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

Floor Speech

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Mr. DURBIN. Mr. President, over the last few days, three Republican Senators have publicly stated that they

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will vote against the healthcare repeal bill that may come to the Senate this week.

In announcing his opposition, one Republican Senator, John McCain of Arizona, issued the following statement: ``As I have repeatedly stressed, healthcare reform legislation ought to be the product of regular order in the Senate.''

Last night, Republican Senator Susan Collins of Maine stated: ``This is simply not the way that we should be approaching an important and complex issue.''

She went on to say: ``The fact that a new version of this bill was released the very week we are supposed to vote compounds the problem.'' This should be the end of the Graham-Cassidy repeal debate.

Republican leadership should finally scrap this one-sided effort to literally change the healthcare system for America.

There was a hearing yesterday--the only hearing on the bill we are about to vote on. It was a lengthy hearing, but it, frankly, did not entertain all of the witnesses or any amendment process so that Members could really have input into the bill we are going to face.

The Congressional Budget Office is supposed to tell us what this critical legislation will do for America. It issued a preliminary finding yesterday that millions of Americans would lose their health insurance and that those with preexisting conditions, as well as their families, if they could buy insurance, would find it very, very expensive.

At the end of this week, funding for our Nation's community healthcare centers will run out, as will funding for the Children's Health Insurance Program. Shouldn't we be focused on reauthorizing those programs appropriately in a timely way? Let's allow the HELP Committee, which is the committee of jurisdiction when it comes to healthcare, to do its work. I have faith in two Senators--one Republican and one Democrat--to do the right thing on this. Senator Lamar Alexander of Tennessee, a Republican, and Senator Patty Murray of Washington, a Democrat, have proven before that they can take complex issues such as Federal funding for education and find a bipartisan compromise.

What would America say if we announced at the end of next week or even this week that we have a bipartisan compromise to make healthcare stronger in the United States, that it is going to pass the Senate, that we are going to send to it the House, and that we are going to get something done this year in the Senate?

First, most Americans would be amazed and skeptical, as they should be, but if we can prove that we are going to do it, they would applaud us for finally reaching a point at which we do something on a bipartisan basis.

That was the process that was underway until last week. Senator Alexander was given orders by the leadership: Step back. Let's vote on Graham-Cassidy. Don't do anything more on a bipartisan basis.
Well, this is the week for that vote, and I hope it is the week in which that vote ends in the basic defeat of the approach and a return to bipartisan compromise and bipartisan negotiation.

I don't know what it will take for the Republicans in the Senate and the House to end this never-ending crusade against so-called ObamaCare.

They have voted 50, 60, 70 times. We know how they feel about it, but the American people have said to them: It is not enough to oppose ObamaCare; give us a better alternative. And that is where they have stumbled each time.

Over the weekend, rather than making improvements to fix what is wrong with their bill, many Republicans doubled down in secret meetings, negotiations, and with incentives that were built into the newest version of the bill.

The latest Graham-Cassidy repeal measure would slash funding to the States, decimate the Medicaid Program, eliminate protections for people with preexisting conditions, and basically throw our entire healthcare system into chaos. A few special changes were made for special States, but the changes that have come to Graham-Cassidy in the closing days have not really changed the fundamental problem with the bill in that it diminishes Medicaid coverage.

Medicaid is the health insurance program about which most people say:
Well, that is for the poor people of America. To some extent, that is true, but it has reached far beyond that. Two out of three senior citizens in nursing homes and other institutional settings rely on Medicaid for basic healthcare. If the cutbacks in Medicaid take place that Graham-Cassidy calls for, what will these seniors do? What will you do for Mom, for your grandmother, or for your grandfather when it reaches a point at which they cannot any longer count on Medicaid to help them pay their medical bills? Will American families have to step up with their own savings? Will they have to look for alternative settings to those in which their parents and grandparents are today? That is the stark choice Graham-Cassidy will create for many families across America.

