i want to make sure my intern is on the floor and im going to interrupt myself and ask that miles odeman, intern in my office, be granted floor privileges for the duration of todays session of the senate. The presiding officer without objection. Ms. Heitkamp okay. Lets just all acknowledge what we know who serve on this committee, that we have challenges that far exceed many other populations. And weve come to the floor to talk about how the repeal of the republican or the Affordable Care act, how the Republican Health care bill would hurt different populations. Weve talked about the elderly. Weve talked about children with disabilities. Weve talked about rural communities. Weve talked about many, many more folks. I think we havent done enough to talk about what this means for indian people. And we have a special relationship with indian people in my state because every tribe in my state is in fact a treaty tribe with a treaty right to health care. Last year or last night it obviously became clear that the bill as it stands wouldnt get enough votes to move forward. But we need to keep talking about this bill, and we need to keep talking about what the questions are. And we need to start, instead of talking about this bill or that bill or, you know, all the acronyms, lets start with health care. Lets have a conversation about health care that starts with health care. Where are we doing it right . Where are we doing it wrong . How can we reduce costs . And whos getting left behind . And its clear to me that in the Health Care World never mind any of the Affordable Care act or the Better Health care whatever the republican bill was called. Thats a discussion for politics. Thats not a discussion for health care. And so lets talk about what native americans need. And lets talk about how we have failed. As i said earlier today, senator udall led a really important discussion about how we need to preserve medicaid. I think that when you look at Indian Health service, i think anyone who really looks at the numbers has to admit that it is chronically underfunded. Last year i brought the former i. H. S. Director to north dakota to press her on maintaining quality care in our tribal communities. This was especially important because of the severe challenges that Indian Health care has, and the lack of funding for Indian Health care we know can be critically augmented by three main sources medicaid, medicare, and private insurance. And if every person walking in has the ability to pay, were going to improve access to care. Were going to improve an opportunity to recruit a workforce. And i can tell you, i think some people may roll their eyes when they say dont get sick in june. My husband who is a family physician and practices about 60 miles north of Standing Rock sioux nation, he can tell you there have been times when people from the reservation have come to the clinic to see him because the clinic in fort yates is shuttered. No money that day. No opportunity for health care. And so people come to get the health care they need, but they have to drive a long way. And its wrong. And so you see a new doctor that youve never seen before who may not in fact understand your conditions. So the mountain band of chippewa who is represented today has over 33,000 enrolled members of which approximately 14,500 actively receive treatment and benefit for services at the local i. H. S. Hospital. Thanks to Medicaid Expansion and increased enrollment efforts by the Turtle Mountain band of chippewa in my state of north dakota their Indian Health hospital is able to offer so much more in services to their people and increase their outreach and prevention. In june alone, Turtle Mountains i. H. S. Clinic served nearly 13,000. Think about that. 13,000 clinical patients, and provided over 1,000 emergency room services. Thirdparty billing revenue has always allowed the tribes to make renovations, has now allowed the tribes to make renovations to their emergency room and their clinic, purchase new medical equipment including neonatal monitors, recruit and hire additional staff including licensed professionals, increase staff training and education, provide wifi throughout the hospital, and expand their Behavior Health care facility to serve more patients. Since the Medicaid Expansion, they have had a 9 increase in the number of individuals theyve served. Their hospital is also experiencing a decrease in the number of uninsured patients. Still too high, in my opinion; still at 39 . We can get that even lower if we get more people to take advantage of Medicaid Expansion. But unfortunately, a Republican Health care plan which would eliminate costsharing subsidies is making that private Health Insurance less affordable and less accessible. So lets be honest about how we are affecting our native American Population and talk about the multiple times that this expansion has been so important to our native families. In north dakota, the republican bill would cause an estimated 984 native americans to lose costsharing reduction subsidies. The senate Republican Health care bill would also get rid of the Medicaid Expansion and cap the amount of federal funding states can get to cover those on traditional medicaid. As a result, it would drastically reduce the amount of medicaid funding going to the states. This would push the remaining costs to the states and counties that can afford it. The American Hospital Association Estimates that north dakota medicaid would lose 1. 