One Big Beautiful Bill

Floor Speech

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Mr. SANDERS. Mr. President, the so-called reconciliation bill or Mr. Trump's Big Beautiful Bill that the Republican leadership is now attempting to rush through the Senate is a rather extraordinary piece of legislation. In many respects, given the crises facing our country, this legislation does exactly the opposite of what should be done.

Whether you are a Democrat, a Republican, or an Independent, you know--no one has any doubt about it--that our current healthcare system is broken. It is dysfunctional. It is a cruel system, and it is wildly expensive. We spend over $14,500 per person on healthcare, double what most countries around the world pay per person.

And despite all of that spending, some 85 million Americans today are uninsured or underinsured. And we remain the only major country on Earth not to guarantee healthcare to all people as a human right. And one out of four people who go into a pharmacy to get their prescription drugs can't afford that medicine because of the outrageously high prices.

So now, given that reality, how does this reconciliation bill address the horrific healthcare crisis that our country is experiencing?

What one might think is that given 85 million people being uninsured or underinsured, this bill would lower that number. It would provide healthcare to more Americans. Given the fact that we are spending twice as much per capita on healthcare as any other nation, one might think that this legislation would lower the cost of healthcare. Given the fact that the insurance companies and the drug companies rip us off every day and make huge profits out of the system, one might think that this legislation would take on the greed of the pharmaceutical industry and the insurance companies.

Well, if that is what you think rational legislation should do, understand that this bill does none of that--in fact, does exactly the opposite.

This legislation, if enacted, would make the largest cut to healthcare in our Nation's history in order to pay for the largest tax breaks for the rich that we have ever, ever seen--massive cuts to healthcare in order to provide tax breaks for billionaires.

The Congressional Budget Office has estimated that this legislation would cut Medicaid and the Affordable Care Act by over $1 trillion. Those cuts, along with ending the enhanced premium credits for the ACA, will lead to 16 million people losing their health insurance.

That is not what Bernie Sanders has said; that is what the director of the Congressional Budget Office has told us. That is the nonpartisan group that works with Congress.

Mr. President, this bill, further, for the first time, forces millions of Medicaid recipients who make as little as $16,000 a year to pay a $35 copayment every time they visit a doctor. So 16 million people are thrown off of healthcare. Low-income, working-class people are now forced to pay a $35 copayment.

What is the impact of all of that? Well, it will not surprise anybody, if people don't have access to healthcare, if they can't get to a doctor when they are sick, people will suffer, and tens of thousands of them will die.

The Yale University School of Public Health and the University of Pennsylvania estimated in a recent study that if the reconciliation bill is enacted, over 50,000 Americans will die unnecessarily every year. That is what we are talking about--50,000 Americans dying unnecessarily because they are thrown off of healthcare; they can't afford to see a doctor each and every year.

What is the reason for that? What is the motivation for that horrific action? It is to give massive tax breaks to the very wealthiest people in this country, people who do not need them. Not only would millions of Americans lose their health insurance and tens of thousands of our constituents needlessly die if this legislation is enacted, rural hospitals all over this country--rural hospitals that are already struggling--would be forced to shut down, lay off workers, or substantially reduce the services they provide. In other words, at a time when rural America is struggling--and I come from one of the most rural States in America, that is what Vermont is--this bill would be a disaster for rural America.

Further, when Trump and the Republicans in Congress make massive cuts to Medicaid, they are not just attacking individuals, they are also going after and negatively impacting community health centers, which provide primary healthcare to 32 million lower income and working-class Americans in every State in this country. Community health centers rely on Medicaid for 43 percent of their revenue. And when you cut hundreds of billions of dollars in Medicaid, you are significantly cutting back on the access that millions of Americans will have to the primary healthcare they desperately need.

At a time when the healthcare system in America is broken, when primary healthcare is even in worse shape, this will make access to primary healthcare even more difficult.

Some 22 percent of our seniors in this, the richest country on Earth, are trying to survive on less than $15,000 a year. This legislation will make it harder for seniors and people with disabilities to receive the care they desperately need in nursing homes. Nursing homes in Vermont--and I expect in every State in this country--are struggling. They are understaffed. Workers there are underpaid. The quality, in many cases, is not as good as it should be. But when Medicaid now provides 60 percent of the revenue nursing homes rely on, slashing Medicaid will make a disastrous situation even worse for some of the most vulnerable people in our country.

Let us be clear. Let us not run away from it. Let us not double-talk this issue and come up with all kinds of absurd rationalizations. This legislation coming before the Senate this week is the most significant attack on the healthcare needs of the American people in the modern history of our country.

