HEALTHCARE LEGISLATION; Congressional Record Vol. 163, No. 109
(Senate - June 26, 2017)

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[Pages S3751-S3761]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                         HEALTHCARE LEGISLATION

  Mr. MERKLEY. Mr. President, I appreciate the comments of the Senator 
from Hawaii tonight. They are certainly very relevant to the issue of 
healthcare here in America because each of us hopes that if a loved one 
gets ill, they will have the peace of mind that they know they will be 
able to get the healthcare they need and they will not go bankrupt in 
the process. Yet here we are tonight debating a bill titled ``Better 
Care Act.''
  Better Care, has ever there been a bill in the history of the United 
States of America so more perversely named than this Better Care Act 
which strips care from 22 million Americans?
  I was very struck by one equation of this bill; that is, that it 
provides to the richest 400 Americans $33 billion over a 10-year 
period. That is enough to pay for healthcare under Medicaid for 700,000 
individuals--700,000 individuals. It rips the healthcare away from them 
to give $33 billion to the richest 400 families. That is obscene. That 
is certainly not better care.
  It is hard for me to imagine that a single Member of this body would 
vote to proceed to this bill, but here we are. Until we get agreement 
that we are not going to proceed, we have to continue to carry on this 
fight.
  We know that 15 million people, CBO estimates, will lose healthcare 
in the next 12 months. That is even worse than the House bill. Last 
week, I came to this floor to call the Senate draft mean and meaner. 
The House bill was mean. The Senate's is meaner. Now we have the CBO 
estimate that says, yes, it is worse. One million more people would 
lose healthcare in a short period of time.
  Furthermore, the rate at which standard Medicaid is compressed--
Medicaid, as it existed before ObamaCare, that rate has increased to 
further diminish healthcare, having nothing to do with ObamaCare, just 
to add to the cruelty of this bill. So millions lose, but we deliver 
billions of dollars to the richest Americans.
  In my home State of Oregon, just the elimination of the expansion of 
Medicaid, the Oregon health plan--just that would eliminate 400,000 
Oregonians off healthcare.
  Imagine those individuals holding hands, 400,000 Oregonians, 
stretching from the Pacific Ocean to the State of Idaho. Anyone who has 
driven across Oregon would realize it is 400 miles across Oregon. If 
you are driving it, it is 7 hours of driving. For 7 hours, at 50 miles 
an hour, 60 miles an hour, you are passing a stream of people who would 
lose their healthcare just from the elimination of the expansion of 
Medicaid.
  My colleagues across the aisle have crafted this so as to put it 
beyond the next Presidential election, beyond the 2018 election and 
beyond the 2020 election. Why? They are so terrified of the impact of 
this on the election they decided to postpone it until after 2018 and 
2020, as if that makes it acceptable to rip healthcare from millions of 
people. That type of cynical, cynical act, purely political, is not 
going to be viewed well by the American public.
  If you are so ashamed of this bill, if someone is so ashamed that 
they want to postpone the effects beyond the next Presidential election 
3\1/2\ years from now, then maybe you should be so ashamed as not to 
vote to move to the bill here in the short term.
  One of our colleagues across the aisle noted today: I can't imagine--
not quite the exact word-for-word, but it is close. I can't imagine 
that anyone in America would have a chance to review this bill and 
truly understand it in time to proceed to it this week, including 
myself.
  Well, that is certainly true. Has there ever been a case where a bill 
profoundly affecting so many has not had the benefit of committee 
deliberation here in the Senate? Are we a legislative body or are we a 
dictatorship where everything is done behind closed doors

[[Page S3752]]

and then rammed through? That is not the American way, and that is not 
the constitutional vision for how the Senate should work. There is 
supposed to be time to consult healthcare experts and time to go home 
to consult our constituents and find out how they feel.
  If one is so terrified of this bill that you are afraid of your 
constituents, then you shouldn't vote to proceed to the bill. If one is 
so terrified you don't want to consult the experts, you shouldn't 
proceed to this bill. If you are so terrified that the reaction from 
the public will be so strong that it will put you in an awkward spot, 
then you shouldn't proceed to this bill--because you have the 
responsibility to consult with your folks back home, a responsibility 
to consult with healthcare experts, to understand every nuance of this 
bill.
  One of those facts is going to have a devastating impact on those who 
would go to nursing homes. Folks who are under Medicaid and in a 
nursing home have given up their entire income and assets before they 
can get Medicaid support.
  I was in Klamath Falls the weekend before this last weekend, went to 
a nursing home, and they said: Senator, almost 100 percent of the folks 
here on long-term care are paid for by Medicaid. I thought they were 
going to say 60 percent or two-thirds, because that is the national 
statistic. No, in rural Oregon, in Klamath Falls, almost 100 percent.
  Then we had the CEO of the Oregon Health Association reach out and 
address this issue of how it is going to affect seniors. Here are his 
exact words:

       I was on a call early today looking at some projections of 
     how hard Oregon and Medicaid-funded long-term care service 
     would be hit. If this bill passes, it literally could force 
     the closure of the majority of nursing facilities in Oregon 
     by 2025.

  One thing I can't get out of my mind. At another nursing home I went 
to is a woman named Deborah. I explained I was coming by to talk to 
people because I wanted to understand better the impact of this bill on 
long-term care.
  She said: Senator, I am paid for by Medicaid. If Medicaid disappears, 
I am on the street, and that is a problem because I can't walk.
  That is exactly what Deborah said. And, of course, it is a problem, 
not only because she can't walk but because she needs extensive care, 
which is why she is in long-term care to begin with.
  The anxiety was palpable among the nursing home residents, among the 
long-term care residents, because they have no backup plan, because 
they had to spend down their assets before they qualified for Medicare. 
Don't think of this just as ripping healthcare away from millions of 
working families, millions of struggling families, millions of 
children, but also from our seniors who are in long-term care, who need 
extensive care, and who have given up their assets in order to qualify 
for Medicaid. They used those assets to pay for it as long as they 
could, and now they are on Medicaid. We are prepared to take those 
folks, many of them in wheelchairs--like Deborah, unable to walk--and 
throw them into the street and say: too bad.
  The President called the House bill mean and indicated he wanted a 
bill with more heart. This is not a bill with more heart. We should not 
move to proceed to this bill.
  The PRESIDING OFFICER. The Senator from Minnesota.
  Ms. KLOBUCHAR. Mr. President, I thank my colleague from Oregon for 
his words.
  I rise today to give voice to the concerns I am hearing from so many 
people in my State and across the country about this repeal bill.
  First, I want to recognize my colleague from Hawaii, Senator Hirono, 
who spoke earlier tonight about her personal battle with kidney cancer, 
as she is an example to all of us of determination and grit when the 
going gets tough. She not only is going to the hospital for surgery 
tomorrow--which isn't an easy surgery--but she decided she wanted to 
spend the night before she went into the hospital here because she is 
so passionate about this issue.
  I know she is going to fight this disease and win and come out 
stronger than ever. I have been so moved by how she has taken on her 
personal fight against cancer at the same time that she has kept this 
fight going in the Senate. She is doing it not just for herself or for 
her State but for people all over the country.
  As Senator Hirono has said, her experience shows how quickly a 
routine visit to the doctor can turn into a serious diagnosis--a 
diagnosis that becomes a preexisting condition.
  Everyone who faces a serious illness, no matter who they are, should 
be able to focus all of their energy on getting better, not on how they 
are going to pay their medical bills. Unfortunately, the bill we are 
considering doesn't allow everyone to do that.
  As the nonpartisan Congressional Budget Office noted earlier today, 
this bill could mean the return of annual or lifetime limits on what 
insurance would cover for people with expensive conditions like cancer 
or Alzheimer's, and some key healthcare benefits might be excluded from 
insurance coverage altogether.
  It is no surprise that the Minnesota Hospital Association has said 
that this proposal ``creates a lot of chaos.''
  I was just at Northfield Hospital this weekend. It is a college town, 
but it is in the middle of a very rural part of our State, with a lot 
of farms surrounding it. In fact, they call the town ``Cows, Colleges, 
and Contentment.'' In that town and in that hospital, there wasn't a 
lot of contentment during my visit.
  The CEO of the hospital told me that he was worried that this bill 
could drive more of his patients to bankruptcy. I met with a number of 
people who were on the board and work at the hospital, and they were 
all very concerned about what the bill would mean.
  This did not mean that they didn't want to see changes to the 
Affordable Care Act. They do. They see the issues with premiums in our 
State. That is why our Republican legislature worked with our 
Democratic Governor to pass a bill for reinsurance, to try to use 
something to leverage the risk for the people in the exchange. We could 
do something similar on the Federal level, and we should, but that is 
not what this bill is about.
  The head of another hospital in my State said: ``They are shortening 
up the money, but they're not giving us the ability to manage the 
care.''
  A Minnesota seniors organization said that this bill ``feels like 
we're pulling the rug out from underneath families and seniors.'' That 
is why AARP strongly opposes the bill as well.
  According to the CBO report that we got today, this bill would cause 
22 million people to lose their coverage over the next 10 years--22 
million people. On Friday, my Republican colleague Senator Heller said 
that he ``cannot support a piece of legislation that takes insurance 
away from tens of millions of Americans.'' I agree.
  I hope our Republican colleagues will come to the negotiating table 
in a bipartisan way. I hope this administration will not sabotage the 
bill that we have now and will work with States like mine that want a 
waiver to be able to do the kind of cost sharing and the reinsurance 
that I just described. During that time, we can work together to 
actually make healthcare in America better and more affordable.
  We need to think about the real and devastating impacts on people's 
lives that this piece of legislation would have because that is what 
this debate is about. It is not about all of us going back and forth 
and citing facts and figures. In the end, it is about how this will 
affect people.
  It is about the lives of people like the mom in Minnesota who has a 
child with Down syndrome. She told me how she has seen Medicaid help 
parents of kids with disabilities avoid bankruptcy and how it helps 
school districts pay for the therapy children like hers need. She said 
that this bill is ``unconscionable''--that is her word--because of what 
it would do to adults and kids who have disabilities.
  We have more than half a million children in Minnesota who rely on 
Medicaid and the Children's Health Insurance Program. This includes 
kids like the students of a retired teacher from Northwestern 
Minnesota, right across from the North Dakota border. The teacher wrote 
in, saying that the bill is ``cruel and mean,'' especially for the 
families of special needs students.