2 billion let me say that again. North dakota medicaid would lose 1. 2 billion through 2026. Right now 9,000 rely on medicaid for affordable quality care, but this bill would rip it away in so many wrong ways. The uninsured rate for native americans has fallen nationally from 24 to 15 . Largely due to Medicaid Expansion. And so we go on and on. Currently medicaid accounts for 24 of the Indian Health workforce. Senate republican bill would strip away 772 billion from medicaid and the white house proposes an already underfunded Indian Health Service Budget by 6 . We already know that the perpatient cost in the Indian Health care system is greatly below that medicaid reimbursement cost on average. So if we take away medicaid reimbursement, were hurting not only the providers but we are once again making Health Care Less affordable. This is a crisis. I cant begin to tell the members of this body what a crisis Indian Health care is in. Weve known it on the committee for many, many years. In fact, senator dorgan was the first one to really sound the alarm of the crisis in the great plains area, thinking that a report which was so damaging would result in change. Guess what . It didnt. It didnt result in change. But the one thing that we can point to that is a bright, shiny light has been access to medicaid dollars. It has given them access to capital expenditure. It has given them access to workforce. Its given a more consistent way for people who dont live on the reservations to get health care. And ive said this many, many times. We need to we need to not go backward. We need to go forward. And when people say were going to take a step back. Were going to get rid were going to reduce actual appropriations by 6 for Indian Health, and were going to eliminate Medicaid Expansion, i said you better look before you take a step backward because you might be off the cliff. Thats how dire it is in Indian Country. So the one thing im going to conclude with is that for many, many years in health care, we have not done what we need to do to consult with tribal people. Heres the facility. This is what were going to provide. Good luck. One size fits all. What we need to do and what medicaid has allowed is that flexibility for tribes to engage, for tribal people to engage in what their needs are, to take a look at those Community Health models that do dental and eye care and Mental Health and addiction counseling. All of this needs to be wrapped up. And when people say there is no hope, there certainly is no hope without health. You know, the old saying of when you have your health, you have everything, i can tell you from personal experience that is absolutely true. That without your health, you know, you could be the richest man in the world, but if you dont have good health, your quality of life is not what it could be. And when we look across the indicators of whats happened in Indian Health with Indigenous People throughout our country, when we know this is our obligation, this is a treaty obligation, a treaty right thats been bargained for, shame on us. So medicaid can be that bridge. It can be the bridge to better quality care. And thats why its so critical, mr. President , and to my vice chairman, that we be out here speaking for our communities, speaking for these unique group of folks who depend so much on Medicaid Expansion. But also depend on us to do a better job, to be better stewards of that relationship, to be better citizens as it relates to living up to the obligations that our ancestors negotiated. And so with that, i would ask that everybody who hasnt really been exposed to this issue, read the articles in the wall street journal. But dont just read them and wring your hands and say this is horrible. Take a step to change the outcome. Dont just read them and say, boy, thats horrible. Take responsibility for what you read. Because every one of us in the United States senate and in the congress, we are all responsible for fulfilling the obligation of these treaties. And when we arent doing it, it is a failure on every one of us. It is a failure of some of the most vulnerable to protect some of the most Vulnerable People in our country. And thats native american children. So with that, mr. President , i yield the floor and turn it back to my vice chairman, senator udall. Mr. Udall mr. President. The presiding officer the senator from new mexico. Mr. Udall let me just and i know senator durbin is here on the floor, and so im going to wrap up very quickly. I first just want to thank senator franken who came down here and advocated for his state and for native americans across the country. I thank senator heitkamp for her passionate speech here about native americans and children. I have known her since she was a state attorney general and was doing the same thing and has made real progress. You can see from the roundtable, and i appreciate, senator heitkamp, to help me chair that. I had to ship out to foreign relations, but you spent a significant amount of time chairing that roundtable and i think it made a difference to all of the tribal leaders there. I want to finish with what one of the tribal leaders said. This tribal leader reminded us he said decades ago he said that tribes made a downpayment on the health care they receive. He said, were not asking for a handout. We made a downpayment. What was he talking about . He said, we made a downpayment with our land, water, and with large areas with what were