No one has had time to properly review this latest proposal, in large part because it was drafted behind closed doors--no input from experts, no support from the medical community. You would think, after saying it over and over again, that the Republicans would challenge the following statement: There is no medical advocacy group in the United States of America who supports the Graham-Cassidy bill. That is the case in my State. The Illinois Hospital Association, doctors, nurses, surgeons, pediatricians, and community health are all opposed to this bill, every single one of them, as they were to the previous versions. It says something when the bill to change America's healthcare system is opposed by the people who provide healthcare to America. All of them oppose it. It is that bad.

Republican leaders want to force a vote this week. If that is what it takes, then we have to move to that vote, but I wish they would save some time. I wish they would move to this bipartisan negotiation I referred to earlier.
The Congressional Budget Office is a nonpartisan agency that is supposed to measure the impact of legislation so that, before we vote on it, we know if it is good or bad for the Nation and for the people we represent. Here is what it told us last night in a preliminary review, but it has not had time to review this bill in detail.

In a preliminary review, the CBO told us: ``The number of people with comprehensive health insurance . . . would be reduced by millions each year.''

How in the world can we as Senators make a proposal for the United States of America which we know will take health insurance coverage away from millions of Americans--exactly the opposite of what our goal should be?

The CBO went on to write: ``Federal spending on Medicaid would be reduced by about $1 trillion.''
There are some Republicans, fiscal conservatives who say that we have to stop the growth of this program, but none of them--not one of them-- can address the fundamental issue: Who will then take care in paying for the delivery of babies to low-income families? Half of the children who are born in my State of Illinois are paid for by Medicaid. Their moms are taken care of by Medicaid until the moment of birth. What will you replace that with if you eliminate Medicaid funding? What about the disabled who count on Medicaid as their health insurance? If you are blind or face a serious disability, Medicaid is the answer for basic health insurance for you. If you are going to cut $1 trillion out of Medicaid, what will you say to those disabled Americans who want the same peace of mind that we all want in having health insurance?

School districts all over Illinois and all over the Nation receive Medicaid funds to care for special ed students--counselors, transportation, even feeding tubes. If you take the money out of Medicaid, what will we do for those school districts that are trying their best to give kids a fighting chance, even those with serious disabilities? That is the reality.

The CBO went on to write: ``Coverage for people with preexisting conditions would be much more expensive . . . and could become unavailable for many more people.''

This Republican proposal takes us back to that moment in history when health insurance was so expensive and so hard to find--almost impossible for those with preexisting conditions. Why would we ever want to go back to that? There is hardly a family in America

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who does not have someone they love, who is part of the family, who has a preexisting condition.
Let me remind those who do not have that circumstance that you are one accident or one diagnosis away from being part of this class of Americans who wants health insurance even though the health of those Americans has not been perfect.

In sum, this bill does not do what its authors say it will. They like to tell the American public that States will magically be able to cover the same number of people and provide the same level of benefits with billions of dollars less in funding. The Governors--Democrats and Republicans--have stepped up and said: This is ridiculous. We cannot be asked to accept the burden of health insurance for generations to come, while the Federal Government continues to cut the money that is necessary to provide that protection.

The CBO rejected the claims that are the basis for this Republican bill. Since the Republicans refuse to wait for the CBO to complete its full analysis, we have asked outside health experts what they think the impact would be of this legislation which is before us this week.

Here is what they say: Within a few years, this bill would likely rip health insurance away from more than 20 million Americans, including 1 million people in the State of Illinois. In a State of 12\½\ million people, which I represent, 1 million people would lose health insurance because of this Republican proposal that is before us this week.

The average 60-year-old person in Illinois would see his health insurance premiums increase by $11,700 a year. Almost by $1,000 a month his health insurance would go up. Why? Because they change a basic formula. In the Affordable Care Act, we see that the disparity in premiums charged between the highest and lowest will be no more than 3 to 1. They change the ratio in their Republican bill to 5 to 1. It means that those over the age of 50 and under 65 are going to see premium increases estimated to be almost $1,000 a month.
By 2026, Illinois would see its healthcare funding slashed by $8 billion. By 2036, this number would soar to $153 billion.