  A lot of us have talked about how the President called the House bill 
mean and how we hoped to avoid a bill like

[[Page S3753]]

this in the Senate. In fact, this last weekend, he did admit that he 
had called the House bill mean after he had celebrated its passage. 
That is behind us.
  The President is the one who is known for speaking his mind and 
speaking directly. He didn't need a poll or a focus group or an 
accountant to look at the House bill. He just called it what it was--
mean.
  In Minnesota, people don't mince words either, and that is why that 
teacher told me exactly what the impact of this Senate bill would be. 
In fact, today the Congressional Budget Office--the nonpartisan 
Congressional Budget Office--confirmed it earlier today with its 
estimate that millions of people, 22 million people, would lose their 
Medicaid coverage because of the bill.
  Our debate today is about the lives of people like the retiree with 
Parkinson's in Minneapolis, who told me she is ``scared and worried.'' 
She is not just worried about the cuts to Medicaid but also about 
depleting the Medicare trust fund to pay for tax cuts for the very 
wealthy. As she told me, the future of these vital programs that so 
many Americans depend on is on the line.
  This healthcare bill is also about the people who are worried about 
taking care of their baby boomer parents at the same time that they are 
caring for their children. One woman told me about her mom, who died 2 
years ago at 95 after suffering from dementia for more than 20 years. 
She had worked her whole life, but as she got older, she couldn't 
afford the nursing care she needed so much. Luckily, she was able to 
rely on Medicaid to pay for it.
  More than half--54 percent--of nursing facility residents in 
Minnesota rely on Medicaid. I think when this House bill first came 
out, people thought, well, Medicaid--what does that have to do with my 
life? Then they started talking to their parents, their grandparents or 
they started talking to their neighbors, and that is when they 
realized, whoa, over 50 percent of people who go into assisted living 
and nursing homes end up relying on Medicaid.
  This woman's daughter told me she is worried that this bill's cuts 
would put those vital services for seniors at risk for so many other 
parents and their kids. And even for older people who don't use 
Medicare or Medicaid, this bill could put health coverage out of reach. 
That is because it has an age tax for seniors, allowing older people to 
be charged five times as much as younger people for insurance. As AARP 
has said, that is just not right.
  These are the concerns I have heard from seniors and their families 
in Minnesota. They are shared by people across the country, especially 
by people in our rural areas, where they tend to have a little older 
population. One reason for that is because the Senate bill, actually 
more than the House bill when it comes to Medicaid, makes even deeper 
cuts over the long term that will hurt seniors and rural hospitals 
along with children, people with disabilities, and people suffering 
from opioid addiction.
  We actually have a strong bipartisan group working on the opioid 
addiction problem. Four of us--two Democrats, two Republicans--were the 
chief authors of the bill that passed last year, which set the 
framework for the Nation. We then put billions of dollars into 
treatment last year, and we shouldn't blow it up now by passing a bill 
that, because of the Medicaid cuts, would--in my State, one-third of 
the people who get opioid addiction treatment get it from Medicaid. 
Actually, it would be moving ourselves backward.
  I know my colleagues Senator Collins and Senator Murkowski have 
expressed real concerns about these kinds of Medicaid cuts in their 
States of Maine and Alaska, which also have big rural populations.
  In my State, Medicaid covers one-fifth of our total rural population, 
about 20 percent of our rural population. These cuts could cause the 
rural hospitals that serve this population to close. This doesn't just 
threaten healthcare coverage; it threatens the entire local economy. 
That is a big deal for rural hospitals, which often have operating 
margins of less than 1 percent. These rural hospitals are on the 
frontlines of the opioid epidemic that is hitting communities across 
the country.
  In my State, deaths from prescription drugs now claim more lives than 
homicides. They claim more lives than car crashes. While there is more 
work to do to combat the epidemic, I want to recognize our progress. 
Yes, we passed the blueprint bill, which I just mentioned, with the 
help of Senators Portman, Whitehouse, and Ayotte. Unfortunately, we are 
moving ourselves backward.
  Medicaid expansion has helped 1.3 million people receive treatment 
for mental and substance abuse across the country. I know this bill's 
cuts to these important services for people struggling with addiction 
have real concerns in States like West Virginia and States like Ohio.
  The problems with this bill, of course, go beyond Medicaid cuts, as a 
mom from Belgrade, MN, told me when she wrote about her daughter who 
died way too young from cancer. She asked me to oppose this bill in 
honor of her daughter and the thousands of other children diagnosed 
with cancer each year. She is worried that the waivers in this 
legislation would undercut protections for people with preexisting 
conditions, threatening to make health insurance unaffordable for 
families like hers who have children or children with cancer.
  One man from Minneapolis told me that what this does is ``downright 
scary.'' Those were his words. He is scared because he is self-
employed. He has a preexisting condition, and he gets his insurance on 
the individual market. He is worried that under this bill, his costs--
which are already high--would skyrocket.
  I am the first to say that we need to fix the individual market. In 
fact, I started out by talking about the fact that we have done some 
work in our State, and I would like to bring that out nationally. This 
bill is not the way to do it because--as the CBO said earlier today--it 
would actually cut assistance and increase deductibles for many people 
on the individual market. Based on CBO's projections, the Joint 
Economic Committee estimates that average premiums in Minnesota would 
go up substantially next year, even more than they have gone up 
already.
  People across the country are making their voices heard about these 
types of problems. According to the Kaiser Family Foundation poll that 
came out just last week, only 30 percent of Americans had a favorable 
view of the House bill, and these concerns go across party lines. Only 
about half of Republicans--56 percent--supported the House bill.
  I know this bill has some differences from the House version, but as 
Speaker Ryan said last week, the two are very similar. I hope that 
hearing from Americans on both sides of the aisle prompts my colleagues 
to start working together to make our system better in a bipartisan 
way.
  Here are some ideas. I would love to include, if we worked on a 
bipartisan basis together, not only the work that needs to be done on 
the individual market, but on the exchanges, on the rates, and for 
small businesses. But I would also like to work on prescription drugs. 
I have a bill that would harness the negotiating power of 41 million 
seniors on Medicare to bring drug prices down. We have a number of 
Senators on the bill. Right now, Medicare is absolutely banned from 
negotiating with 41 million seniors. That is just wrong. Our seniors 
should be able to use their market power to negotiate.
  I would also love to see more competition in this market. There are 
several ways we can do it. One is by bringing in less expensive drugs 
from other countries when we have drug shortages now in this country. 
Senator Collins and I worked on this, and the bill passed this Senate 
and got signed into law. Now the Secretary of Human Services can 
actually bring in drugs that are safe from other countries when we have 
a drug shortage. We refined some of the language where the rules 
already allowed the Secretary to do that. They could do the same thing 
right now, but we can make it even more clear if this Congress got 
behind it.
  Senator McCain and I have a bill to bring in less expensive drugs 
from Canada, which is very similar to the American market. We have a 
provision in the bill so they would be safe. Many people in my State 
are doing this now. We once had bus rides of seniors going up there to 
get less expensive drugs. We could do it with other countries, as

[[Page S3754]]