then territories or the United States that they considered their homeland. How sad it is to see that we are not fulfilling the promises of these sacred treaties that they entered into. With that, i would just conclude, as senator franken did, and follow up on what senator heitkamp was saying, we hit a wall with health care. We came up to a point where we dont know what to do. The best thing to do is to go back to regular order, go into committee, let people put proposals forward, have amendments, open up the process. S that where we need to go at this point. I would urge the Republican Leadership to take a look at the regular order. That may help us find our way out to improve the Health Care Situation for not only native americans, but for all americans, which is what we face with this trumpcare which is taking us in the wrong direction. With that, i will yield the floor. Mr. Durbin mr. President. The presiding officer the senator from illinois. Mr. Durbin let me thank my colleagues for coming to the floor and speaking on behalf of native americans andean Health Service and Indian Health service and the challenges. I do have an indian reservation in my state but have visited indian reservations in other states. We have a moral responsibility to those who have not been treated well. When it comes to the challenges they face it is as bad as any group we have met in america. We need to start with Indian Health service and Health Services. I thank my colleagues for raising that issue. This is a historic week in the senate. We have been engaged in debates for weeks about what to do with health care in america. The senate, of course, is under the majority control of the republicans, as is the house of representatives, and, of course, with a republican president. They came to washington at the beginning of this year and said we want to repeal obamacare. We said it for six years. Were finally going to do it. Were going to get rid of obamacare wawnsd for all. Once and for all. President trump said, do everything you can to discourage obamacare, and he turned around and did just that. His agencies stopped advertising for people to sign up for obamacare. They were term to put an end to it. In the house of representatives they took a step beyond that. They introduced legislation to repeal it and replace it, but what they replaced it with was a disaster. The Congressional Budget Office took a look at the republican repeal plan in the house and said it will cost america 24 24 Million People will lose their Health Insurance. Beyond that, they talked about the changes that would take place with the Health Insurance policies with the republican repeal plan. It passed the house by four votes, which meant that if two republican members and oant republicans and only republicans voted for it if two republicans voted for it, it wouldnt pass. They sent it to others to find out what they would do. They spent many weeks with suggestions. 13 members said in private sat in private rooms and talked about what they would do to replace obamacare. And finally they reported a bill. It turns out that their bill was an improvement over the house bill. The house bill eliminated Health Insurance for 24 million americans. The senate bill eliminated Health Insurance for 23 million americans. But still when you look at it is a horrible thing. In my state of illinois, a Million People in my state would have lost Health Insurance with either the house or Senate Republican bills, and its the reason why theres been resistance in my state to this republican effort from the start. You would expect that on a political basis sure the democrats will oppose republicans on issues, but this went beyond it. There wasnt a single medical Advocacy Group in the United States that supported what the republicans were doing. Not one of the Hospital Association across america, the medical society of doctors, the nurses, the pediatricians, they all opposed what the republicans set out to do. And so when it looked like there were problems in passing one version of the Senate Republican repeal bill, they sat down to retwrie. And as they sat down to rewrite it, they got into deeper water and bigger problems. Senator cruz, the junior senator from texas said, well, one way to bring down the cost of Health Insurance is to take out some of the protections of a Health Insurance policy. We can get premiums down pretty low if we take away the protections of a Health Insurance policy that were in the Affordable Care act. That was his proposal. This weekend, Bluecross Blueshield and the major Health Insurance industry said this will be a disaster. If you have some people buying real insurance and real protection and others paying rockbottom premiums for little or no coverage, you are going to create two classes of americans and you are going to see premiums going through the roof for those who are buying fullcoverage policies. They. Came out against the cruz proposal. Well, this week we returned to face the votes. We were supposed to be voting today a vote on whether or not to repeal obamacare. As of last night things started changing here. Two republican are senators joined two others and said they were opposing the effort and so the republican majority did not have the votes they needed to go forward. They said at least we will vote on repealing obamacare. Three republican senators have announced, as of today, that voting for simple repeal is something they wont do. Many of them make