MEDICARE; Congressional Record Vol. 165, No. 8
(Senate - January 15, 2019)

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[Pages S227-S230]
From the Congressional Record Online through the Government Publishing Office []


  Mr. CASEY. Madam President, I rise to talk about the Medicare Program 
and in particular a news story that came to our attention this past 
  This is the headline from a story dated January 11, late in the day, 
and it is by The Hill newspaper. You will not be able to see it from a 
distance, but the headline reads: ``Trump officials consider allowing 
Medicaid block grants for states.''
  Here is what just the first two short paragraphs outline. The story 
begins as follows:

       The Trump administration is considering moving forward with 
     a major conservative change to Medicaid by allowing States to 
     get block grants for the program, sources say.
       Capping the amount of money that the federal government 
     spends on the health insurance program for the poor through a 
     block grant has long been a conservative goal. It was a 
     controversial part of the ObamaCare repeal debate in 2017, 
     with much of the public rallying against cuts to Medicaid.
       After the failure of that repeal effort, the Trump 
     administration is now considering issuing guidance to states 
     encouraging them to apply for caps on federal Medicaid 
     spending in exchange for additional flexibility on how they 
     run the program, according to people familiar with the 

  I will not read the rest of the story, and I will not enter the whole 
story into the Record because folks can look it up, and there are other 
stories as well that cover this same news. So, in a sense, it is a big 
new development, but it is an old story.
  It is an old story of Members of Congress and the administration 
coming together to try to make changes to the Medicaid Program. In this 
case, it differs only slightly in that, so far at least, this seems to 
be an initiative that is an administration-led initiative. We are not 
aware of any--as far as I know--congressional involvement, but it is 
not all that much different, right? It is the same thing.
  We had a long debate in 2017 about whether we should not only repeal 
the Affordable Care Act but thereby do two things to Medicaid--one is 
to end over time Medicaid expansion, and second would be to have cuts 
to Medicaid that would result from this same idea, the so-called block 
granting of Medicaid.
  I believe we litigated--if we can use that word in a legislative 
sense--that in 2017. The repeal bill did not pass the Senate in the 
summer of 2017. There were other attempts that didn't come to a vote on 
full repeal. Then we had an election in 2018. Healthcare was a major 
part of that debate, most of it centering on protections for 
preexisting conditions and other consumer protections in the law.
  If you look at the last 2 years, we had one-party rule in 
Washington--Republican President, House, and Senate. There were major 
efforts by the administration and by both majorities in the Houses of 
Congress to make substantial changes to Medicaid, and it did not 
happen. So failing all those attempts, now the administration, I would 
assume, is trying to do it secretively but, now exposed, wants to make 
changes to Medicaid by way of granting waivers and inviting States to, 
in essence, change Medicaid at the State level.
  This initiative will not affect Pennsylvania--or it is highly 
unlikely to affect Pennsylvania in the near term. So this is about 
major parts of the country but not every State. It is a bad idea, in 
short order, because what this block granting means is benefits get 
  It is very simple. When you cut a program that is focused on 
healthcare for low-income children, healthcare coverage for those with 
disabilities, children and adults, and helping seniors have the benefit 
of skilled care in a nursing home--that is another benefit of 
Medicaid--you are talking about benefits being cut over time. Maybe 
there will be more cuts in one State versus the other, depending upon 
the nature of the waiver and the particulars of the program in that 
State, but it is going to be cutting Medicaid. It is a bad idea, and I 
think the American people understand that, especially after the debate 
in 2017. It is a bad idea, and I think the American people understand 

  Maybe there are some folks who didn't really appreciate Medicaid; 
probably a lot of them in Washington didn't appreciate Medicaid before 
the 2017 and 2018 debates. Maybe there are folks who weren't paying 
attention for a lot of years and didn't realize the scope of Medicaid, 
didn't realize it covers 70 million Americans. I know that is why some 
Republican-elected officials in the Congress are very hostile to it; 
they think it covers too many people. But after 2017, those who were 
misinformed or had forgotten or just were never aware of the benefits 
of Medicaid got a real good reminder because of the debate we had. That 
was one positive outgrowth of that long and difficult debate on 
healthcare generally--the Affordable Care Act specifically--but also, 
by extension, Medicaid.
  A proposal like this to block-grant Medicaid, which was proposed 
numerous times here in the Congress over the last couple of years, 
hurts basically those three groups of Americans. It hurts kids, hurts 
people with disabilities, and hurts our seniors.
  I think the part of it that people tend to forget is that this 
program helps middle-class families as well. If you have a disability, 
your income might be higher than low income, but you get the benefit of 
Medicaid. A lot of middle-class families have a loved one in a nursing 
home who would not be able to afford that kind of long-term care 
without the benefit of Medicaid. A lot of those families are middle 
  When it comes to children, of course, it is for children from low-
income families, but those children are getting