well, as long as they were certified as safe. For one of the ways you 
could do it, Senator Lee and I have a bill that looks at this. Again, 
this a bipartisan bill. If you have less competition in the market and 
you have less competitors, that would trigger the ability to bring in 
more drugs. You could do it based on the price. If it goes up high and 
the Secretary or someone else that we could put in that place finds 
that it is not because of input costs, you could allow this competition 
to come in from other countries. It would be a trigger. I would bet you 
right now that if you did that, it would create incentives on American 
drug companies not to jack up the prices like they have been doing.
  The top 10 selling drugs in America have gone up over 100 percent. 
Things like insulin are up three times. Things like naloxone, which we 
rely on for overdoses from opiates, have gone up astronomically. It 
feels like when these drug companies get a monopoly in their lap, they 
go for it. That is what is happening.
  A second way to bring in competition is by encouraging more generics. 
Senator Grassley and I have a bill to stop something called ``pay for 
delay.'' This is unbelievable to me, when I describe this to people--
that big pharmaceutical companies are actually paying generic companies 
to keep their products off the market. The nonpartisan Congressional 
Budget Office has found that this would save something like $3 billion 
over a number of years if we passed our bill. That is for the 
government and taxpayers, but you could save an equal amount of money 
for consumers who are paying for this in premiums. How could you ever 
explain that pharmaceuticals are actually paying generics to keep their 
products off the market? That is a vote I would like this Senate to 
take. I would like to challenge anyone to explain why they would vote 
against that.
  We also have another bill called the CREATES Act, with Senators 
Grassley, Leahy, Lee, and me, which makes it easier to get generics to 
market by sampling and other things.
  These are just a few of the examples of bills that I think would be 
very good if we would consider them, but so far, we have done nothing. 
We banned seniors from negotiating. There is nothing in the House or 
the Senate repeal bills that does anything about these pharma issues. 
Again, that is one reason alone to be concerned about these bills.
  I was at that baseball game a few weeks ago and saw firsthand that 
incredible bipartisan spirit, and at the women's softball game, as 
well. At the men's baseball game, the players played together, and, at 
the end of the game, when one team won--the Democratic team--they took 
their trophy and they gave it to the Republican team, and they asked 
them to put it in Representative Scalise's office. That is what we need 
to see more of--not just two teams but one team. Certainly, on an issue 
as complex as healthcare, we just can't be playing in our separate 
ballparks. This is the time to come together. We have changes that we 
must make to the Affordable Care Act. I said that the day it passed--
that it was a beginning and not an end.
  I always thought it was unfortunate that it was more of a Democratic 
bill than it was a bipartisan bill. So we have an opportunity now to 
fix that, to make fixes to the bill, and to work together. But this 
bill is not the answer--this bill that we were not allowed to take part 
in, where the doors were closed, not only to Democratic Senators but to 
Americans themselves.
  So I hope, as we go forward, that our colleagues on the other side 
will work with us on a truly bipartisan bill that would make some of 
the changes we need to bring down healthcare costs, instead of moving 
forward with this bill.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Massachusetts.
  Mr. MARKEY. Mr. President, I would like to thank my friend and 
colleague Senator Hirono for her words and her willingness to share how 
this bill could impact the millions of Americans with preexisting 
conditions. I, along with everyone else in this Chamber, wish her the 
best and a speedy recovery so she can continue to fight for the people 
of Hawaii and the people of the United States.
  After weeks of secret meetings, Senate Republicans released their 
healthcare legislation last week. In many ways, it is even worse than 
expected. It is no wonder that the Senate Republicans kept this 
legislative malpractice hidden behind closed doors. For working 
families and the elderly, for the disabled and for those suffering from 
opioid addiction, this legislation is a death sentence. This bill takes 
a machete to Medicaid. It abandons people with preexisting conditions. 
It punishes Grandma and Grandpa, who live in a nursing home, and 25,000 
seniors in Massachusetts' nursing homes who are on Medicaid.
  It causes the single greatest rollback of civil rights for people 
with disabilities in a generation, by taking away the funding for those 
with disabilities. It creates an age tax for those over the age of 50. 
It shreds a critical healthcare program for the disabled, working 
families, and children just to bestow billions in tax breaks for the 
wealthiest in our country.
  This is an amazing number. The richest 400 billionaires in the United 
States will get a tax break of more than $33 billion, which is roughly 
equivalent to the cuts from ending Medicaid expansion in four States. 
That is more than 700,000 people in just those four States who could be 
kicked off of their health insurance coverage to benefit just 400 
billionaires in America who do not have to worry about their healthcare 
or their family's welfare. But for those who are going to lose the 
coverage--people with cancer, people with Alzheimer's, people who need 
opioid addiction treatment, people with diabetes--they will have their 
healthcare coverage slashed so that 400 billionaires can get a tax 
break, which they don't need and they don't deserve. That is at the 
heart of this Republican healthcare bill. It is what it is all about. 
This legislation is of the rich, by the rich, and for the rich.
  It is a ``wealth care'' bill for the upper 1 percent in our country, 
and it says to everyone else: Your healthcare is going to suffer in 
order to take care of that 1 percent with their tax breaks. It is a 
more than $500 billion tax break to corporations and individuals making 
$200,000 or more. It is no wonder that President Trump has kept his tax 
returns secret, because he knew he was about to get a massive tax break 
through this legislation from slashing healthcare for people with 
cancer, diabetes, Alzheimer's, heart disease, and substance use 
disorders. This selfish Senate Republican legislation will increase 
premiums and out-of-pocket costs, while decreasing the quality of 
health insurance coverage for most Americans.
  This bill would result in many Americans--especially those over the 
age of 50--paying thousands more in premiums for skimpier health plans. 
It will put insurance companies back in charge of our healthcare by 
allowing them to waive coverage of the essential health benefits like 
emergency care, prescription drugs, maternity care, or mental health 
treatment.
  That means that someone with a preexisting condition, like a cancer 
survivor or a child with asthma, might have insurance but not actually 
be covered for the treatment they need, because under this bill, the 
anxiety of suffering from an illness or the constant fear of relapse 
will once again be exacerbated by financial insecurity.
  Yet some of the most damaging provisions of this legislation are the 
brutal cuts to Medicaid, which already serves more than 70 million 
Americans, including, very importantly, two-thirds of all seniors in 
nursing homes in America, who are on Medicaid. Let me say that again: 
Two-thirds of all seniors in America are on Medicaid. Half of all 
seniors over the age of 85 have Alzheimer's, and 15 million baby 
boomers are going to have Alzheimer's. They are going to need some 
help. People have a hard time paying $60,000, $80,000, $100,000 a year 
for a nursing home bed. What are the Republicans planning on doing over 
the next 15 years? Slashing that funding in Medicaid for seniors in our 
country who will need that help just to stay in a nursing home, or else 
they are going to have to go home to their families who will be 
responsible for providing the care for them.
  The Senate Republicans doubled down and opted for even steeper cuts 
in their bill than in the House version. In

[[Page S3755]]

3 years, the Senate bill will start the process of kicking millions off 
of their Medicaid coverage by ending Medicaid expansion in States 
around the country. It will mean 22 million Americans are kicked off of 
coverage.

  Then, as if that wasn't enough, starting in 2025, the plan will 
institute even more drastic Medicaid cuts that every year become a 
deeper cut than the year before, and it will literally mean death by a 
billion cuts for millions of Americans who will lose their healthcare 
coverage, especially those suffering from substance use disorders. 
Medicaid covers about one-third of Americans with an opioid use 
disorder and pays for nearly half of the medication-assisted treatments 
in Massachusetts. Taking away this treatment would be a death sentence 
for thousands of Americans.
  A vision without funding is a hallucination. The Republicans are 
saying: We will find the will to take care of these people with opioid 
treatments. Well, you can't will your way to dealing with an opioid 
crisis. It is a disease. You need funding. You need treatment. And 
right now, there are millions of Americans who don't have the treatment 
they need. Medicaid is the way in which it will be provided, but the 
Republicans are just going to slash it, and the consequences are going 
to be catastrophic.
  Now, here is what the Republicans are saying: To make up for the cuts 
to Medicaid, the Senate Republican healthcare legislation creates an 
opioid fund of $2 billion for 2018. Compare that to the $91 billion in 
funding for opioid use disorder treatment that would be provided by the 
Affordable Care Act over the next 10 years. A $2 billion opioid fund is 
pocket change for a crisis that took 2,000 lives just last year in 
Massachusetts and 33,000 lives across the country. And if people were 
dying from opioid addiction at the rate they are dying in 
Massachusetts, that would be a 100,000 people a year--two Vietnam wars 
a year dying from opioid addiction. They are going to slash the funding 
for treatment for these families. It will be a death sentence for these 
individuals if they do not have access to the funding.
  So the formula of this bill is simple: First, increase the cost of 
care, so working families pay more. Second, decrease the quality of 
care for seniors and the sick. Finally, hand over the hundreds of 
billions of dollars in tax breaks to the wealthiest people in our 
country--billions in tax breaks to people who don't need them, who 
don't deserve them, paid for by people who can't afford it. It is 
healthcare heartlessness.
  To add insult to injury, it will devastate the budgets of already 
strapped States, which may be forced to raise taxes or cut other 
benefits, such as education or housing assistance, to make up for the 
billions of dollars States will lose because of this bill.
  It is cruel. It is inhumane. It is immoral. It is just plain wrong to 
cut healthcare benefits for those who need them to give tax breaks to 
those who do not need them. That is the Republican plan.
  The Republican leadership is trying to catch a political unicorn with 
this bill--to make moderate Republicans happy while satisfying the most 
conservative elements of the Republican Party. But there is no 
treatment for TrumpCare. It is dangerous for healthcare, and there is 
no reviving Medicaid if this bill passes.
  This Republican proposal has never been about policy. It isn't about 
covering more people or decreasing costs of healthcare or making it 
more patient-centered. The Republican proposal has always been about 
slashing healthcare for ordinary Americans to give a massive tax break 
to the wealthy in our country. That is the Republican policy agenda, 
not patient-centered care, because this will hand back over the power 
to insurance companies in our country, not to patients.
  If Republicans were really concerned about reducing the deficit, then 
every single dollar in this bill would go to reducing the deficit--the 
crocodile tears which they shed about the deficit. No, ladies and 
gentlemen, they are shoving this money straight to the biggest number 
of billionaire beneficiaries than any tax bill in our country's 
history. They are, in fact, the party of the wealthy. They are the 
party trying to make sure that those who are in charge of funding the 
Republican Party now receive their pay back in the form of tax cuts at 
the expense of the healthcare of the ordinary people in our country. 
That is selfish, that is unconscionable, and that is why the Democrats 
are going to fight this every step of the way this week in order to 
protect healthcare for every American.
  Mr. President, I yield the floor.
  The PRESIDING OFFICER. The Senator from Vermont.
  Mr. SANDERS. Mr. President, today's Congressional Budget Office 
analysis of the Trump-McConnell healthcare bill gives us 22 million 
reasons why this legislation should not see the light of day. What CBO 
tells us in truth is that this bill really has nothing to do with 
healthcare; rather, it is an enormous transfer of wealth from the sick, 
the elderly, the children, the disabled, and the poor into the pockets 
of the wealthiest people in this country.
  According to CBO--and that report came out just a few hours ago--this 
bill would throw 22 million Americans off of health insurance, cut 
Medicaid by over $770 billion, defund Planned Parenthood, and 
substantially increase premiums for older Americans. Under this bill, a 
64-year-old with an income of $56,000 could see his or her premiums 
increase from $4,400 under current law to $16,000--an increase of 
nearly 850 percent. How are older workers in this country going to deal 
with an 850-percent increase in their premiums? Meanwhile, the Trump-
McConnell bill would provide a $231 billion tax break to the top 2 
percent and hundreds of billions more in tax breaks to the big drug 
companies and insurance companies that are ripping off the American 
people every day.
  At a time when the middle class of this country continues to shrink 
and when families all across America are struggling to make ends meet, 
to put food on the table, to pay their rent, to save a few bucks for 
retirement, we cannot take from working-class families and we cannot 
take from the sick and the elderly and the children in order to give 
even more to the very wealthiest people in this country--people who are 
at this moment doing phenomenally well.
  Mr. President, this, in fact, is a barbaric and immoral piece of 
legislation. But let's be very clear. It is not just Bernie Sanders who 
opposes this bill. It is not just every Member in the Democratic caucus 
who opposes this bill. It is not just that the overwhelming majority of 
the American people oppose this legislation. According to a recent NBC/
Wall Street Journal poll, only 16 percent of the American people 
thought this bill was a good idea. This bill is opposed by virtually 
every major healthcare organization in this country--the people on the 
frontlines, the people who today, yesterday, and tomorrow are dealing 
with healthcare issues, dealing with the sick, working in hospitals, 
working in community health centers. Almost without exception, every 
major healthcare organization in this country opposes this bill.
  Maybe my Republican friends might want to get beyond the politics, 
get beyond Republicans and Democrats, and ask the people who really 
know about healthcare in America and ask yourself, how does it happen 
that virtually every major healthcare organization in this country 
opposes this legislation?
  The AARP opposes this legislation--the largest senior group in 
America, which knows what high premiums for healthcare will do to their 
membership. The American Hospital Association knows a little bit about 
hospitals and what will happen to rural hospitals if this legislation 
is passed. The American Medical Association is a conservative 
organization. This is the doctors organization all over this country. 
This is not any progressive radical group; these are our doctors, the 
doctors we go to. They oppose this legislation because they know what 
will happen if there are massive cuts to Medicaid, if 22 million people 
are thrown off of health insurance. The American Academy of Family 
Physicians knows what this legislation will mean to the children of our 
country. The American Psychiatric Association, the Federation of 
American Hospitals, the Catholic Health Association, the American Lung 
Association, the Cystic Fibrosis Foundation, the March of Dimes, the 
National MS Society, the American Nurses Association--every one of 
these

[[Page S3756]]

organizations opposes the Republican legislation; not Bernie Sanders 
but every major healthcare organization says do not go forward with 
this disastrous bill.
  This is what the AARP, the largest senior group in America, said 
recently:

       This new Senate bill was crafted in secrecy behind closed 
     doors without a single hearing or open debate--and it shows. 
     The Senate bill would hit millions of Americans with higher 
     costs and result in less coverage for them.
       AARP is adamantly opposed to the Age Tax, which would allow 
     insurance companies to charge older Americans five times more 
     for coverage than every one else while reducing tax credits 
     that help make insurance more affordable.