the argument that just repealing obamacare without replacing it is irresponsible. They are right. If you dont like the Current System, i believe youre duty bound as a senator or congressman to come up with a better idea, something that serves america better. They havent been able to reach that point. So where are we . At this moment we are at a stand still. The republican efforts to repeal and replace have stopped as of this moment. There may be a vote an official vote this week. I dont know. S that up to senator mcconnell thats up to senator mcconnell as the republican leader. There appears no plan coming from the republican side to replace the Affordable Care act. I am proud to have voted for it. I voted for it for simple reasons. When it comes to Health Insurance, i believes that one of the basics in life. Im one of those politician also that believes health care is a right, just like police an fire protection. It should be part of and fire protection. It should be part of who we are in america. I dont believe its a question of how rich you are or how lucky you are as to whether you have Health Insurance in this country. We can do better as a nation and the Affordable Care act set out to do that. We reduced the number of uninsured americans with obamacare when we passed it six years ago by 50 . We reduced by half the uninsured People Living in my state of illinois. Many of them went to the insurance exchanges, bout private Health Insurance. If they had lower incomes, they got subsidies to help pay the premiums. Others picked up medicaid coverage as their Health Insurance. It was significant. I ran into people all across my state from chicago to down state who never had nish one day in their lives had Health Insurance one day in their lives. These were not lazy people. They were working people. They didnt have Health Insurance from from their employer. Ray momanoski is a musician, he said i didnt have Health Insurance. Nobody was going to prie that for me. But i have it now. I have diabetes and i have Health Insurance through medicaid. Almost an identical story in southern illinois. Betty who works in a local hotel and greets you with a smile when you come in for a free breakfast. She is 62 and never had Health Insurance one day in her life. She holds town two and three jobs holds down two and three jobs at a time. The now she has medicaid. What will happen to those under medicaid coverage with the proposals suggested where medicaid is cut back dramatically . Those two people, ray, judy, will have to face health challenges. They will still get sick and go to the hospital, but they dont have Health Insurance. Will the hospital treat them . Yes. What will happen to those bills . Their costs will be passed on to everyone else. S that the way it used to be done. What we learned this week in washington and this National Health care debate, is there is, of course, concerns about whether the current Health Care System is what it should be. And i think it could be improved. But weve learned one basic thing, were not going back. Were not going back to the days when the Health Insurance companies could deny coverage to you or your family because of a preexisting condition. Were not going back to the days when they would put a limit on how much they would pay on your Health Insurance plan. Remember when you first realized that a 100,000 limit wasnt worth that much if you had a serious diagnosis or serious accident . Were not going back to the days when that Health Insurance plan literally expired in coverage, forcing you and your family into bankruptcy over medical bills. Were not going back to the day when families couldnt cover their kids coming out of college. The Affordable Care act said you can keep your child on your Health Insurance plan as a family until they reach the age of 26. Those of us who have had kids who graduated from college, realize they dont always get a great job right off the bat. Some of them start as interns or partpiem workers parttime workers, some of them dont have Health Insurance. Now they have the peace of mind of the family Health Insurance plan. We want to make sure we protect that. Were not going back to the day when those young people had no coverage at a critical moment in their lives. Were not going back to the day when we allowed Insurance Companies to charge whatever premiums they wished. We put limits in the law that limits the premium to be charged on americans, to limit the profits that could be taken out of Health Insurance companies. Those were moves that had to be made to protect innocent American Families who, unfortunately, are struggling with medical bills before this law passed and now at least have some chance of paying for them. So what we learned in the course of this National Debate is significant. We learned that if you put up a proposal, as republicans did in the house and the senate, that takes Health Insurance away from over 20 million americans, youve got a problem. People are going to push back and say that isnt fair to take away Health Insurance and the protection and peace of mind that comes with it. If you come up with a plan that ends up dramatically cutting medicaid, you will get a lot0 of people who are concerned about it a lot of people who are concerned about it. The Medicaid Program, as we know it across america, does many significant things. One half of the babies born in my state of illinois are covered by medicaid. Mom and the prenatal care and delivery of