National Defense Authorization Act for Fiscal Year 2018 - Motion to Proceed

Floor Speech

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Mr. President, I rise to speak about the debate this week over the Graham-Cassidy proposal with respect to healthcare that is being considered by the body. I have high regard for both of these colleagues. I serve with each of them on different committees. I oppose the bill and want to talk a little bit about why I do but more specifically about an aspect of the bill that I find puzzling.

It is no surprise to me that there are many in this body who would like to repeal and replace the Affordable Care Act. When the Democrats were in the majority for my first 2 years in the Senate, I often sat in the chair where the Presiding Officer sits. I heard a lot of people giving speeches on the floor. I was in the Chair during an all-night sort of filibuster by the Senator from Texas about the repeal and replacement of the Affordable Care Act. I get that there are arguments about it. While I support the Affordable Care Act--I strongly did in 2010 and still do--I do want to work with my colleagues to find solutions to improve healthcare. There are differences of opinion about it.

One thing I never heard during all of the speeches that I heard, either as a presider or paying attention on the floor, was Members getting up and saying they wanted to dramatically cut Medicaid. That is not anything that anybody has filibustered about. That is not anything that people speak about.

When President Trump campaigned, he said: I am unique on the forum right now of all these candidates in that I will not cut the Medicaid Program. When the Senate started to consider versions of the ObamaCare repeal and replacement over the summer, after the House acted, what interested me was not the portions of the bill that attempted to replace the Affordable Care Act but the significant changes to the Medicaid Program that were never advertised. There was never this discussion: We are going to repeal ObamaCare, and we want to cut Medicaid. It was always about ObamaCare.

I am puzzled, standing here today, considering a Graham-Cassidy proposal that not only would be a fundamental change of repeal and replacement of the Affordable Care Act but also contains a very significant revision of Medicaid that would hurt my State and would hurt a lot of people I care about. That never seems to be acknowledged, and I am puzzled about why.

As to the Graham-Cassidy proposal, again, I respect my colleagues, and I think they are putting it on the table because they think it would be preferable to the current system. I don't question their motives. I was a Governor, and the notion of block grants and discretion and dollars back to the State can be a good thing. Quickly, before I get to the Medicaid piece, the problem is if you take the Graham-Cassidy proposal, it takes the dollars that are currently being delivered to the States through the Affordable Care Act, shrinks them by about $240 billion over 10 years, and then eliminates them. Even with the shuffling of the deck on a block grant that might benefit one State over another, you can't take $240 billion out of the system, in my view, without making people's premiums go up.

The money that is being delivered to States is largely delivered to help people either get a tax credit premium or pay out-of-pocket costs. If you take that much out of the system over 10 years, people's premiums are going to go up. That breaks a promise of President Trump's, who said that nobody is going to lose coverage and nobody is going to pay more. People will pay more, if Graham-Cassidy passes, in the short term, over the next 10 years. Then, when all of the money expires after 10 years, they will pay a lot more. I oppose that.

Second, I also oppose the way this bill treats preexisting conditions. By allowing States to waive essential health benefits, it might be technically true to say that you could get a policy even if you had a preexisting condition, but the insurance company could say to you: I will write you a policy, but you are a diabetic; so the policy will not cover insulin. Or I will write you a policy, but you are a woman of childbearing age; the policy will not cover maternity care.

If the policy doesn't cover your preexisting condition, then preexisting conditions are not protected. To my read of the 141-page bill--which has been revised a little bit, or so I hear, since I got the most recent version Friday to read it over the weekend--that is exactly what States can do. Because 43 of 50 States did not protect people with preexisting conditions before the Affordable Care Act, handing this power back to the States and allowing them to waive these benefits, I think, would jeopardize the tens of millions of Americans who do have preexisting conditions.

Finally, I don't like the fact that the current bill, as I understand it, ends funding for Planned Parenthood. Planned Parenthood doesn't have a line item in the budget. To the extent that Planned Parenthood gets funding, it gets funding for this reason: It provides primary medical care to women who are Medicaid-eligible, and they get services at Planned Parenthood that are Medicaid-eligible to be reimbursed.