Medicaid, which covers half of all children in Illinois and two out of three seniors in nursing homes, would be decimated. Also, the Medicaid expansion in Illinois, which helps us to combat the opioid epidemic, provide coverage for 650,000 Illinoisans, and bring stability to our hospitals all across the State, would be shut down.
Here is what the Illinois Hospital Association said about this bill:

Illinois cannot absorb additional financial burdens and would be forced to reduce eligibility, covered services, and payments to providers. The magnitude of these cuts and changes to Medicaid is staggering.

Let's also review what this does to people with preexisting conditions. The Republicans say that this is all about giving flexibility to States. We hear that over and over again. It sure sounds nice until you realize that it is a code word for there being massive funding cuts and the elimination of basic health protection.

In the name of ``State flexibility,'' this bill would allow insurers to charge those with preexisting conditions sky-high premiums the moment they get sick.

Under this bill, ``State flexibility'' means reimposing annual and lifetime limits on patients, including infants who are born with serious medical problems.

Under TrumpCare, ``State flexibility'' means charging Americans over the age of 50 up to five times more than younger people. That is exactly why the American Association of Retired Persons, the AARP, has steadfastly opposed these Republican changes.

To my Republican friends, ``State flexibility'' means tossing out essential health benefits, which is the guarantee that your insurance will cover the basic services your family may need--prescription drugs, maternity care, mental health and addiction treatment.

I spoke to one of my Republican colleagues the other day and asked: What are you driving at here? Are you saying that we can reduce the cost of health insurance if we give people the option of saying that they will not buy coverage for mental illness and substance abuse treatment?
He said: Yes, that is one thing they can do.

I said: Then what happens next month when you discover that your daughter, a sophomore in high school, is now taking opioids and may move to heroin next? You want to intervene. You want to do it, but now you have to pay out of pocket because you didn't buy the essential coverage of mental illness and substance abuse treatment.

It is a shortsighted game to reduce premiums and give up basic essential benefits, but that is what Republicans propose. That is why this measure is opposed by every major medical provider and patient organization nationwide: AARP, the American Hospital Association, the American Medical Association, the American Academy of Pediatrics, nurses, disability groups, the American Heart Association, the American Lung Association, the American Diabetes Association, and the Alzheimer's Association--the list goes on and on. But guess who also came out in opposition to this bill? Insurance commissioners and Medicaid directors. These are the officials who would actually have to implement these cuts. They agree with the Congressional Budget Office that you can't slash the healthcare budget by 20 to 30 percent and expect that States will have ``flexibility'' to make up the difference.

The bipartisan association representing every Medicaid director in the country--every one of them--stated that Medicaid cuts would ``constitute the largest transfer of financial risk from the federal government to the states in our country's history.''

Show me a State that can cover as many people with the same benefits if one-third of the money is taken away. That is what the Republican bill does.

Here is what Governor Sandoval, a Republican Governor in Nevada, said:

Flexibility with reduced funding is a false choice. . . . I will not pit seniors, children, families, the mentally ill, hospitals, care providers, or any other Nevadan against each other because of cuts to Nevada's health system proposed by Graham-Cassidy.

This is a Governor speaking in the same clear terms as Governors of both political parties about the impossible dilemma that would be created by this bill.

Enough is enough. The law that we passed, the Affordable Care Act, helped 20 million people get health coverage. People with preexisting conditions were finally protected. Women are no longer discriminated against when it comes to health insurance. Americans get free preventive healthcare, such as cancer screenings. Is it a perfect law? Not by any means, but at 3 percent of the individual market, we need to do better, and we can. We need to improve that market.