the baby and taking care of the baby afterwards is covered by medicaid. If you take away medicaid you endanger the treatment so you can have a healthy baby. The second thing we know is that medicaid is critical for people with disabilities. I met a mother in champagne, illinois, and she told me she has a 23yearold autistic son. It has been a struggle for her and her family but now he has a somewhat independent life. She said, senator, you take away medicaid insurance from him, ive got to put him in some Institutional Program that i cannot afford. Theres nowhere to turn. I also want to remind people that medicaid pays School Districts to take care of kids with special education needs, transportation, counselors, even feeding tubes for the severely disabled. Thats what an important part of medicaid. But i havent touched on the most expensive part of the Medicaid Program in america. The most expensive part is for those who are in nursing homes, those who are Older Americans and need medicaid to get by. They have Social Security, they have medicare, but they need medicaid. If you cut back on medicaid, as proposed by the republicans in both the house and the senate, who takes care of these elderly folks who are in a situation where they have exhausted their savings . Do they move back in with their family . Sometimes thats not even possible but thats one of the prospects faced. So what we need to do is to accept the objection. We have reached an important political milestone here where the republicans dont have the vote to move forward, but we still have the challenge of the Current System. I was proud to vote for it but it is far from perfect. The current Health Care System in america, the Affordable Care act, needs help, needs changes. We need to do it. We ought to surprise the heck out of america by working together both Political Parties to solve the problems. And lets identify a few of the most obvious problems. Number one, the Affordable Care act in America Today does not address the cost of prescription drugs. You ask a Health Insurance company whats driving the cost of premiums. Prescription drugs. Did you ever notice when you turn on the television certain times of the day, its all about drugs . Its all about new drugs . Things that you could hardly pronounce. These new drugs are being advertised on Television Time and again and then a two or threeminute disclaimer, be careful if you take this drug you might die. Be sure and tell your doctor if youve ever had a liver transplant. I listened to all a these warnings and im thinking this is being sold in advertising for the general population. Did you know that there are only three countries in the world that allow Television Advertising of prescription drugs . The United States, new zealand and brazil. Why do the pharmaceutical companies advertise drugs on televisions . Certainly if you want to inform a doctor about a new drug, you wouldnt buy a television ad, would you . The reason theyre on television is so that we as individual consumers and patients will walk into that Doctors Office and say, doctor, it took me five times but i finally figured out how to spell diso zorelto and is my blood thinner. The doctor has a choice. They may explain to you you may not need zorelto or this is not the one that fits your needs in the circumstance. Doctors dont do that. Many just write out the prescription. Thats why the Television Advertising is taking place to convince the consumer who asks the doctor who ends up with the highpriced drug being scripted for them. Thats the reality of why the costs of health care keep going up. What does the Affordable Care act do about that . Nothing, nothing when it comes to the cost of prescription drugs. I want these Drug Companies to make a profit. Dont get me wrong. If their profitable, looking for new cures, thats the way it should be. But when they charge through the roof and double and triple the cost of these pharmaceutical drugs, thats not fair. Its not fair to consumers and its not fair to taxpayers. Think about the fax that many of the same drugs, exactly the same drugs made in the United States are sold for a fraction of what we charge in the United States for other countries. Even in canada they charge about a half to a third for many of the popular drugs because the canadian government said to the Drug Companies in america, were drawing the line. Were not going to let you charge anything you want to charge. Why dont we do something in america to protect consumers . Why dont we at least inform people when pharmaceutical companies are overwharnlging so we can overcharging so we can put some pressure on them to stop. Thats the part of the Affordable Care act that will save us money and at the same time deal with an issue that most americans are concerned about. We also should be concerned about the fact that when it comes to the individual Health Insurance market, thats where most of the problems are. 6 of the American Population, buying Health Insurance through the exchanges, half of them have to pay the full premium and some of those premiums go through the roof. Why . Because the people who are buying this insurance are usually people with a history of a medical history or theyre older folks and they want to have the peace of mind of coverage. The healthy, younger folks arent buying. As a result, the Insurance Risk pool gets pretty expensive when it comes to premiums. We need to fix that and we can fix that. Thats another thing. We