  I ask all of my Republican friends to think for a moment about the 
implications of this bill and what it will mean to your constituents 
when they lose the healthcare they currently have. Put yourself in 
their place. Today you have health insurance, but tomorrow, next year, 
you might not. What does that mean? Think about it.
  What does it mean if you are an individual today--and, sadly, there 
are too many of them. If you are a person today suffering with cancer 
and you are fighting for your life--maybe you are on radiation 
treatment. Maybe you are on chemotherapy. You are scared to death. You 
don't have a lot of money. You have cancer. You are struggling. And now 
you are reading in the papers that this Republican bill may take your 
health insurance away from you? How do you think they feel? I suspect 
scared to death. It is the same with people who have heart disease, who 
have asthma, who have diabetes or any other life-threatening illness. 
What happens to those millions of people when they cannot afford to go 
to the doctor when they are sick, cannot afford to buy the medicine 
they desperately need?
  Mr. President, I know this is a sensitive issue, but I am going to 
raise it, and that is that the horrible and unspeakable truth is that 
if this legislation were to pass, and I am going to do everything I can 
to see that it doesn't, but if it were to pass, many thousands of our 
fellow Americans every single year will die, and many more will suffer 
and become much sicker than they should. That is not, again, Bernie 
Sanders talking; that is exactly what a number of studies have shown. 
Study after study, including one from the American Journal of Public 
Health to the New England Journal of Medicine, to the Harvard School of 
Public Health have told us. Again, this is not Bernie Sanders engaging 
in a rhetorical debate; this is what scientists and doctors who have 
studied the issue are telling us.

  In fact, just this afternoon, a few hours ago, the Annals of Internal 
Medicine, a prestigious medical journal, published an article from 
researchers at the City University of New York School of Urban Public 
Health at Hunter College and Harvard Medical School entitled: ``The 
Relationship of Health Insurance and Mortality: Is Lack of Insurance 
Deadly?'' That is the title of the article appearing today.
  According to a summary of this article, ``Insurance decreases the 
odds of dying among adults by at least 3 percent and as much as 29 
percent and `being uninsured substantially raises the risk of dying.' 
''
  The coauthor of this article, Dr. David Himmelstein, commented:

       According to the CBO, the Senate Republicans' plan would 
     strip coverage from 22 million Americans. The best estimate 
     based on scientific studies is that about 29,000 Americans 
     would die each year as a result.

  I know no Republican wants to see anybody die--none of us do--but 
that is the reality we are dealing with, and you cannot ignore it. If 
somebody has cancer, if somebody has heart disease and you take away 
their health insurance, I don't need studies from Harvard University to 
tell me and to tell you what you know to be the case. This is the 
United States of America, and we can do better than that.
  Mr. President, I ask unanimous consent that the article that appeared 
today in the ``Annals of Internal Medicine'' be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

           [From Annals of Internal Medicine, June 27, 2017]

    The Relationship of Health Insurance and Mortality: Is Lack of 
                           Insurance Deadly?

    (By Steffie Woolhandler, MD, MPH, and David U. Himmelstein, MD)

       (About 28 million Americans are currently uninsured, and 
     millions more could lose coverage under policy reforms 
     proposed in Congress. At the same time, a growing number of 
     policy leaders have called for going beyond the Affordable 
     Care Act to a single-payer national health insurance system 
     that would cover every American. These policy debates lend 
     particular salience to studies evaluating the health effects 
     of insurance coverage. In 2002, an Institute of Medicine 
     review concluded that lack of insurance increases mortality, 
     but several relevant studies have appeared since that time. 
     This article summarizes current evidence concerning the 
     relationship of insurance and mortality. The evidence 
     strengthens confidence in the Institute of Medicine's 
     conclusion that health insurance saves lives: The odds of 
     dying among the insured relative to the uninsured is 0.71 to 
     0.97.)
       This article was published at Annals.org on 27 June 2017.
       At present, about 28 million Americans are uninsured. 
     Repeal of the Affordable Care Act would probably increase 
     this number, while enactment of proposed single-payer 
     legislation would reduce it. The public spotlight on how 
     policy changes affect the number of uninsured reflects a 
     widespread assumption that insurance improves health.
       A landmark 2002 Institute of Medicine (IOM) report on the 
     effects of insurance coverage on the health status of 
     nonelderly adults buttressed this assumption. The IOM 
     committee responsible for the report found consistent 
     evidence from 130 (mostly observational) studies that ``the 
     uninsured have poorer health and shortened lives'' and that 
     gaining coverage would decrease their all-cause mortality.
       The IOM committee also reviewed evidence on the effects of 
     health insurance in specific circumstances and medical 
     conditions. It concluded that uninsured patients, even when 
     acutely ill or seriously injured, cannot always obtain needed 
     care and that coverage improves the uptake of essential 
     preventive services and chronic disease management. The 
     report found that uninsured patients with cancer presented 
     with more advanced disease and experienced worse outcomes, 
     including mortality; that uninsured patients with diabetes, 
     cardiovascular disease, end-stage renal disease, HIV 
     infection, and mental illness (the five other conditions 
     reviewed in depth) had worse outcomes than did insured 
     patients; and that uninsured inpatients received less and 
     worse-quality care and had higher mortality both during their 
     hospital stays and after discharge.
       At the time of the IOM report, only one adequately 
     controlled observational study had examined the effect of 
     coverage on all-cause mortality. In this review, we summarize 
     key evidence on this issue (Table 1), focusing on studies 
     that have appeared since the IOM report and other previous 
     reviews. Although not reviewed in detail here, more recent 
     studies generally support the earlier reviews' conclusions 
     that insurance coverage improves mortality in several 
     specific conditions (such as trauma and breast cancer), 
     augments the use of recommended care, and improves several 
     measures of health status.


                                METHODS

       We searched PubMed and Google Scholar on May 19, 2017, for 
     English-language articles by using the following terms: 
     ``[(uninsured) or (health insurance) or (un-insurance) or 
     (insurance)] and [(mortality) or (life expectancy) or (death 
     rates)].'' After identifying relevant articles, we searched 
     their bibliographies and used Google Scholar's ``cited by'' 
     feature to identify additional relevant articles. We limited 
     our scope to articles reporting data on the United States, 
     quasi-experimental studies of insurance expansions in other 
     wealthy nations, and recent cross-national studies. We 
     contacted the authors of 4 studies to clarify their published 
     reports on mortality outcomes.
       We excluded most observational studies that compared 
     uninsured persons with those insured by Medicaid, Medicare, 
     or the Department of Veterans Affairs because preexisting 
     disability or illness can make an individual eligible for 
     these programs. Hence, relative to those who are uninsured, 
     publicly insured Americans have, on average, worse baseline 
     health, thereby confounding comparisons. Conversely, 
     comparisons of the uninsured to persons with private 
     insurance (which is often obtained through employment) may be 
     confounded by a ``healthy worker'' effect: that is, that 
     persons may lose coverage because they are ill and cannot 
     maintain employment. Nonetheless, most analysts of the 
     relationship between uninsurance and mortality have viewed 
     the privately insured as the best available comparator, with 
     statistical controls for employment, income, health status, 
     and other potential confounders.
       Finally, we focus primarily on nonelderly adults because 
     most studies have been limited to this group, and this group 
     is likely to experience large gains or losses of coverage 
     from health reforms. Since the advent of Medicare in 1966, 
     almost all elderly Americans have been covered, precluding 
     studies of uninsured seniors. Although Medicare's 
     implementation may not have accelerated the secular decline 
     in seniors' mortality, the relevance of this experience, 
     which predates many modern-day therapies, is unclear.
       Children have also been excluded from most recent analyses 
     of the relationship of

[[Page S3757]]

     insurance to mortality. Deaths in this population beyond the 
     neonatal period are so rare that studies would need to 
     evaluate a huge number of uninsured children to reach firm 
     conclusions, and high coverage rates make assembling such a 
     cohort difficult. The few studies addressing the effect of 
     insurance on child survival have found that coverage lowers 
     mortality and few policy leaders contest the importance of 
     covering children.