And once again--once again--we are throwing millions of people off the healthcare that they depend upon to stay alive in order to give tax breaks to billionaires who have more wealth today than they will need for a hundred lifetimes. And yet, oddly enough, despite the enormity of what this legislation is about, not a single committee in the Senate has held a single hearing on the impact this legislation will have. In my view, really, this is absolutely irresponsible.

I am not quite sure why we continue to even have committees if the Health and Labor Committee, of which I am ranking member, does not hold a hearing on the most important piece of health legislation in the modern history of this country. That is why this morning, I released, as leader of the minority on the committee, a report discussing the impact that this legislation would have on our Nation's healthcare system. I did that by doing something pretty radical, I guess. We actually reached out to healthcare providers all over the country.

If you are going to decimate American healthcare, you may want to talk to the doctors and the nurses and the healthcare organizations around America. I think that is kind of a commonsense thing to do.

Let me take this opportunity to thank the over 750 healthcare providers from 47 States who responded to my request. I want to thank them sincerely for their thoughtful responses. We basically said: What is this legislation going to do in your State? And we got hundreds and hundreds and hundreds of responses.

Executive Summary

The Senate is rushing to pass the largest cuts to federal health care programs in the history of Medicaid and the Affordable Care Act (ACA). The Republican budget bill, which passed the House by only a single vote, would slash federal health care programs by over $1 trillion. These cuts, along with the elimination of tax credits for ACA coverage, will take health care away from 16 million people. In some states, such as Florida, Louisiana, Massachusetts, and Washington, the Republican budget bill will nearly double the number of people without insurance.

Remarkably, despite the major changes the Republican budget bill would make to our health care system, the Senate is moving towards passing the bill without a single hearing or vote in Committee. No doctor, nurse, hospital, community health center, or nursing home has been formally consulted to help explain to the American people what these proposed changes would actually mean.

This month, Senator Bernie Sanders (I-Vt.), Ranking Member of the Senate Committee on Health, Education, Labor, and Pensions (HELP), asked health care providers across the country what this bill would mean for their patients. Over 750 health care providers from 47 states and the District of Columbia shared their serious concerns.

HELP Minority Staff reviewed these submissions from health care providers, as well as health policy research and other publicly available information, to document how the Republican budget bill would turn the crisis in American health care into a national emergency.