First, the Trump administration must do its best to help us, not hurt healthcare in America. If they are setting out to sabotage this healthcare system, they can do it, but I hope they will not. The President will not suffer if they do, but a lot of innocent American families will. It will make it harder for people to enroll in insurance groups. It will slash funding for outreach. It will actively discourage insurers to offer health plans to individuals.
Mr. President, I am going to yield the floor to the Democratic leader.

In closing, I ask unanimous consent that the September 22, 2017, article in the New Yorker by Dr. Atul Gawande be printed in the Record.
There being no objection, the material was ordered to be printed in the Record, as follows:

[From the New Yorker, Sept. 22, 2017]

If the U.S. Adopts the G.O.P.'s Health-Care Bill, It Would Be an Act of Mass Suicide

(By Atul Gawande)

The fundamental thing to understand about Senate Republicans' latest attempt to repeal Obamacare is that the bill under consideration would not just undo the Affordable Care Act--it would also end Medicaid as we know it and our federal government's half-century commitment to closing the country's yawning gaps in health coverage. And it would do so without putting in place any credible resources or policies to replace the system it is overturning. If our country enacts this bill, it would be an act of mass suicide.

In my surgery practice in Boston, I see primarily cancer patients. When I started out, in 2003, at least one in ten of my patients was uninsured. Others, who had insurance, would discover in the course of their treatment that their policies had annual or lifetime caps that wouldn't cover their costs, or that

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they would face unaffordable premiums going forward because they now had a pre-existing condition. When he was governor of Massachusetts, it was Mitt Romney, a conservative, who brought Republicans and Democrats together to make a viable state system of near-universal coverage. That system then served as a model for the A.C.A. The results have been clear: increases in coverage have markedly improved people's access to care and their health. For the last four years, health- care costs in Massachusetts have risen more slowly than the national average--while the national numbers themselves have been at historic lows. I have not seen a single uninsured patient--zero--in a decade. And now comes an utterly reckless piece of legislation that would destroy these gains.

To review how we got to this point: last spring, the House passed a health-care-reform bill that proposed to hollow out the A.C.A.'s funding, insurance mandates, and protections for people with pre-existing conditions. It was immensely unpopular with the public. The problem was not just that twenty-three million Americans would lose their health insurance if the bill becomes law but also the Republicans' vision of a health system where insurance with deductibles of five thousand dollars and more, and little or no primary-care coverage, would become the norm.

This summer, Senate Republicans failed to secure enough votes to pass a modified version of the House bill. Later, in a dramatic late-night session, the Senate also rejected, by a single vote, a ``skinny'' repeal bill. That bill would have repealed only the parts of the A.C.A. that required large businesses to insure their workers and all Americans to carry coverage. It would have resulted in a mere sixteen million more uninsured people, according to estimates.

The Republican bill currently being rushed to a vote was put forward by a group of senators led by Lindsey Graham, of South Carolina, and Bill Cassidy, of Louisiana. As has become the apparent rule for Republican health-care bills, there have been no hearings or committee reviews of the Graham- Cassidy bill. And, this time, lawmakers and the public do not even have a Congressional Budget Office analysis of the effects the bill would have on the budget, insurance costs, or the uninsured rate.

This is unprecedented: senators are moving ahead with a vote on a bill that would alter the health care of every American family and the condition of a sixth of our entire economy, without waiting to hear any official, independent estimates of the consequences. The irresponsibility is as blithe as it is breathtaking. Before becoming a senator, Cassidy spent twenty-five years working as a physician in hospitals devoted to the uninsured. I find it baffling that a person with his experience would not recognize the danger of this bill. But here we are.

The Graham-Cassidy bill goes even further than the bill passed by the House. It would bring to a virtually immediate end not only the individual and employer mandates but also the whole edifice of the Medicaid expansion, insurance exchanges, and income-based coverage subsidies set up under the A.C.A. Graham-Cassidy expects all fifty states to then pass, and implement, alternative health systems for tens of millions of people within two years--with drastically less money, in most states, than the current law provides. This is not just impossible. It is delusional.