                     RANDOMIZED, CONTROLLED TRIALS

       Only one well-conducted randomized, controlled trial 
     (RCT)--the Oregon Health Insurance Experiment (OHIE)--has 
     assessed the effect of uninsurance on health outcomes. In 
     2008, the state of Oregon opened a limited number of Medicaid 
     slots to poor, able-bodied, uninsured adults aged 19 to 64 
     years. The state held a lottery among persons on a Medicaid 
     waiting list, with winners allowed to apply for a slot. The 
     OHIE researchers took advantage of this natural experiment to 
     assess the effect of winning the lottery on the 74,922 
     lottery participants.
       Many lottery winners did not enroll in Medicaid, and 14.1% 
     of lottery losers obtained Medicaid through other routes 
     (some also got private coverage). Hence, the difference in 
     the ``dose'' of Medicaid coverage was modest, an absolute 
     difference of about 25%; to adjust for this, the OHIE 
     researchers multiplied outcome differences by about 4.
       At 1 year of follow-up, the death rate among lottery losers 
     was 0.8%, and the winners' death rate was 0.032% lower, a 
     ``dose-adjusted'' difference of 0.13 percentage points 
     annually. This difference was not statistically significant, 
     an unsurprising finding given the OHIE's low power to detect 
     mortality effects because of the cohort's low mortality rate, 
     the low dose of insurance, and the short follow-up.
       The findings on other health measures, obtained from in-
     person interviews and brief examinations on a subsample of 
     12,229 individuals in the Portland area, help inform the 
     mortality results. Most physical health measures were similar 
     among lottery winners and losers in the subsample. However, 
     winners had better self-rated health, were more likely to 
     have diabetes diagnosed and treated with medication, and were 
     much less likely to screen positive for depression. Medicaid 
     coverage was associated with a nonsignificant decrease of 
     0.52 (95% CI, 2.97 to -1.93) mm Hg in systolic blood pressure 
     and 0.81 (95% CI, 2.65 to -1.04) mm Hg in diastolic blood 
     pressure. In addition to the low dose of insurance, these 
     wide CIs reflect the lack of baseline blood pressure data; 
     this precludes analyses that take advantage of paired 
     measures on each individual, which would reduce the variance 
     of estimates.
       In sum, the OHIE yields a (nonsignificant) point estimate 
     that Medicaid coverage reduced mortality by 0.13 percentage 
     points, equivalent to a (nonsignificant) odds ratio of 0.84.
       Two older RCTs are also relevant to the effect of insurance 
     and access to care on mortality, although neither directly 
     compared insured and uninsured persons. In the RAND Health 
     Insurance Experiment, random assignment to full (first-
     dollar) coverage reduced diastolic blood pressure by an 
     average of 0.8 mm Hg (P < 0.05) relative to persons randomly 
     assigned to plans that required cost sharing, an effect size 
     similar to the blood pressure findings in the OHIE. Unlike 
     the OHIE, the RAND Health Insurance Experiment obtained 
     baseline blood pressure readings, allowing researchers to 
     determine that for participants with hypertension at 
     baseline, full coverage reduced diastolic blood pressure by 
     1.9 mm Hg, mostly because of better hypertension detection; 
     the effect was larger among low-income (3.5 mm Hg) than high-
     income (1.1 mm Hg) participants.
       The Hypertension Detection and Follow-up Program also 
     suggests that removing financial barriers to primary care in 
     populations with high rates of uninsurance may reduce


         TABLE 1.--SUMMARY OF STUDIES ON RELATIONSHIP BETWEEN INSURANCE COVERAGE AND ALL-CAUSE MORTALITY
----------------------------------------------------------------------------------------------------------------
                                                                               Estimated
                                                        Information on     Mortality Effect
     Study, Year (Reference)         Participants       Baseline Health     of Coverage vs.        Comments
                                                                               Uninsured
----------------------------------------------------------------------------------------------------------------
RCTs
    Oregon Health Insurance       74,922 nondisabled  Retrospective       OR, 0.84 (NS).....  Study was
     Experiment, 2013, 2011,       adults on waiting   survey of a                             underpowered
     2012.                         list for Medicaid.  subsample; no                           because of
                                                       baseline blood                          crossovers
                                                       pressure or other                       between insured
                                                       measurements.                           and uninsured
                                                                                               groups, low
                                                                                               mortality rate,
                                                                                               short follow-up.
                                                                                               Coverage was
                                                                                               associated with
                                                                                               nonsignificantly
                                                                                               lower (0.91 mm
                                                                                               Hg) average
                                                                                               diastolic blood
                                                                                               pressure
Quasi-experimental studies,
 population-based
    Sommers et al., 2012, 2017..  Nonelderly adults   None at individual  RR of death         Study examined
                                   in states           level; compared     expansion/          Medicaid
                                   expanding           trends in death     nonexpansion        expansions that
                                   Medicaid            rates in            states, 0.939 (P    preceded the
                                   (Arizona, New       expansion with      = 0.001).           ACA's expansions
                                   York, Maine) and    those in
                                   comparison states.  neighboring
                                                       states.
    Sommers et al., 2014........  Nonelderly adults   None at individual  RR for death in     The 2006 reform
                                   in Massachusetts    level; compared     Massachusetts       expanded Medicaid
                                   and comparison      trends in death     counties/matched    and implemented
                                   counties.           rates in            counties, 0.971     subsidized
                                                       Massachusetts       (P = 0.003).        coverage for low-
                                                       with those in                           income persons
                                                       matched control
                                                       counties.
    Hanratty, 1996..............  Newborns in         None at individual  RR for death, 0.95  Estimates varied
                                   Canadian            level; compared     or 0.96 (P < 0.05   slightly
                                   provinces           infant mortality    for both).          depending on how
                                   expanding           trends pre- vs.                         time trends were
                                   coverage at         postreform.                             modeled
                                   different times.
Quasi-experimental studies,
 clinic cohorts
    Lurie et al., 1984, 1986....  186 clinic          Clinic-based data.  OR at 1 y, 02.3     Large effect
                                   patients                                (NS).               probably reflects
                                   terminated from                                             very high
                                   Medicaid vs. 109                                            baseline risk.
                                   who remained                                                Among terminated
                                   eligible.                                                   patients with
                                                                                               hypertension,
                                                                                               average diastolic
                                                                                               blood pressure
                                                                                               increased 10 mm
                                                                                               Hg at 6 mo vs.
                                                                                               decrease of 5 mm
                                                                                               Hg among controls
                                                                                               (P = 0.003)
    Fihn and Wicher, 1988.......  157 patients        Clinic-based data.  OR not calculable   Marked
                                   terminated from                         from published      deterioration in
                                   outpatient VA                           data; per           blood pressure
                                   care vs. 74                             authors, ``at       control among
                                   controls.                               least 6% of         terminated
                                                                           terminated          patients
                                                                           patients died''.
Quasi-experimental studies using  Several cohorts     Repeated            Conflicting         Studies compared
 longitudinal data from the        followed for        questionnaires      results; some       mortality before
 Health and Retirement Study.      varying time        linked to           found lower         age 65 y and
                                   periods from age    Medicare records    deaths among        relative changes
                                   51 y.               and National        insured, and        in death rates
                                                       Death Index; no     others were null.   after acquisition
                                                       examination or                          of Medicare
                                                       laboratory data.                        eligibility.
                                                                                               Different
                                                                                               analytic
                                                                                               strategies
                                                                                               yielded different
                                                                                               conclusions
Population-based cohort follow-
 up studies.
    Sorlie et al., 1994.........  CPS respondents     None other than     HR for employed     No data on
                                   1982-1985.          being employed.     white women, 0.83   smoking, health
                                                                           (NS); HR for        status or other
                                                                           employed white      non-demographic
                                                                           men, 0.77 (P =      predictors of
                                                                           0.05).              mortality at
                                                                                               baseline
    Franks et el, 1993..........  NHANES respondents  Surveys, physical   HR, 0.8 (P = 0.05)  Controls for
                                   1971-1975.          examinations, and                       baseline health
                                                       lab test results.                       status included
                                                                                               physician-
                                                                                               assessed
                                                                                               morbidity
    Kronic, 2009................  NHIS respondents    Questionnaires      HR, 0.91 (P <       Control for self-
                                   1986-2000.          only.               0.05; without       rated health may
                                                                           control for self-   bias findings
                                                                           rated health) and   because this
                                                                           0.97 (NS;           variable is
                                                                           including self-     probably
                                                                           rated health).      confounded by
                                                                                               coverage
    Wilper et al 2009...........  NHANES respondents  Surveys and         HR, 0.71 (P <       Controls for
                                   1988-1994.          physician-rated     0.05).              baseline health
                                                       health after a                          status included
                                                       physical                                physician-
                                                       examination.                            assessed health
                                                                                               status
----------------------------------------------------------------------------------------------------------------

     mortality. That population-based RCT carried out in the 1970s 
     screened almost all residents of 14 communities, with 
     oversampling of predominantly black and poor locations. 
     Persons with hypertension were randomly assigned to free 
     stepped care in special clinics or referral to usual care. 
     Although the clinics' staff treated only hypertension-related 
     problems, they provided informal advice and ``friendly 
     referrals'' for other medical issues. Strikingly, all-cause 
     mortality was reduced by 17% in the intervention group, with 
     similar reductions in deaths due to cardiovascular and 
     noncardiovascular conditions.
       Finally, a flawed RCT carried out by the Social Security 
     Administration starting in 2006 bears brief mention. That 
     study randomly assigned people who were receiving Social 
     Security disability income and were in the waiting period for 
     Medicare coverage to receive immediate or delayed coverage. 
     Unfortunately, randomization apparently failed, with many 
     more patients with cancer assigned to the immediate coverage 
     than to the control group, precluding reliable interpretation 
     of the mortality results. Interestingly, persons receiving 
     immediate coverage had rapid and significant improvements in 
     most measures of self-reported health.


         MORTALITY FOLLOW-UP OF POPULATION-BASED HEALTH SURVEYS

       Several routinely collected federal surveys that include 
     information about health insurance coverage have been linked 
     to the National Death Index, allowing researchers to compare 
     the mortality rates over several years of respondents with 
     and without coverage at the time of the initial survey. One 
     weakness of these studies is their lack of information about 
     the subsequent acquisition or loss of coverage, which many 
     people cycle into and out of over time. This dilutes coverage 
     differences and may lead to underestimation of the effects of 
     insurance coverage.
       Sorlie and colleagues analyzed mortality among respondents 
     to the 1982-1985 Current Population Survey, with follow-up 
     through 1987. In analyses limited to employed persons, the 
     relative risk for death associated with being uninsured was 
     1.3 for white men and 1.2 for white women (neither overall 
     figures nor those for minorities were reported).