Health care providers expressed deep concerns that the bill would lead to more patients getting sick and dying; higher health care costs as patients delayed preventative care and visited more emergency rooms; and more hours spent on paperwork. Taken together, higher costs and lower reimbursement would cause providers to cut health services, lay off clinical staff, and close facilities entirely. This would impact everyone--not just those receiving health coverage through Medicaid and ACA. TABLE 1--HEALTH CARE PROVIDERS RAISE SERIOUS CONCERNS ABOUT REPUBLICAN HEALTH CARE CUTS ------------------------------------------------------------------------ Concern Provider Response ------------------------------------------------------------------------ More patients will get sick and die.... ``If Medicaid is cut, my patients will die. I realize I am being dramatic. It is a dramatic situation.'' Dr. Helen Pope, Louisiana. ``[T]hey are humans who are doing their best. Please don't allow them to suffer more.'' ``Patients will fall through the cracks, not because they're unwilling to care for themselves, but because we've made the system too complicated, too conditional, and too punitive. In rural communities like mine, people already struggle with trust, stigma, and access. This bill risks making all three worse.'' Bradley, Medical Student, Kentucky. ``Plainly said, children will die as a result of these cuts. Hospitals will cut back on ICU doctors, doctors will leave because of salary cuts, critical ancillary services will be reduced, more medical students will avoid going into pediatric residencies.'' Dr. Farhan Malik, Florida. ``The proposed cuts to Medicaid will cause untold hardship and deaths among my patients. DON'T DO THIS! You don't want the deaths of tens of thousands of Americans on your hands.'' Dr. Sanjay Chaube, Louisiana. Costs will increase as sick patients ``Outcomes are worse when care delay care and visit emergency rooms. is less accessible. Few doctors, hospitals, clinics mean more visits to the emergency room with worse presentation and ultimately is more expensive.'' Dr. Bonnie Sand, Maine. ``The provisions would ultimately make healthcare more expensive and less accessible while paradoxically making Medicaid unsustainable. When patients lose access to preventive care, they rely on emergency services and dangerous self-treatment, both driving up costs for everyone. Medicaid allows us to treat and prevent disabling conditions like diabetes and hypertension--without it, these become irreversible.'' Dr. Nikhil Kurapati, Ohio. ``If the proposed bill is passed and [my patients'] Medicaid insurance is cut, it doesn't mean their asthma will go away. It will mean that in most cases they will not receive preventative care, and as a result, their asthma will worsen. . . . Worse yet, they would be seen in the emergency room more often and admitted to the hospital. This care is more expensive, and less effective, than preventative care, and some children will die of their asthma.'' Dr. Gregory Omlor, Akron Children's Hospital, Ohio. Providers will need to spend hours more ``Our care managers and front- to handle extra paperwork, including desk staff would likely spend by hiring more staff. an additional 10-15 hours per week assisting patients with insurance-related forms . . . In small clinics, that's the equivalent of losing nearly half a staff member's availability for patient support.'' Trent Bourland, Regional VP of Rural Health, SSM Health Oklahoma. ``These changes would dramatically increase the administrative burden on our care team. We would likely need to hire at least 1-2 full- time administrative staff just to track patient eligibility, navigate complex documentation requirements, and assist families with enrollment or appeals. This would divert already limited funding away from clinical care and impose new costs on our department.'' Ashley, Social Worker, South Carolina. Facing higher costs and lower ``These harmful proposals will reimbursement, providers will be impact access to all patients forced to cut health services, layoff who are served by our nation's staff, and even close facilities hospitals and health systems. entirely. These cuts will strain emergency departments as they become the family doctor to millions of newly uninsured people. Finally, the providers will force hospitals to reconsider services or potentially close, particularly in rural areas.'' Rick Pollack, President and CEO, American Hospital Association. ``Louisiana's rural hospitals and healthcare providers are already operating on razor- thin margins, struggling to keep their doors open while serving some of our most medically vulnerable communities. In Louisiana, 38% of hospitals operate on negative margins and 27% are currently vulnerable to closure. Medicaid cuts would worsen these losses, putting more hospitals at risk of shutting down entirely.'' Louisiana Rural Health Association. ``If our patients lose Medicaid coverage, they will still need our care and our hospital will provide it. But this will mean more uncompensated care and even worse bottom lines. The city will need to pull funding from elsewhere to help the hospital keep running as is, or we will be forced to cut staffing or services in order to stay open.'' Dr. Katrina Marie Green, Tennessee. ``These cuts will cause rural hospitals in Texas to close entirely. As a neurologist, I am terrified that the closest hospital for many rural folks may then be hours away. During an ischemic stroke, there is only 3 hours of precious time . . . the increased travel time may cause unnecessary cases of paralysis and death.'' Dr. Audrey Nath, Texas. ``The proposed cuts would require our organization to cut back on the number of clinical staff that serve our residents. It would also cause [us] to stop our plan to improve the physical plant improvements for our skilled nursing center that are designed to bring greater dignity, safety, and clinical effectiveness to our residents.'' President & CEO of a provider organization, Kentucky. ``Our margin last year was - 31%, burning through cash to see patients, the majority of whom are on Medicare or Medicaid. If they lose Medicaid, we'll still take care of them because that's what we do, but the bills won't get paid.'' Tom Reinhardt, CEO, Cascade Medical Center, Cascade, Idaho. ``With significant cuts to Medicaid (and any cuts to HRSA or other grant funding for FQHCs), we may not be able to keep the doors open. We would potentially have to stop caring for many of our patients.'' Dr. Mia Henderson, Missouri. ------------------------------------------------------------------------

The responses included in the report represent a mere fraction of the responses reviewed by HELP Minority Staff raising concerns about the Republican health care cuts. Taken together, doctors, nurses, hospitals, and providers are clear about the immense harm the Republican health care cuts pose to their patients. The consequences also extend well beyond Medicaid and the Affordable Care Act. As one California doctor described it, ``If Medicaid collapses, the entire health care system collapses.''

The American people should not be forced to lose their health insurance--or pay higher premiums, higher copays, and higher costs at the pharmacy counter--so that Republicans can pay for tax breaks for the wealthy. Consider, for example, that the one trillion-dollar cuts to health care in the bill are nearly equivalent to the $1.1 trillion in tax breaks that households above $500,000 will receive from the legislation. Or that the bill provides tax breaks to more than 800,000 millionaire households, while ripping health insurance away from 16 million people--a ratio of over 19 to 1.

When all the spending and tax cuts are put together, the Penn Wharton Budget Model finds that the 40 percent of Americans making $51,000 or less would see their taxes go up in 2026 by hundreds of dollars, while those making at least $4.3 million would see a tax cut of $390,000.