should come together as democrats and republicans to try and achieve. For those who say well, i promised my entire political career and i couldnt way for the day to come forward and repeal obamacare, i just want to tell them they should be aware that when the Congressional Budget Office looked at the impact of just repealing the Affordable Care act and not replacing it, they said the following this would force more Insurance Companies to leave the market immediately. It would increase premiums by 20 a year and double the price of premiums over ten years and it would take Health Insurance away from 32 Million People. So taking that vote just to repeal the Affordable Care act may earn you a chair at some political rally, but its not responsible. Its not good. It raidses the raises the cost f hill of Health Insurance for families across the country if we just repeal ndz dont replace and it takes Health Insurance away from over 30 Million People according to the Congressional Budget Office. Better that we replace with something responsible, better that we take the Current System and make it stronger. This has been an interesting debate. Ive learned a lot in the course of this debate because i went and visited the hospitals of illinois. The illinois Hospital Association opposed the republican plan in the house, opposed the proposal in the senate. They said it would cost us 60,000 to 80,000 jobs in illinois and it could close down some hospitals we need in rural parts of our state, small town hospitals that are critically important. I dont want to see that happen. The people who live there dont want to see it happen, and you cant keep and attract good employers and good jobs if it does happen. And so ive worked with these hospital administrators and want to move forward with them with an alternative. I will close by saying this. Its interesting how many people say i cant wait until i reach age 65 because ill qualify for medicare. Medicare doesnt discriminate based on preexisting conditions and provides good Health Insurance for americans, millions of americans. Its an illustration and a lesson for us that if you have something that isnt driven by the profit motive, that people trust, that has provided basic good care for americans, good hospitals, and good doctors, thats what people are looking for and why shouldnt they . That should be part of the american dream. It should be part of our right as americans. Mr. President , i yield the floor. I suggest the absence of a quorum. The presiding officer the clerk will call the roll. Quorum call quorum call quorum call quorum call quorum call quorum call the presiding officer without objection. Mr. Enzi thank you. I just in our job we get a lot of books, probably two or three a week at least. And for the last year, most of those have been on health care and Health Care Reform. And a book that i received lately was one called demystifying obamacare by david g. Brown, who is a doctor. It was helpful enough to me that i thought id share part of it with anybody listening. It always fascinates me when were here talking, and maybe somebodys listening. On page 70, it starts out by talking about how does obamacare look after seven years . Incidentally, this one is all well documented and footnoted, which is one of the unusual things about this book. Its not just speculation on his part. Its a lot of research that hes done and shared. He says, obamacare actually reduces Insurance Market competition by strict rules, regulations, and mandates. Obamacare significantly increases the Health Care Cost by the way it attempts to assist those who cannot afford coverage. Obamacare does not tackle the underlying causes of increased costs. Instead it worsens the factors that drive up the cost of health care with addition of mandates, regulations and taxes. Obamacare does nothing to decrease the factors that increase costs. Obamacare has increased the total of health care spending. The cost is not 938 billion. But now is 2. 6 trillion over ten years, or almost three times the original figure. Obamacare increases costs for families, businesses, and individuals for their health care. This includes not simply Obamacare Exchanges, but Health Insurance across the board. Associated with this, there has been a marked increase in health care premiums, costs for medications, deductibles, and copays. There has been reduction of access to care in obamacare plans. I. E. , Obamacare Exchanges, so insurance does not equal access. Obamacare to some extent has reduced the number of uninsured but not handled the problem of uninsured populations. Obamacare does not effectively address the problems of a safety net system, putting new people into medicaid has exasperated the problems for medicaid and removes its originally safety net function. Obamacare has reduced funding and thus care for programs for the elderly under medicare. Obamacare has taken the decisionmaking process out of the hands of patients and their families. It has done so by removing their freedom to make these decisions. This is from the book demystifying obamacare by david brown, who is a doctor. It goes on later to say, the individual mandate was instituted as a way to force patients into having Health Insurance or else pay a financial penalty for not having it. The employer mandate which was just instituted in 2016 after several delays was intended to move those with employerbased insurance into the government sector. Additionally, the health