[[Page S3758]]

     The study's lack of data on important determinants of health, 
     such as smoking, and its reliance on employment status as the 
     only proxy for baseline health status weaken confidence in 
     its conclusions.
       Kronick used data from the 1986-2000 National Health 
     Interview Surveys, with mortality follow-up through 2002. The 
     mortality hazard ratio for uninsured versus insured 
     individuals was 1.10 (95% CI, 1.03 to 1.19) after adjustment 
     for demographic variables, smoking, and body mass index. The 
     hazard ratio fell to 1.03 (95% CI, 0.95 to 1.12) after 
     additional adjustment for baseline health, defined by using 
     self-reported disability and self-rated health. Although the 
     self-rated health scale is known to be a valid predictor of 
     mortality, it may introduce inaccuracies in comparisons of 
     uninsured versus insured persons. Recent data indicate that 
     gaining coverage improves self-rated health, before 
     improvements in objective measures of physical health are 
     detectable (or plausible). This suggests that uninsurance may 
     cause people to underrate their health, perhaps because of 
     anxiety or the inability to gain reassurance about minor 
     symptoms. Analyses, such as Kronick's, that rely on self-
     rated health for risk adjustment therefore may inadvertently 
     compare relatively sick insured persons to relatively healthy 
     uninsured persons, obscuring outcome differences caused by 
     coverage. Studies that include more objective measures of 
     baseline health should be less subject to any such bias.


   MORTALITY FOLLOW-UP OF POPULATION-BASED HEALTH EXAMINATION SURVEYS

       Two studies have analyzed the effect of uninsurance on 
     mortality using data from the National Health and Nutrition 
     Examination Survey (NHANES), which obtains data from physical 
     examination and laboratory tests among participants.
       Franks and colleagues analyzed the 1971-1975 NHANES, with 
     mortality follow-up through 1987. They compared mortality of 
     uninsured and privately insured adults older than age 25 
     years, adjusted for demographic characteristics, self-rated 
     health, smoking, obesity, leisure time exercise, and alcohol 
     consumption. In addition, their models controlled for 
     evidence of morbidity determined by laboratory testing and 
     medical examinations performed by NHANES staff. By 1987, 9.6% 
     of the insured and 18.4% of the uninsured had died. After 
     adjustment for baseline characteristics and health status, 
     the hazard ratio for uninsurance was 1.25 (95% CI, 1.00 to 
     1.55).
       Wilper and colleagues' study (which we coauthored) used 
     data from the 1988-1994 NHANES, with mortality follow-up 
     through 2000. The study assessed mortality among uninsured 
     and privately insured persons age 17 to 64 years, controlling 
     for demographic characteristics, smoking, alcohol 
     consumption, body mass index, leisure time activity, self-
     rated health, and physician-rated health after the NHANES 
     physician completed the medical examination. The study also 
     included sensitivity analyses adjusting for the number of 
     hospitalizations and physician visits within the past year, 
     limitations in work or activities, job or housework changes 
     due to health problems, and number of self-reported chronic 
     diseases, which yielded results similar to those of the main 
     model. In the main model, being uninsured was associated with 
     a mortality hazard ratio of 1.40 (95% CI, 1.06 to 1.84).


 QUASI-EXPERIMENTAL STUDIES OF STATE AND PROVINCIAL COVERAGE EXPANSIONS

       In two similar studies, Sommers and colleagues compared 
     mortality trends in states that expanded coverage to low-
     income residents (before implementation of the Affordable 
     Care Act) with trends in similar states without coverage 
     expansions.
       Their analysis of Medicaid expansions in Maine, New York, 
     and Arizona during the early 2000s found that adult mortality 
     rates fell faster in those states than in neighboring ones (a 
     relative reduction of 6.1%, or 19.6 deaths per 100,000), 
     coincident with a decline in the uninsurance rate of 3.2 
     percentage points. Mortality reductions were largest among 
     nonwhites, adults age 35 to 64 years, and poorer counties. 
     Sommers and colleagues' subsequent reanalysis using data that 
     allowed better matching to control counties yielded a 
     slightly lower estimate of the mortality effect. As the 
     authors note, the large mortality effect from a relatively 
     modest coverage expansion may reflect the fact that Medicaid 
     enrollment often occurred ``at the point of care for patients 
     with acute illnesses,'' leading to the selective enrollment 
     of those most likely to benefit from coverage.
       A study of the effect of Massachusetts' 2006 coverage 
     expansion compared mortality trends in Massachusetts counties 
     with those in propensity score-matched counties in other 
     states. Mortality decreased by 2.9% in Massachusetts relative 
     to the comparison counties, a difference of 8.2 deaths per 
     100,000 adults, with larger declines in poorer counties and 
     those with lower coverage rates before the expansion.


                    OTHER QUASI-EXPERIMENTAL STUDIES

       Several researchers have used data from the Health and 
     Retirement Study (HRS)--a longitudinal study that has 
     followed cohorts enrolled at age 51 years or older--to assess 
     the effect of insurance coverage on mortality. The HRS 
     periodically surveys respondents and their families and has 
     been linked to Medicare and National Death Index data.
       McWilliams and colleagues found significantly higher 
     mortality rates among uninsured compared with insured HRS 
     respondents, even after propensity score adjustment for 
     multiple predictors of insurance coverage. Baker and 
     colleagues found that respondents who were uninsured 
     (compared with those who had private insurance) had higher 
     long-term but not short-term mortality. After adjustment for 
     multiple baseline characteristics, including instrumental 
     variables associated with coverage (such as a spouse's union 
     membership), Hadley and Waidmann found a strong positive 
     association between insurance coverage and survival before 
     age 65 years. Black and colleagues suggested, on the basis of 
     a ``battery of causal inference methods,'' that others 
     overestimated the survival benefits of insurance and that 
     uninsured HRS respondents had only slightly higher (adjusted) 
     mortality than those with private coverage. Finally, studies 
     have reached conflicting conclusions as to whether the health 
     of previously uninsured persons improves (relative to those 
     who were previously insured) after they reach age 65 years 
     and become eligible for Medicare. Overall, the preponderance 
     of evidence from the HRS suggests that being uninsured is 
     associated with some increase in mortality.
       Some studies using other data sources suggest that death 
     rates drop at age 65 years, coincident with the acquisition 
     of Medicare eligibility, whereas others do not.
       Finally, several studies have assessed the relationship 
     between insurance coverage and hypertension control, a likely 
     mediator of any relationship between coverage and all-cause 
     mortality. Lurie and colleagues followed a cohort of 186 
     patients who lost Medicaid coverage because of a statewide 
     policy change and a control group of 109 patients who 
     remained eligible. Among those who lost coverage, 5 died 
     within 6 months (compared with none in the control group; P = 
     .16), and the average diastolic blood pressure of those with 
     hypertension increased by 10 mm Hg (compared with a 5-mm Hg 
     decrease in controls; P= 0.003). At 1 year, 7 patients who 
     had lost Medicaid and 1 control had died; blood pressure 
     differences were slightly less marked than seen at 6 months. 
     A similar study of patients terminated from Veterans Affairs 
     outpatient care because of a budget shortfall found marked 
     deterioration in hypertension control among the terminated 
     patients relative to controls who maintained access. These 
     clinic-based findings accord with cross-sectional population-
     based analyses of data from NHANES, which have found worse 
     blood pressure control among uninsured than insured patients 
     with hypertension.


      EVIDENCE FROM OTHER NATIONS AND FROM CROSS-NATIONAL STUDIES

       The United States lags behind most other wealthy nations in 
     life expectancy and is the only one with substantial numbers 
     of uninsured residents. Although many factors confound cross-
     national comparisons, a recent study suggests that worse 
     access to good-quality health care contributes to our 
     nation's higher mortality from medically preventable causes 
     (so-called amenable mortality). Similarly, a recent review of 
     studies from many nations concluded that ``broader health 
     coverage generally leads to better access to necessary care 
     and improved population health''.
       Quasi-experimental studies assessing newly implemented 
     universal coverage in wealthy nations have reached similar 
     conclusions. For instance, Taiwan's rollout of a single-payer 
     system in 1995 was associated with an accelerated decline in 
     amenable mortality, particularly in townships where coverage 
     gains were larger. In Canada, a study exploiting the 
     different dates on which provinces implemented universal 
     coverage estimated that coverage expansion reduced infant 
     mortality by about 5% (P < 0.03).
       Finally, a recent study of cystic fibrosis cohorts also 
     suggests that coverage improves mortality. Such patients 
     live, on average, 10 years longer in Canada than in the 
     United States. Among U.S. patients, those without known 
     coverage have the shortest survival; among the privately 
     insured, life expectancy is similar to that among patients in 
     Canada.

 TABLE 2.--WHY THE CAUSAL RELATIONSHIP OF HEALTH INSURANCE TO MORTALITY
                            IS HARD TO STUDY
------------------------------------------------------------------------
 
-------------------------------------------------------------------------
Deaths, especially from causes amenable to medical treatment, are rare
 among nonelderly adults, who account for most of the uninsured.
Because insurance might prevent death by slowing the decline in health
 over several years, short-term studies may underestimate its effects.
Many people cycle in and out of insurance diluting differences between
 groups.
Randomly assigning participants to no coverage is unethical in most
 circumstances.
Observational studies must address reverse causality. Illness sometimes
 causes people to acquire public insurance by qualifying them for
 Medicaid, Medicare, or Department of Veterans Affairs disability
 coverage. Conversely, illness may cause job loss and resultant loss of
 private coverage.
In cohort studies, adequate control for baseline health status is
 difficult, particularly in uninsured patients, whose lack of access
 lowers self-rated health and also causes less awareness of important
 risk factors, such as hypertension or hyperlipidemia.