Like the House bill, Graham-Cassidy would cut Medicaid payments for traditional enrollees--the elderly in nursing homes, pregnant women in poverty, disabled children, etc.--by a third by 2026. A portion of the money saved would go into a short-term fund for states to use for health-care costs. The rationale is that this would give states ``flexibility'' to design coverage for their residents as they see fit. But the amount of funding provided is, by multiple estimates, hundreds of billions of dollars below what the A.C.A. provides.

The bill also nakedly shifts funds from Democratic-leaning states that expanded Medicaid under the A.C.A. to Republican- leaning states that didn't. Analyses indicate that states like California, Massachusetts, and New York will receive block-grant funding anywhere from thirty-five to almost sixty per cent below the health-care funding their residents would receive under current law. Much of those missing funds would be transferred to states like Texas, Mississippi, and Wisconsin. And special deals to make further shifts from blue states to red states such as Alaska are being negotiated to win votes.

As for what states can do with the funds they do receive, they would not be allowed to use them to enroll people in Medicaid, or able to establish a single-payer system. And states would not be receiving enough to continue Obamacare on their own. The only options for spending are for commercial coverage. States will be permitted to let insurers bring back higher costs for people with pre-existing conditions and to reinstate annual and lifetime limits on coverage. And then, starting in 2026, the funding turns out to only be temporary.

Under the bill's provisions, unless further action is taken then, four trillion dollars will be removed from health-care systems over twenty years.

With these massive sums being flung around, it is easy to forget that this is about our health as human beings. The evidence is that health-care programs like the A.C.A. save lives. The way they do so is by increasing the number of people who have affordable access to a regular source of care and needed medications. Such coverage has been shown to produce a substantial and increasing reduction in mortality-- especially among those with chronic illnesses, such as heart disease, cancer, or H.I.V.--in as little as five years.

Virtually all of us, as we age, will develop serious health conditions. A critical test of any health reform, therefore, is whether it improves or reduces our prospects of having the continuous care and medicines we need when we come to have a chronic illness. The Graham-Cassidy bill fails this test. It will terminate Medicaid coverage and insurance subsidies for some twenty million people. The entire individual-insurance market will be thrown into a tailspin. Federal protections for insurance coverage will be gone.

Every major group representing patients, health-care professionals, health-care institutions, and insurers has come out vociferously against this plan. Governors from Alaska to Ohio to Virginia have opposed the bill. In a highly unusual, bipartisan statement, the national association representing the Medicaid directors of all fifty states has also opposed the bill. The top health official in Louisiana, Cassidy's home state, has opposed the new plan. There is not a single metric of health or health care that the Graham- Cassidy plan makes better. This bill is a national calamity.

It should not even come to a vote.

Mr. DURBIN. Mr. President, I ask unanimous consent that the statement
of A.J. Wilhelmi, president and CEO of the Illinois Health and Hospital Association also be printed in the Record.
There being no objection, the material was ordered to be printed in the Record, as follows:

[From the Illinois Health and Hospital Association, Sept. 21, 2017]

The Graham-Cassidy-Heller-Johnson ACA Repeal Proposal

(By A.J. Wilhelmi)

The Illinois Health and Hospital Association opposes the latest Senate proposal to repeal the Affordable Care Act, which would do great harm to patients, hospitals, the healthcare delivery system, and our state budget and economy.

The Graham-Cassidy-Heller-Johnson bill is even more damaging than the previous Senate and House repeal proposals. Not only will it result in the loss of healthcare coverage for up to one million Illinoisans, but it will erode key protections for patients and consumers and will cut federal healthcare resources to Illinois by more than $150 Billion.

IHA also opposes changing Medicaid to a capped funding model. Illinois already ranks 50th in the country in federal funding support per Medicaid beneficiary. Capped funding would lock Illinois into low, insufficient federal funding levels and shift costs to the state.

Illinois cannot absorb additional financial burdens that would be imposed on the state and would be forced to reduce eligibility, covered services, and payments to providers. The magnitude of these cuts and changes to Medicaid is staggering.