and Human Services required all individual and small Group Policies to meet the essential Health Benefit requirements. These benefits were determined by the secretary of the health and Human Services and required involvement of not simply government, but also nongovernment plans. The individual and smallGroup Policies then had to be sold at a more, most significant cost to the consumer. So how is the employer based system changed so employees could be moved into the system . Businesses with 50 or more fulltime employees had to provide Health Insurance approved by h. H. S. Or be financially penalized. The cost for business for the penalties for not providing insurance was less than the cost of insurance. Obamacare exchanges were there to take in anyone who needed to have insurance. Employerbased mandates were a way of moving employees out of the employeebased marketplace into a government program. Its the backdoor way of having a governmentbased Health Care System. It was ingenious but fortunately for the American People it was flawed. Yes, americans in the individual market lost their insurance five million americans but the employerbased mandate was postponed through the efforts of congress. Many of the Larger Companies have selfinsured their employees. The Obamacare Exchange program has been very expensive for the consumers. It also has significantly limited access to care, narrowed networks of providers which are the doctors and hospitals. Obamacare has increased the numbers in medicaid, but this program itself has severe flaws. And again, in demystifying obamacare by david brown, a doctor, going to page 18, what are the facts about medicaid and Medicaid Expansion . Costs of medicaid total federal and state spending will more than double, more than 4828 been 47 428 been to over 800 billion. Its often the second most expensive budgetary item. With Medicaid Expansion increased costs to the states, even in those states which have accepted Medicaid Expansion and increased federal funding for it. Other state services may have to be reduced even in states which have not accepted Medicaid Expansion. Medicaid is actually a safety net for the poorest and most vulnerable americans, but exchanges expansion changes this. It reduces the access to care for others who are already in the system. The single adult, ablebodied american is competing for care with those who need the care as a safety net. It severely underpays doctors and hospitals and the number of medicaid providers are declining. It compensates doctors an average of 50 less than the private insurance. A by c. B. O. Estimates by the time of full implementation of obamacare one out of every six hospitals will be in the red because of severe underpayment from medicaid and medicare. Medicaid expansion does not reduce inappropriate utilization of Emergency Rooms. A recent study showed medicaid patients utilize the Emergency Rooms for their routine care 40 more than those who are uninsured. Medicaid has the worst clinical outcomes compared with any other medical program. There are worse outcomes, including conditions such as heart disease, cancer, complications from major surgery, transplants and aids. These outcomes are dependent of patient factors and reflect the program itself. It may be no better than having no insurance at all. A recent study comparing medicaid patients with those who are uninsured showed no difference in blood pressure, glucose, and cholesterol levels after two years of observation. In short, Medicaid Expansion has reduced access to care, increases cost of care, and places people within the program that has the worst possible outcomes to care. Going on in demystifying obamacare by david brown, page 25, 31 states ing Medicaid Expansion update, how does it stand today . 31 states and the District Of Columbia have adopted Medicaid Expansion. Three states have considered it but rejected Medicaid Expansion. The other 16 states have refused to participate in it. Medicaid expansion has increased medicaid numbers from 58 million to approximately 70 Million People. 20 of the uninsured. It has caused overall expansion of the number of people in the program. Obamacare has increased the number of individuals insured by allowing them to participate in the existing Medicaid Program. In order to do so, the inclusion criteria for their enrollments have changed. Medicaid expansion is now based on age and financial criteria. That includes both the ablebodied individuals who are able to work and chose not to, and those who were previously involved in medicaid safety net. For example, the lowerincome mother with children. It was thought that the states that accepted Medicaid Expansion would have, quote, free money, end quote if they participated with the federal program. 