As one doctor from Maine notes: ``We have an existential choice to make. The very wealthy want to steal from the less wealthy and poor Americans. We cannot allow that to happen. This legislation must not pass. Appendix

HELP Minority Staff used KFF data to estimate the increase in the uninsured rate from 2023 to 2034 as a result of the One Big Beautiful Bill Act. A 100 percent increase means the number of uninsured doubled. REPUBLICAN BILL WILL LEAD TO A MASSIVE INCREASE IN AMERICANS LOSING HEALTH INSURANCE ---------------------------------------------------------------------------------------------------------------- 2023 Uninsured 2034 Uninsured Percent State Rate Rate Increase ---------------------------------------------------------------------------------------------------------------- Alabama......................................................... 8.2% 11.6% 46% Alaska.......................................................... 10.0% 13.3% 35% Arizona......................................................... 9.6% 13.4% 50% Arkansas........................................................ 8.9% 13.1% 48% California...................................................... 6.2% 10.2% 74% Colorado........................................................ 6.5% 8.6% 50% Connecticut..................................................... 5.4% 9.6% 77% Delaware........................................................ 6.6% 10.0% 60% District of Columbia............................................ 2.6% 7.3% 229% Florida......................................................... 10.4% 18.8% 98% Georgia......................................................... 11.1% 16.7% 61% Hawaii.......................................................... 2.7% 4.9% 99% Idaho........................................................... 8.8% 10.2% 28% Illinois........................................................ 6.0% 10.4% 74% Indiana......................................................... 6.6% 10.0% 55% Iowa............................................................ 4.9% 7.6% 61% Kansas.......................................................... 8.1% 10.5% 32% Kentucky........................................................ 5.5% 9.7% 81% Louisiana....................................................... 6.7% 12.4% 91% Maine........................................................... 5.9% 8.8% 49% Maryland........................................................ 6.2% 8.7% 50% Massachusetts................................................... 2.5% 5.6% 135% Michigan........................................................ 4.3% 7.6% 78% Minnesota....................................................... 3.9% 6.8% 84% Mississippi..................................................... 10.1% 15.7% 54% Misouri......................................................... 7.3% 10.6% 47% Montana......................................................... 8.3% 11.7% 48% Nebraska........................................................ 6.2% 8.4% 44% Nevada.......................................................... 10.5% 11.9% 27% New Hampshire................................................... 4.4% 6.4% 47% New Jersey...................................................... 7.0% 10.9% 63% New Mexico...................................................... 8.7% 13.0% 51% New York........................................................ 4.7% 8.8% 100% North Carolina.................................................. 8.9% 13.0% 54% North Dakota.................................................... 4.0% 6.0% 73% Ohio............................................................ 5.9% 9.5% 63% Oklahoma........................................................ 11.0% 14.8% 38% Oregon.......................................................... 5.3% 9.5% 97% Pennsylvania.................................................... 5.2% 8.2% 59% Rhode Island.................................................... 4.3% 8.2% 98% South Carolina.................................................. 8.7% 13.1% 58% South Dakota.................................................... 8.3% 10.0% 26% Tennessee....................................................... 9.0% 12.5% 45% Texas........................................................... 16.0% 20.0% 39% Utah............................................................ 7.6% 11.3% 69% Vermont......................................................... 3.3% 6.0% 85% Virginia........................................................ 6.2% 9.0% 56% Washington...................................................... 6.2% 11.0% 102% West Virginia................................................... 5.8% 10.0% 68% Wisconsin....................................................... 4.8% 6.3% 34% Wyoming......................................................... 10.2% 12.2% 20% ----------------------------------------------------------------------------------------------------------------

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Mr. SANDERS. Mr. President, let me just summarize and quote a small number of the responses that we got. If this legislation were to be signed into law, it would drive up the number of uninsured Americans in every single State in this country.

For example, if this legislation was signed into law, the uninsured rate in my State of Vermont would go from 3.3 percent to 6 percent. In Louisiana, the uninsured rate would go from 6.7 percent to 12.4 percent. In the State of Washington, the uninsured rate would go up from 6.2 to 11 percent. In Florida, the uninsured rate would go up from 10.4 percent to 18.8 percent, almost 19 percent of people in Florida will be uninsured if this bill goes through. And this is true for every State in the country--in many cases, almost doubling the number of uninsured.

Let me just quote for you what healthcare providers and State organizations around the country are saying as to the horrific impact that this legislation would have. I know many of my Republican colleagues get up and say it is not true; it is this, that, and the other thing. Listen to the doctors, listen to the organizations, the healthcare providers in your own State.

Let me just begin with Texas, a Dr. Audrey Nath, where the uninsured rate will reach 20 percent. Anybody from Texas watching this, you are going to be--if this bill goes through, you might want to say hello to your Senators here. Your uninsured rate is going to go up to 20 percent.