We were encouraged by recent bi-partisan negotiations to stabilize the individual marketplace. The Graham-Cassidy- Heller-Johnson bill will do nothing in the short or long term to create marketplace stability.

We urge the Senate to reject this proposal, and we implore the members of the Illinois House Delegation to oppose the bill if it passes the Senate. There is a great deal at stake for the health and well-being of the people of Illinois.

Mr. DURBIN. Finally, I ask unanimous consent that the statement by the National Association of Medicaid Directors, to which I referred, be printed in the Record.

There being no objection, the material was ordered to be printed in the Record, as follows:

[From the National Association of Medicaid Directors, Sept. 21, 2017]

NAMD Statement on Graham-Cassidy

The Board of Directors of the National Association of Medicaid Directors (NAMD) urges Congress to carefully consider the significant challenges posed by the Graham- Cassidy legislation. State Medicaid Directors are strong proponents of state innovation in the drive towards health care system transformation. Our members are committed to ensuring that the programs we operate improve health outcomes while also being fiscally responsible to state and federal taxpayers. In order to succeed, however, these efforts must be undertaken in a thoughtful, deliberative, and responsible way. We are concerned that this legislation would undermine these efforts in many states and fail to deliver on our collective goal of an improved health care system.

1. Graham-Cassidy would completely restructure the Medicaid program's financing, which by itself is three percent of the nation's Gross Domestic Product and 25 percent of the average state budget. Like BCRA, the legislation would convert the traditional Medicaid program into a per-capita cap financing system. All states will be impacted by this change, regardless of their decisions to leverage the Medicaid expansion option under the ACA. It would also incorporate

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Medicaid expansion funding and other ACA health funds into a block grant, made available to all states. How these block grants will be utilized, what programs they may fund, and the overall impact they will have on state budgets, operations, and citizens are all uncertain. Taken together, the per- capita caps and the envisioned block grant would constitute the largest intergovernmental transfer of financial risk from the federal government to the states in our country's history. While the block grant portion is intended to create maximum flexibility, the legislation does not provide clear and powerful statutory reforms within the underlying Medicaid program commensurate with proposed funding reductions of the per capita cap.

2. The Graham-Cassidy legislation would require states to operationalize the block grant component by January 1, 2020.

The scope of this work, and the resources required to support state planning and implementation activities, cannot be overstated. States will need to develop overall strategies, invest in infrastructure development, systems changes, provider and managed care plan contracting, and perform a host of other activities. The vast majority of states will not be able to do so within the two-year timeframe envisioned here, especially considering the apparent lack of federal funding in the bill to support these critical activities.

3. Any effort of this magnitude needs thorough discussion, examination and analysis, and should not be rushed through without proper deliberation. The legislative proposal would not even have a full CBO score until after its scheduled passage, which should be the bare minimum required for beginning consideration. With only a few legislative days left for the entire process to conclude, there clearly is not sufficient time for policymakers, Governors, Medicaid Directors, or other critical stakeholders to engage in the thoughtful deliberation necessary to ensure successful long- term reforms.

For these reasons, we encourage Congress to revisit the topic of comprehensive Medicaid reform when it can be addressed with the careful consideration merited by such a complex undertaking--as we articulated in our June 26 statement on BCRA.

Mr. DURBIN. Mr. President, what America wants is to solve problems, not create them. The Graham-Cassidy bill will create problems for every American family. Let's do something right. On a bipartisan basis, let's sit down and work out improvements to our healthcare system. Let's stop the partisanship when it comes to healthcare. Let's come together now.

We each have our grievances against one another, one party or the other. The American people are tired of our grievances. They are expecting us to do something positive. We can do it. Let's return to the bipartisan negotiation process.

I think that Senators Lamar Alexander and Patty Murray, Republican and Democrat, can lead us to a good path to strengthen our healthcare system.

I yield the floor.

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