1 00 of the costs of adding new patients were picked up by the federal government, with that figure gradually being reduced to 90 of the costs starting in 2017. This was for new patients added to medicaid and not the existing patient population. States, however, found that their Medicaid Programs were flooded with new enrollees, many of which had met the criteria for medicaid before the, quote, woodwork effect. End quote. The overall expansion of medicaid with increasing number of enrollees has led to a marked increase in the spending on medicaid and marked increase in total costs for medicaid. He goes on with a lot of numbers which have a lot of significance , thus accountants, but ill skip over those and continue on with his last two points. Medicaid is associated with the worst possible Clinical Success rate across the board for all medical and surgical illnesses. Its worse than any other program, including any Government Programs such as medicare or any private program. In certain studies, it is shown to have worse clinical outcomes than having no insurance at all. No data has developed during the course of Medicaid Expansion to change these findings. Medicaid expansion is associated with the huge financial burden on the states and cost of the states with the Medicaid Expansion has increased dramatically. Again, at the end of the chapter, it shows a lot of references for where he got this information. Continuing with demystifying obamacare and moving on to page 31, what are obamacare insurance exchanges . Obamacare insurance exchanges are federally constructed and staterun markets where individuals and families can purchase insurance. Private health care Insurance Companies participate, but the Insurance Companies are only able to sell plans that are acceptable to the secretary of health and Human Services. Many individuals and families then could receive subsidies provided by the government. I. E. , taxpayerfunded subsidies. The subsidies are to be on a sliding scale. Families whose income is up to 400 of the federal Poverty Level can be in the Obamacare Exchange. 97,000 a year for a family of four is the income. The program is tightly regulated by the federal government. The choice is limited to four plans bronze, silver, gold, and platinum. Each state was required to set up their own insurance exchanges and then regulate them. If a state did not set up an exchange, the federal government did that for them. So what are the effect the policies have inside and outside the exchanges . The public must know that exchanges dramatically restrict patient care by restricting access to care. Exchanges decrease access by reducing access to doctors and hospitals. This includes access to some of the most important specialized medicine. The exchanges have a limited network for providers. The public must understand that they do not have protection from fraud. Some of the most Sensitive Information is given to navigators to help enroll people in the exchanges. The enrollees then become fair game. The obamacare website healthcare. Gov does not automatically verify enrollees eligibility whether they legally qualify for subsidies. Various sources indicate that at least two million enrollees, some estimates are significantly higher, are receiving subsidies that they did not legally qualify for. Douglas holtzeakin, former director of the c. B. O. , estimates that the first ten years of obamacare, overpayments and inappropriate payments could add up to 152 billion. Who pays the bill . The american taxpayer. The website healthcare. Gov costs taxpayers 1. 4 billion in 2014. He goes on to explain how that increases the costs for all taxpayers. So i will continue with some of the other lessons in this book at another time. I note the leader is coming to the floor to speak in a few moments. What were trying to do is to find some solutions for the American People so they have access to health care. And more extensively than now, and i recommend for reading this book called demystifying obamacare by david brown. Its very eye opening. There is a section that ill cover later that covers some of the solutions that will be useful. I yield the floor and suggest the absence of a quorum. The presiding officer the clerk will call the roll. Quorum call quorum call quorum call mr. Mcconnell mr. President . The presiding officer majority leader. Mr. Mcconnell i ask consent that further proceedings under the quorum call be dispensed with. The presiding officer without objection. Mr. Mcconnell mr. President , for the information of all senators, at the request of the president and the Vice President and after consulting with our members, well have the vote on the motion to proceed to the Obamacare Repeal bill early next week. I ask unanimous consent the senate be in a period of morning business with senators permitted to speak therein for up to ten minutes each. The presiding officer without objection. Mr. Mcconnell i ask unanimous consent that when the senate completes its Business Today it adjourn until 9 30 a. M. Wednesday, july 19. Further, that following the prayer and pledge, the morning hour be deemed expired, the journal of proceedings be approved to date, the time for the two leaders be reserved for their use later in the day and morning business be closed. Further, following leader remarks the senate proceed to executive session and resume consideration of the bush nomination. Finally, that the time until the cloture vote on the bush nomination be equally divided between the two leaders or their designees. The presiding officer without objection. Mr. Mcconnell so if theres no further business to come before the senate, i ask that it stand adjourned under the previous order. The presiding officer the Senate Stands adjourned until Senate Stands adjourned until we will have live coverage when senators return here on cspan2. To pass the one of the acts was to pass a legislative tool for healthcare. They did so because the American People had suffered for years under the failures of obamacare. Pleryone knows about obamacares cost. Too often discussion seems to veer into the abstract. These are not just numbers on the page. These are real people