[[Page S3759]]

 
Quasi-experimental studies, which exploit factors associated with
 coverage (such as policy changes), rest on unverifiable assumptions
 (e.g., that without a coverage expansion, mortality trends in states
 expanding coverage would parallel those in comparator state).
------------------------------------------------------------------------

                               DISCUSSION

       The evidence accumulated since the publication of the IOM's 
     report in 2002 supports and strengthens its conclusion that 
     health insurance reduces mortality. Several newer 
     observational and quasi-experimental studies have found that 
     uninsurance shortens survival, and a few with null results 
     used confounded or questionable adjustments for baseline 
     health. The results of the only recent RCT, although far from 
     definitive, are consistent with the positive findings from 
     cohort and quasi-experimental analyses.
       Several factors complicate efforts to determine whether 
     uninsurance increases mortality (Table 2). Randomly assigning 
     people to uninsurance is usually unethical, and quasi-
     experimental analyses rest on unverifiable assumptions. 
     Deaths are rare and mortality effects may be delayed, 
     mandating large studies with long follow-up. Many people 
     cycle into and out of coverage, diluting the effects of 
     insurance. And statistical adjustments for baseline health 
     usually rely on participants' self-reports, which may be 
     influenced by coverage. Hence, such adjustments may under- or 
     overadjust for differences between insured and uninsured 
     persons.
       Inferences about mechanisms through which insurance affects 
     mortality are subject to even greater uncertainty. In some 
     circumstances, coverage might raise mortality by increasing 
     access to dangerous drugs (such as oral opioids) or 
     procedures (such as morcellation hysterectomy). On the other 
     hand, coverage clearly reduces mortality in several serious 
     conditions, although few are common enough to have a 
     detectable effect on population-level mortality. The 
     exception is hypertension, which is prevalent among the 
     uninsured and seems a likely contributor to their higher 
     death rates. Although uncontrolled hyperlipidemia is also 
     more common among the uninsured, the OHIE--the only RCT 
     performed in the statin era--found no effect of coverage on 
     cholesterol levels.
       Finally, our focus on mortality should not obscure other 
     well-established benefits of health insurance: improved self-
     rated health, financial protection, and reduced likelihood of 
     depression. Insurance is the gateway to medical care, whose 
     aim is not just saving lives but also relieving human 
     suffering.
       Overall, the case for coverage is strong. Even skeptics who 
     suggest that insurance doesn't improve outcomes seem to vote 
     differently with their feet. As one prominent economist 
     recently asked, ``How many of the people who write such 
     things . . . choose to just not bother getting their 
     healthcare?''


                           Key Summary Points

       In several specific conditions, the uninsured have worse 
     survival, and the lack of coverage is associated with lower 
     use of recommended preventive services.
       The Oregon Health Insurance Experiment, the only available 
     randomized, controlled trial that has assessed the health 
     effects of insurance, suggests that insurance may cause a 
     clinically important decrease in mortality, but wide Cls 
     preclude firm conclusions.
       The 2 National Health and Nutrition Examination Study 
     analyses that include physicians' assessments of baseline 
     health show substantial mortality improvements associated 
     with coverage. A cohort study that used only self-reported 
     baseline health measures for risk adjustment found a 
     nonsignificant coverage effect.
       Most, but not all, analyses of data from the longitudinal 
     Health and Retirement Study have found that coverage in the 
     near-elderly slowed health decline and decreased mortality.
       Two difference-in-difference studies in the United States 
     and 1 in Canada compared mortality trends in matched 
     locations with and without coverage expansions. All 3 found 
     large reductions in mortality associated with increased 
     coverage.
       A mounting body of evidence indicates that lack of health 
     insurance decreases survival, and it seems unlikely that 
     definitive randomized, controlled trials can be done. Hence, 
     policy debate must rely on the best evidence from 
     observational and quasi-experimental studies.

  Mr. SANDERS. Mr. President, this issue is really not just about 
healthcare. This is a profound moral debate defining who we are as a 
people today and whom we want to be as a people in the future.
  A great nation is not simply one judged by how many millionaires and 
billionaires we have and by how many tax breaks we can give to 
billionaires. A great nation is judged by how we treat the weakest and 
the most vulnerable amongst us--those people who don't have fundraising 
dinners, those people who don't contribute hundreds of thousands of 
dollars into the political process. A great nation is judged by how we 
treat the children, the elderly, the sick, the poor, the people who 
have disabilities. This is what a great nation is. This legislation is 
not worthy of a great nation. This legislation must be defeated.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Washington.
  Ms. CANTWELL. Mr. President, I come to the floor to join my 
colleagues. We can see there are numerous colleagues on this side of 
the aisle who are speaking, just as my colleague from Vermont just did 
with great passion or my colleague from Massachusetts did with great 
passion and as I am sure my colleague from Minnesota will. We have all 
been home for the weekend talking to our constituents. We are all back 
here now with the CBO news, and we are here because we are very 
concerned about the next steps the Senate might take in this healthcare 
debate.
  When I was at home, I heard some unbelievably positive stories about 
healthcare. I was at a hospital in our State, Virginia Mason, which has 
been one of the leaders in reducing healthcare costs by utilizing new 
efficiencies. They have improved the return time of getting lab results 
to patients by 85 percent; they have increased productivity in some 
areas by 90 percent; they have reduced liability insurance premiums by 
76 percent. They have innovated. They have innovated. They have 
innovated. They talked about the direction healthcare should go, and 
not once did they mention cutting or capping Medicaid as a solution.
  I also talked to a community health center which, under the 
Affordable Care Act, was actually able to expand in a community. They 
literally cut in half the uninsured, and they are delivering great 
adult dental access to thousands of people in a county that didn't have 
good access to dental care. They are making great progress.
  I talked to a veteran who served our country, who literally got out 
and is now going to school but without the help of Medicaid would not 
have been able to cover her healthcare expenses.
  I met a woman on the street who told me her husband had lost his job. 
She never thought they would be on Medicaid, but when he lost his job, 
they went on Medicaid, and they depended on that to provide healthcare 
for themselves and their children.
  I met a gentleman who also said he, too, lost his job, and after that 
came down with a serious, life-threatening illness, and it was only 
Medicaid that saved him.
  So what do we know today that is different than last Friday? We now 
have some CBO numbers. We know the numbers. We know the numbers: that 
22 more million Americans, as a result of this bill, if it is passed, 
would be uninsured; 15 million of them on Medicaid; and $772 billion in 
Medicaid cuts. We know we thought it was heartless. Now we see the 
numbers that say cutting that many people off of Medicaid is, in my 
opinion, as my colleagues have also said, not something we should be 
pursuing as a nation. It leaves us to ask about not just the impact of 
this on individuals, as I just mentioned--because I believe there is a 
much better way to go with innovation--but what it also does for the 
individual market. A lot of this debate started because people thought 
the individual market hadn't seen some of the benefits of the employer-
sponsored system. Well, why not talk about the individual market?
  If 7 percent of the way people access health insurance, the 
individual market, was having a problem, why not talk about ideas to 
improve the individual market? Instead, we have a bill from the House 
and the Senate that beats up on the Medicaid population as if they are 
the culprit. If you want to improve Medicaid and delivery services and 
help decrease costs, let's do that. There are so many innovative ideas, 
but just cutting people off Medicaid to solve the individual market 
problem doesn't even make sense to me.
  We now have, as of last Friday, too, the Center on Budget Policy and 
Priorities' assessment, talking about how this would raise individual 
premiums in the individual market. They gave some examples. For 
example, in West Virginia and Nevada, a 60-year-old with an income of 
$36,000 would pay respectively, $5,000 and $4,000 more than what

[[Page S3760]]

they are paying now. In Alaska, a 60-year-old making $45,000 would pay 
$5,777 more than what they are paying now for premiums. So the notion 
that this bill is driving down costs is just a fallacy.
  We have heard from Republican and Democratic Governors talking about 
this. They sent us a letter saying the first thing we should do is 
focus on improving our Nation's private health insurance system. Where 
did the Governors ask that you come and beat up on Medicaid? They 
didn't say that. They didn't say: Please beat up on Medicaid, have a 
big party covering people on Medicaid as a partner with us for 65 years 
and then leave us stuck with the bill. They didn't say that. They say:

       Medicaid provisions included in this bill are problematic. 
     Instead, we recommend Congress address factors we can all 
     agree need fixing.

  That is a pretty clear message, I believe, from Republican Governors 
who are saying this is not the way to fix healthcare.
  Also, last week, a nonpartisan study by the George Washington 
University found that the House-passed bill would have a huge economic 
impact on our country. States' economies would shrink by $93 billion, 
compared to what they would be without the bill. Business output would 
be cut $148 billion. The study notes that the bill, combined with 
normal economic cycles ``could contribute to a period of economic and 
medical hardship in the U.S.''
  That report also talks about job loss throughout the country, saying 
that individual states would see more than $1 billion in lost gross 
State product, just because of the number of people who wouldn't be 
covered, the number of healthcare providers who would no longer be 
there, the loss of healthcare infrastructure and then the impact on the 
healthcare system overall for uncompensated care. These are costs we 
can't afford.
  As my colleague Senator Sanders mentioned, there are all these 
healthcare organizations that have now come out saying they don't 
support this Senate-drafted bill. The Academy of Family Physicians 
knows about caring for the Medicaid population. They are seeing so many 
patients, and they know what this challenge is. The American 
Psychological Association doesn't support this bill. Other healthcare 
associations, such as the Catholic Health Association, do not support 
this bill. I have a long list.
  Mr. President, I ask unanimous consent to have printed in the Record 
the list of healthcare-related organizations and others that don't 
support this legislation.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