Since Federal funding cannot be used for abortion services, the defunding of Planned Parenthood basically says that if you serve a woman who chooses to go to you for her primary healthcare and she is Medicaid eligible, we will not pay you for that service. That seems, to me, to be wrong. If women are choosing to go to Planned Parenthood, and they think that is the best place to go for primary care, why would we disable them and force them to go elsewhere by disabling Planned Parenthood from reimbursement?

All right. Those are some challenges I have, but I want to get to the real guts of my concern, which is the effort to go after Medicaid.

The Graham-Cassidy bill--and it is similar to the skinny repeal bill and other bills that were on the table that the Senate considered--goes into the Medicaid Program that was passed in 1965, which was long before the Affordable Care Act--long before it--and it puts caps on the program to restrict the growth of Medicaid spending. The estimate is that over the next 10 years, it will take $1.2 billion out of Medicaid. Yet no description of Graham-Cassidy that I have ever heard a sponsor mention and no description of any of the bills that have been pending on the Senate floor say we are going to repeal ObamaCare and that we want to go into the Medicaid Act of 1965 and dramatically cut Medicaid.

Why is that never made plain as it is a core feature of these bills? I would argue, it is sort of the core within the Trojan horse of the repeal of the Affordable Care Act to go in and change Medicaid. Yet it is never advertised that way, and it is never explained. You could have put a bill on the table to repeal the Affordable Care Act and could have left Medicaid alone. You would have touched the Medicaid expansion that was part of the Affordable Care Act, certainly, but you could have left the core Medicaid Program alone. Why was there an effort to both repeal the Affordable Care Act and cut Medicaid but not to say we are cutting Medicaid?

Maybe it is because, if you were to say that, you would directly counter a promise the President made, ``I am not going to cut Medicaid.'' Maybe there is a concern about, boy, we are taking $1.2 billion out of Medicaid, and we are about to come up with a big tax proposal that might give tax breaks for the wealthiest. We do not want to take money away from a program that is for the poor, elderly, disabled, or children and then immediately turn right around and increase the deficit by a tax cut.

I find this to be the big mystery of this entire debate, in that every proposal that is on the floor makes massive cuts to the core Medicaid Program even though it has nothing to do with the Affordable Care Act. Nobody ever acknowledges it, and nobody ever explains it, but I am here to both say it is real and to challenge it.

Who are Medicaid recipients? I think there tends to be a little bit of a misconception about who gets Medicaid in this country.

In Virginia, 50 percent of Medicaid recipients are children. The proposal, under Graham-Cassidy, calls for a $1.2 billion cut in Medicaid in Virginia over the next 10 years and a $120 billion cut in Medicaid nationally. In Virginia, 50 percent of Medicaid recipients are kids. One in three births in Virginia--one in three births every year-- is compensated by Medicaid. Two in three nursing home residents are supported by Medicaid. There are a lot of people with disabilities in Virginia who are supported by Medicaid. The home and community-based waiver programs, under the core Medicaid bill, support nearly 50,000 Virginians in community settings of their own choosing. Medicaid is also the primary payer for behavioral health services--mental health treatment, substance abuse prevention treatment.

That is what this bill goes after even though that Medicaid funding has nothing to do with ObamaCare, nothing to do with the Affordable Care Act. So reducing Medicaid spending by the $120 billion-plus over 10 years or more in the out-years would not hand more power to States. No, it would dramatically limit the States' ability to provide the kinds of services that are needed by our most vulnerable--kids, seniors in nursing homes, and people with disabilities.

Later today, I am going to have a meeting in my office with folks who have communicated with me over the course of this debate--really since January when I was added to the HELP Committee. They are coming in to tell me how frightened they are about what will happen if Graham- Cassidy passes.