This is what Dr. Audrey Nath wrote:

These cuts will cause rural hospitals in Texas to close entirely. As a neurologist, I am terrified that the closest hospital for many rural folks may then be hours away. During an ischemic stroke, there is only 3 hours of precious time--

If you have a stroke, you have to get care very quickly. She writes that ``the ``increased travel time may cause unnecessary cases of paralysis and death.''

That is obviously what happens, not only with a stroke but for many other illnesses if you don't have a hospital nearby.

Dr. Farhan Malik from Florida, where the uninsured rate will surge to almost 19 percent, wrote:

Plainly said, children will die as a result of these cuts. Hospitals will cut back on ICU doctors, doctors will leave because of salary cuts, critical ancillary services will be reduced and more medical students will avoid going into pediatric residencies.

Dr. Mia Henderson, who works at a community health center in Missouri, wrote that the cuts to Medicaid contained in this legislation would mean that ``we may not be able to keep the doors open''--of the community health center. ``We would potentially have to stop caring for many of our patients.''

The Louisiana Rural Health Association wrote:

Louisiana's rural hospitals and healthcare providers are already operating on razor-thin margins, struggling to keep their doors open while serving some of our most medically vulnerable communities. In Louisiana, 38 percent of hospitals operate on negative margins and 27 percent are currently vulnerable to closure. Medicaid cuts would worsen these losses, putting more hospitals at risk of shutting down entirely.

Dr. Sanjay Chaube, a doctor from Louisiana, told the HELP Committee:

The proposed cuts to Medicaid will cause untold hardship and deaths among my patients. DON'T DO THIS!

He puts that in capital letters.

You don't want the deaths of tens of thousands of Americans on your hands.

That is Dr. Chaube from Louisiana.

Dr. Gregory Omlor from Akron's Children's Hospital in Ohio told us:

If the proposed bill is passed and [my patients'] Medicaid insurance is cut, it doesn't mean their asthma will go away. It will mean that in most cases they will not receive preventive care . . . [and][s]ome children will die of their asthma.

And here is what another doctor from Ohio said:

Implementing work requirements into Ohio Medicaid will threaten my patients' gains. Most of my patients WANT to work--they are desperate to. There just aren't jobs available for folks with very low skills and health conditions that could cause them to miss work unexpectedly. The jobs that are available do not pay enough for an adult to survive, and they certainly don't offer health insurance. My patients who rely on Medicaid have frequently been born into generational poverty, have only had access to poor quality schools, and live in neighborhoods where their health suffers.

And by the way, this Dr. Omlor talks about work requirements. Let us understand that every single year millions and millions and millions of Americans lose their jobs not through any fault of their own. The company shuts down, company goes bankrupt, whatever it may be, they lose their jobs. They don't have a job. How are they going to get healthcare? We have taken healthcare away from them because they are not working.

The Vermont Association of Hospitals--my own State--the Association of Hospitals and Health Systems wrote that this bill ``reduces coverage and access, particularly in rural areas such as Vermont where hospitals and other health care providers are already financially fragile'' and that it will force hospitals in Vermont to ``cut back on clinical staff, services and care delivery.'' I can tell you hospitals in Vermont are struggling. This will make a very, very difficult situation even worse.

Now, I have got a radical idea, probably one that, I would say, 70 or 80 percent of the American people agree with, and that is maybe, just maybe, instead of throwing 16 million people off of healthcare, instead of creating a situation where 50,000 Americans die unnecessarily, why don't we do what every other major country on Earth does and guarantee healthcare to all people as a human right.

What about that?

Instead of throwing 16 million people off so we have almost 100 million uninsured, hey, why don't we do what Canada does, what the UK does, what Spain does, what Finland does, what Holland does, what every other major country on Earth does--guarantee healthcare to all people as a human right.

But the problem there is it is easier to throw working people off of their health insurance around here than to take on the Big Money interests who run the insurance industry and the pharmaceutical industry. That is what this is about.

In many respects, this bill represents exactly why many Americans are giving up on democracy and have such contempt for Congress and for the Democratic Party and for the Republican Party. At a time when the richest people have never ever had it so good, they now see Republican leadership working overtime to make the billionaire class even wealthier. At a time when the majority of Americans are struggling to put food on the table and pay for healthcare, they see Republican leadership making life even more difficult for average Americans.

So I would say that I speak for the overwhelming majority of the American people who think that it is basically insane that we are talking about throwing 16 million people off of the healthcare they have and creating a situation where 50,000 Americans will die unnecessarily each year in order to give hundreds and hundreds and hundreds of billions of dollars to billionaires and the wealthiest people in this country. This is a disastrous, obscene piece of legislation. It must be defeated.

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