            Organizations Opposed to Senate Health Care Bill

       Alliance for Retired Persons, America's Essential 
     Hospitals, American Academy of Family Physicians (AAFP), 
     American Academy of Pediatrics (AAP), American Association of 
     People with Disabilities (AAPD), American Association of 
     Retired Persons (AARP), American Cancer Society Cancer Action 
     Network (ACS CAN), American Civil Liberties Union (ACLU), 
     American College of Physicians (ACP), American Congress of 
     Obstetricians and Gynecologists (ACOG), American Diabetes 
     Association, American Federation of State. Country and 
     Municipal Employees (AFSCME), American Federation of Teachers 
     (AFT), American Health Care Association (AHCA), American 
     Heart Association (AHA), American Hospital Association (AHA), 
     American Lung Association, American Muslim Health 
     Professionals, American Nurses Association (ANA), American 
     Osteopathic Association, American Psychiatric Association 
     (APA).
       American Psychological Association, American Public Health 
     Association (APHA), Association of American Medical Colleges 
     (AAMC), Big Cities Health Coalition, Bread for the World, 
     California Public Interest Research Group (CPIRG), Catholic 
     Health Association (CHA), Cato Institute, Center for American 
     Progress, Center on Budget and Policy Priorities (CBPP), 
     Center for Law and Social Policy (CLASP), Center for 
     Reproductive Rights, Children's Hospital Association (CHA), 
     The Chronic Illness & Disability Partnership, Coalition on 
     Human Needs (CHN), Commission on Social Action of Reform 
     Judaism, Community Catalyst, Consumers Union, Cystic Fibrosis 
     Foundation, Ecumenical Poverty Initiative.
       Environmental Organizations, Families USA, Federation of 
     American Hospitals (FAH), First Focus, Friends Committee on 
     National Legislation, Hispanic Federation, Human Rights 
     Campaign (HRC), Indivisible, Leadership Conference on Civil 
     and Human Rights, Lutheran Services in America, Medicare 
     Rights Center, MomsRising, MoveOn.org, NARAL Pro Choice 
     America, National Advocacy Center of the Sisters of the Good 
     Shepherd, National Alliance on Mental Illness (NAMI), 
     National Breast Cancer Coalition, National Center for Lesbian 
     Rights, National Center for Transgender Equality, National 
     Committee to Preserve Social Security & Medicare (NCPSSM).
       National Council on Aging (NCOA), National Council for 
     Behavioral Health, National Council of Jewish Women (NCJW), 
     Planned Parenthood, Presbyterian Church (U.S.A.), Service 
     Employees International Union (SEIU), Trust for America's 
     Health (TFAH), National Multiple Sclerosis Society, National 
     Organization for Rare Disorders, National Partnership for 
     Women and Families, National Physicians Alliance, NETWORK 
     Lobby for Catholic Social Justice, Pacific Institute for 
     Community Organization (PICO) National Network, Physicians 
     for Reproductive Health, Society of St. Vincent DePaul, 
     Tennessee Justice Center, The Arc, Third Way, United Church 
     of Christ Justice & Witness Ministries, U.S. Conference of 
     Catholic Bishops, U.S. Public Interest Research Group (US 
     PIRG), Young Invincibles.

  Ms. CANTWELL. Mr. President, I hope my colleagues understand that 
there are those here who are very willing to talk about how we can 
improve our healthcare system, but we are not going to make poor 
Americans the scapegoat of our healthcare challenges.
  A gentleman named Joe Baker, president of the Medicare Rights Center, 
I think, said it best. He said:

       You or someone you love is going to need Medicaid. You may 
     not need the nursing home care . . . but you may rely on 
     community-based services, like home care, that will allow you 
     to stay in your home and out of a nursing facility. Medicaid 
     is the lifeline that covers many of the benefits that 
     Medicare does not provide.

  Now why did I read that? Why did I pick a guy who is the head of a 
Medicare organization? Because he knows what his individual 
organization participants need in a healthcare delivery system. 
Everybody knows--everybody knows the people of America are living 
longer and as they age they need more healthcare. To our colleagues who 
want to reduce those costs, we are ready to come and talk about how we 
are going to reduce those costs.
  I have talked about how I authored a community-based ``rebalancing'' 
program--the kind of rebalancing that helped our State save more than 
$2 billion. If we did that in every State, we would be saving billions 
of dollars, but the notion that we are going to proceed in the next 24 
hours or so on a motion, after we have a CBO report that says this 
would have a devastating impact on millions of people with Medicaid, is 
not the right way to go.
  Taking this out on the poor people of America who need Medicaid will 
make it worse for us as well. It will raise our rates, return the costs 
to where they were, and not help us solve this problem for the future. 
I hope our colleagues will understand that so many people are raising 
so many concerns about this. Yes, it is about economics, but there are 
also personal stories of people, such as our colleague from Hawaii who 
said: You never know. You never know when an individual situation is 
going to affect you, and you want to make sure there is healthcare to 
help you get through that crisis.
  Thank you. I yield the floor.
  The PRESIDING OFFICER. The Senator from Minnesota.
  Mr. FRANKEN. Thank you, Mr. President.
  I rise to talk about the effort to repeal and replace the Affordable 
Care Act. Before I begin, I thank Senator Hirono for sharing her story 
and for leading us all here in the discussion tonight.
  I thank the Presiding Officer who has been listening, and I 
appreciate that. I really do.
  In recent days, we have finally gotten to see the plan that 13 
Republican Senators have been working on in secret and behind closed 
doors. I really thought the Senate bill would be better. I thought it 
would be better than the House version that was passed. Even Senator 
Burr said of the House bill that it was ``dead on arrival'' in the 
Senate, but, unfortunately, the Senate plan is just as bad.

  The nonpartisan Congressional Budget Office announced just today 
that, under the Senate plan, 22 million more Americans would be 
uninsured. That has consequences. Perhaps worst of all--and partly 
because this causes the reduction in the number of Americans who would 
be covered--the bill ends the Medicaid expansion and cuts the

[[Page S3761]]

funding for the Medicaid Program by nearly $800 billion--a program that 
has been a vital part of our social fabric since 1965.
  This bill--and I do not like to say this--is mean. The President said 
that of the House bill. I do not like to characterize something that 
way, but it is mean and would have far-reaching effects for millions of 
Americans across the country.
  This past weekend, I hosted a healthcare forum in Burnsville, MN. It 
is a suburb that is south of Minneapolis, of the Twin Cities. It was on 
the importance of Medicaid and how the Republican plan's devastating 
cuts would affect Minnesotans. Over 230 people showed up to share their 
stories about how Medicaid changed their lives, and it was very moving.
  I think it is really important to tell this in terms of people, not 
in terms of numbers, although the numbers are pretty stark. Brandon and 
his mom spoke, Brandon and Sheri. They are both from Burnsville.
  Brandon was born 15 weeks premature. He weighed just 1 pound 13\1/2\ 
ounces. He was so small that his parents' wedding rings could slide on 
his arm. He was also born with cerebral palsy and hydrocephalus, which 
is a condition that causes fluid to collect in Brandon's brain, which 
results in brain damage.
  Brandon, who is now 17, got up with a walker at the event. He told me 
that he was taken immediately to the Mayo Clinic in Rochester. He was 
born in the Twin Cities, but Mayo said that his case was too 
complicated to handle, so they sent him back to the Twin Cities, to 
Gillette, which is a children's hospital. It is a great children's 
hospital, a great hospital. Within 24 hours of his birth, the hospital 
told Brandon's parents that his costs were already over $1 million--a 
terrifying addendum to what must have been a harrowing, harrowing 
experience.
  Over the years, Brandon has needed 38 surgeries--surgery to reduce 
the fluid in his brain. He has a shunt. He has had surgeries to 
straighten out his legs. He has had eye surgeries and more. He has also 
needed extensive physical therapy, occupational therapy, speech 
therapy, and across his lifetime, he has needed other interventions to 
help him do basic tasks, like eat and now walk. He could not turn over. 
He could not do the things that babies do, that we parents and 
grandparents relish in every day.
  But guess what. He is thriving. In fact, he just passed his first 
college course at Dakota County Technical College. He proudly told me 
and the rest of us that he received an A-minus, and he hopes someday to 
get a job at Gillette, the Gillette Children's Specialty Healthcare, 
which is the very place that provided him with the unique and high-
quality care that he has needed over the years. All of this has been 
possible because Brandon and his family were able to get health 
insurance through Medicaid.
  Sheri, Brandon's mom, said: ``If we didn't have Medicaid, Brandon 
probably wouldn't be here''--meaning at our forum--``and he wouldn't be 
doing as well as he's doing.''
  Brandon similarly noted:

       Kids with special needs are referred to as ``special 
     needs,'' and I like to think I'm pretty special. I also like 
     to think our needs are also special depending on the kind of 
     care we need and that's what Medicaid provides.

  I really believe that all of us here tonight must do all we can to 
protect these kids and protect their families and everyone who relies 
on Medicaid, and I sincerely believe that means we have to defeat this 
bill.
  My colleague Senator Hirono stated last week: ``We are all one 
diagnosis away from a serious illness.'' That is the case. Do you know 
what else? We are also just one accident away from a life-changing 
injury.
  Another Minnesotan, Deborah, shared her story with my office. She 
described for me a car crash and the subsequent traumatic brain injury 
that she survived in 2012.
  She explained:

       It was just another day. I was on my way to work. I lost 
     control of my SUV after sliding on a patch of ice and slammed 
     into a concrete median.

  Her whole life changed at that moment. She had to relearn basic 
tasks--reading, walking, talking, and eating--but all of it was 
possible because of the home- and community-based services she was able 
to receive through Medicaid.
  She said:

       Without the services funded by Medicaid, my goal of 
     returning to paid employment would be impossible. I honestly 
     worry that proposed changes to the Medicaid program could 
     significantly diminish my overall health outcomes and even 
     leave me facing long-term homelessness.

  As my colleagues and people at home who are watching this debate well 
know, this week could prove to be an extremely consequential week in 
the history of this country. The decisions we make--the 100 of us--over 
the next few days could literally mean life or death for many 
Americans. Lives are on the line.
  Tomorrow, I will give a speech that is more about the data, and we 
have heard about some of that, but there is a study in the New England 
Journal of Medicine that came out this week that reads that Medicaid--
having the insurance--improves people's lives and that--this is not 
precise--for every 300 to 800 who will lose healthcare, who would lose 
Medicaid, there will be a premature death.
  This is a study that is going to be summarized in the New Yorker, in 
an article by Atul Gawande, that the effect of having insurance is not 
about dramatic emergencies. This is especially about things like 
diabetes and heart illness and cancer--the day-to-day. It is about 
having access. Because you have insurance for care, it improves the 
health of people, and it extends mortality. This is real stuff. What we 
are doing is really serious.
  I strongly urge my Republican colleagues to talk with their 
constituents about the bill that was drafted. Again, it was behind 
closed doors, and many of my Republican colleagues did not see it until 
last week. I urge them to talk to their constituents about the 
consequences this bill would have for seniors, for children, and 
parents who have Medicaid coverage.
  Talk to the people who would see their healthcare costs rise. Talk to 
the families who may lose their health insurance. People are afraid.
  I am a cochair of the World Health Caucus. I go all around my State. 
I talk to roundtables at rural hospitals and nursing homes. These are 
the parts of my State that voted for Donald Trump. During the campaign, 
Donald Trump said that he would not cut Medicaid. These are people who 
are scared, whose elderly parents stay home because Medicaid pays for 
their home healthcare, and they are afraid because that will go away. 
Both she and her husband work--this was a woman in Herman, MN--and they 
do not know what they will do.
  Please, listen to your constituents. You need to do the right thing 
and vote no on this bill for their sake--for the sake of your 
constituents.
  I yield the floor.

                          ____________________