Samantha and Justin McGovern are parents. They have a girl, Josephine, who is 1\½\ years old. They are from Springfield, which is right here in Northern Virginia. Josephine is about 18 months old, and she was very premature--24 weeks gestation. She was 1 pound 12 ounces when she was born. That is the size of six sticks of butter. That is how tiny this little girl was. She was hospitalized, after her premature birth, for 407 days, across three units, in two hospitals, in two States. She is home and thriving now, but she is supported by a ventilator 24/7 via a tracheostomy, and she is fed primarily through a gastrointestinal tube.

Her mother Samantha writes:

We are fortunate that we get to focus on her health rather than medical crippling bills. We estimate that her hospital stay would have exceeded $4 million, and the cost for her monthly medical expenses (baseline . . . not sick) is about $26,000 a month (if we didn't have insurance or Medicaid coverage).

Here is what she writes:

We are fortunate we have amazing private insurance through our employer. However, if it were legal to have annual or lifetime caps, I don't know what would happen to us. Part of our Medicaid covers private duty nursing so that we can sleep and go to work. Without nursing, one of us would have to leave their job, and there would be no way we could continue to live in our house [or pay our insurance]. If there are caps and we lost our insurance, we would depend on Medicaid even more than we do now, and we would have less coverage than we currently have, making it virtually impossible for Josephine to continue to be followed by the doctors who saved her life.

Basically, if [this bill] passes, life as we know it could fall apart. I don't know how we would be able to support our daughter, how we could keep her home and not in an institution. She deserves to be home. She deserves to have every opportunity to thrive.

I met Rebecca Wood at a forum in Charlottesville. She has a 5-year- old daughter, Charlie. I met them in July.
Charlie's mom says:

Charlie . . . is five-years-old and loves playing outdoors, live music, things with numbers, and anything with animals.
Charlie was born more than three months early and, as a result, is developmentally delayed. Currently, Charlie requires physical therapy (PT), occupational therapy (OT), and speech therapy. She has a . . . (feeding tube) and wears orthotics. Affordable care is the difference between independence as an adult or a permanent disability. Due to a three month NICU stay [when she was born], Charlie would have exceeded her lifetime cap before she ever came home for the first time. Then, she would have been uninsurable due to her birth being a preexisting condition. Also, Institutional Medicaid paid for a large portion of her NICU stay. Upon discharge, a Medicaid waiver helps with out of pocket costs and provides services that [our private] insurance doesn't cover. She would not be where she is without any of these things. The changes in the proposed healthcare bill would cause Charlie to drastically lose access to these services. Receiving healthcare services is her chance to leave a life-limiting disability behind.

The last story I will tell is of Eric Young, from Norfolk, on behalf of his son, Ethan.

Eric has major concerns about Graham-Cassidy. His son, Ethan, has what is called heterotaxy syndrome, which is an incredibly complex congenital heart defect. There are seven defects that are combined in this brave and thriving youngster. Eric said that Ethan has had two open heart surgeries and is having his third in November.

Eric writes:

I anticipate his healthcare charges to surpass the $1M mark before the end of the year. It's not an ``if'' for Ethan-- it's when. ``He'' will have spent more on healthcare in his first 2 years of life than most people will during their entire lives. He's the outlier. But he's exactly the type of kid that needs protecting.
Dealing with such a critical issue when your baby is first born is overwhelming--having to worry about whether or not your decisions to save your child will affect whether he . .
. [can] even obtain health insurance when he gets to be an adult is just wrong.

Eric writes about the ACA, as Eric works in the healthcare industry:

The ACA is not perfect--it needs to be changed. I work in healthcare--so I have the perspective of seeing it from my job and as a parent. But, we need a real bill that is well thought out, not something just for the sake of passing.

I wanted to come and really just talk about these youngsters. One out of every three children born in Virginia is able to be born in a hospital because of Medicaid, and 50 percent of Medicaid recipients are kids. If you were a child and you needed a wheelchair, your private insurance likely would not cover it. If you get a wheelchair, it is usually Medicaid that pays for it. If you go to school and then you get an individualized education plan and your public school system provides you some services, it is Medicaid that is usually paying the school system to reimburse it for the services that are provided.

My wife used to be a juvenile court judge, and this was the situation she would face all the time with kids in the court. It would be a heartbreaking situation, but there was an answer. You would have teenagers who were working so hard to be successful--not in court because of violating the law, not in court because of trouble but in court because their families were so dysfunctional nobody could take care of them. As a judge, my wife would have to grapple with this: Where is this child going to live? Who is going to help this child get to school? This kid is trying to succeed. Do I have to put the child in a group home or institutionalize the child because there is no family support there?

What my wife could do as a juvenile court judge--and this happens all over Virginia every day and all over the country every day--is say: OK. The child is capable of success, but the family is dysfunctional. May I send a counselor to the home? May I find an aunt or uncle, and maybe with some support of counseling, provide some stability so this child does not have to be institutionalized and can be successful? When my wife would order that, it was Medicaid that was paying for it.

Medicaid pays for your birth, Medicaid pays for your wheelchair, and Medicaid pays for the services a local school system will provide so you can have a life of independence. If your whole world is falling apart around you and you are doing everything you can to succeed, Medicaid can actually pay for counseling so you can keep it together and graduate from high school and go on and go to college and be successful.

Medicaid is advancing these challenged kids toward lives of independence and success. Yet the bill that is on the floor before us would cut, by the most recent estimate, $120 billion out of Medicaid over the next 10 years and more beyond. Why? Why is that not acknowledged? Why would you use the bill to cut Medicaid when all of the rhetoric about it is that we have to repeal the Affordable Care Act?

I think the right answer to this question is just staring us in the face, and it was what we gave Senator McCain a standing ovation for in July when he came back after getting his tough diagnosis. He came back, and he said: Look, healthcare is just too important. It is just too important. It is the most important expenditure anybody ever makes. It is the biggest sector of the American economy. It is the kind of thing that keeps parents up at night, worrying about what is going to happen to their children tomorrow or in 20 years, when the parents are deceased, and they want to know the children can have independent lives.

We just cannot afford to get this wrong, and the answer about getting it right is staring us right in the face. Let the HELP Committee, on which I serve--the Health, Education, Labor, and Pensions Committee-- and let the Finance Committee, which has jurisdiction over Medicaid and Medicare, take up everybody's ideas: the Graham-Cassidy bill and Bernie Sanders' bill. I have a bill about reinsurance, but it is so wonky it is never going to be on a bumper sticker. I think it would be a good bill, but I have not been able to have a hearing on it.

Let the committees that are of a Republican majority but with Democrats who know some things about healthcare take up these bills, hear from the parents, hear from the hospitals, hear from the doctors, and come up with a bipartisan set of solutions that will make healthcare better, not worse.

We were on the verge of doing that in the HELP Committee. We had 4 hearings with about 20 witnesses. We not only had committee members involved, but Chairman Lamar Alexander and Ranking Member Patty Murray did a good thing--they opened up a coffee before every hearing and said: Hey, if you are not on the committee but you want to meet these witnesses and hear what they have to say, come and talk and ask them questions. We had over 50 Senators participate. We were working on a bipartisan bill and basically had a handshake deal last week to stabilize the individual insurance market for a couple of years. In a deliberate way, in a careful way, we considered Republican and Democratic ideas for improving health insurance.

Then, last Wednesday, the President tweeted out, in working with the Speaker and the majority leader, that they did not want the bipartisan effort to go forward. No. We have to push the Graham-Cassidy bill--the bill that is about the repeal of ObamaCare but that also has within the Trojan horse these massive cuts to Medicaid that will hurt kids.

I don't know why we had to set aside the bipartisan effort. I don't know why we had to submarine the good-faith work of the committee under the leadership of a great chair and a great ranking member. It is my hope that at the end of the week, we will have defeated the Graham- Cassidy bill and that we will go back to being the Senate we should be.

I will just say what I have said a couple of times on this floor. This is one we cannot afford to get wrong. The parents of these kids already have enough to worry about. Why would we make it harder on them? We do not have to. We can be better than that. That is what I ask we do.

I yield the floor.

I suggest the absence of a quorum.

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