[[Page S228]]

what many believe to be the gold standard for children's healthcare.
  I like to say that in Pennsylvania, Medicaid is a 40-50-60 program. 
It is real simple: 40 percent of the kids in our State, thankfully, 
have the benefit of Medicaid; 50 percent of people with disabilities--
roughly, about half of the people in our State with disabilities get 
the benefit of Medicaid. Thank goodness they do. Thirdly, 60 percent of 
people getting long-term care in Pennsylvania could not get it without 
the benefit of Medicaid.
  In some States, the percentages might be higher or lower than that, 
but when you have a program that covers 40 percent of your children, 50 
percent of your population with disabilities, and 60 percent of your 
seniors could get long-term care, which they need--those folks who have 
long-term care need it and have to have it. When you have that kind of 
program, which covers roughly 2 million people in Pennsylvania and 70 
million nationwide, you are going to get the attention of a lot of 
people when you are messing with it. That is a technical term, 
``messing with it.'' By saying, to some degree, under the cover of 
darkness--not having a debate on the floor of the House or the Senate 
but sending guidance to States, inviting them to apply for a waiver, 
and it takes a while to approve the waiver, then all of a sudden it 
comes out, and the waiver is granted--guess what. If you live in a 
State where that happens and you are on Medicaid, you might not have 
Medicaid a year from the waiver being granted--or 2 years or 5 years. 
At some point, you may be adversely affected by that. This is very 
serious business when it comes to those very vulnerable Americans.
  In so many ways, Medicaid, like a lot of things we debate here--not 
only Medicaid, but Medicaid is one of many examples we could cite--
tells us who we are as a nation. People around the world don't respect 
America simply because America has the strongest, best military. We 
have the best fighting men and women in the world; no one is even 
close. But there are a lot of nations that spend a lot on their 
military and have strong, fighting men and women; they have a strong 
military, and they are not respected like we are. Thank God we have a 
strong military and the strongest economy in the world. We are blessed 
by that.
  But one of the other ways the world respects us is that they often 
conclude that we treat our own people better than some other places do. 
Medicaid, which is a 50-year-old program, is a program that tells us 
who we are as a nation, whom we value, and whom we are willing to fight 
on behalf of. It tells us a lot about who we are. America is great 
because we care deeply about those 70 million people who get the 
benefit of that program, just as we care deeply about other Americans 
who benefit or have a connection to our government.
  Before any administration or any part of our government takes an 
action that will lead to the cutting back of a program like Medicaid--
whether it is by way of legislation or by way of waiver or regulation--
they need to hear from us.
  I, for one, am willing to fight on this for a long time. If I do 
nothing else but fight this battle, sign me up because we are going to 
fight hard. I am not certain we will win, but I think we will win this 
battle. Medicaid tells us who we are. Why do I say that? Well, because 
we hear from families all the time.

  I got a letter at the beginning of the debate in 2017 from a mom. 
Like a lot of Members of the Senate, you get a letter from a mom or a 
dad or a family member who sits down to put pen to paper--in a sense, 
to write you a letter or send you an email or to express what their 
lives will be like without a program, what their lives will be like if 
a change goes forward.
  In this case it was Pam, a mom talking about her son Rowan. Rowan is 
on the autism spectrum. This mom talks about the prospect of not just 
learning that and what that meant to her and her family and the 
challenge of it, obviously, but also the benefits she received because 
of Medicaid--in Pennsylvania we call it Medical Assistance, or by the 
shorthand, MA.
  I will not read the whole letter, but Pam talks about, in just one 
example of what Medicaid means, the wraparound services--all of the 
services that a child who has a disability gets, maybe on either the 
autism spectrum or a physical disability or maybe a child who has Down 
  In this case, Rowan is on the autism spectrum. She talks about the 
behavioral specialist consultant and the therapeutic staff support work 
that helps her and the benefits of that and what that means to Pam, as 
a mom, and to her family--but also what it means to her son Rowan. She 
talks about Rowan benefiting ``immensely from a program called the 
Child Guidance Resource Center,'' which recently started a new program 
called the CREATE Program. It is a social skills program specifically 
for autistic children ages 3 to 21. She enrolled Rowan in that so-
called CREATE Program.
  She goes on to say: ``I am thrilled by Rowan's daily progress. I 
cannot say enough great things about this program.''
  That program would not be part of the life of that family, absent 
Medicaid. That program would not be part of the life of that family in 
the instance where that family was living in a State that had been 
granted a waiver that allowed block grants that, thereby, allowed cuts 
that resulted in that family not getting that kind of service.
  Thankfully, she is in a State where the Medicaid Program is strong 
and will be defended aggressively. But I don't want a Rowan in another 
State or a Pam--a mom in another State--not having the benefit that 
Rowan in Pennsylvania has and that Pam in Pennsylvania has.
  Pam goes on to say: ``Without medical assistance, our family would be 
bankrupt or my son would go without the therapies he sincerely needs.''
  At the end of the letter, she concludes by asking me, as her 
representative, to think about her family when we are debating these 
issues. She talks about her husband and her son Rowan first, and then 
she concludes the letter this way:

       Please think of my 9-month-old daughter, Luna, who smiles 
     and laughs at her brother daily; she will have to care for 
     Rowan late in her life after we are gone. Overall, we are 
     desperately in need of Rowan's Medical Assistance and would 
     be devastated if we lost these benefits.

  That is what one mom said about the importance of Medicaid to that 
  My point in raising this issue--even though, thankfully, we have 
beaten back an effort to legislatively change the Medicaid Program for 
the worse, and we now have an administrative effort to undermine the 
program, but I raise this simply to say that family in America should 
not have to worry for 10 minutes about whether their government is 
going to continue those important benefits to their son or to their 
daughter, whatever the case may be. Maybe their mom is in a nursing 
home or maybe a neighbor has a son or a daughter who, because of income 
levels, is getting Medicaid. They shouldn't have to worry for 10 or 15 
minutes about that because we are America. We made the decision 50 
years ago--and it was a good decision--to take care of those families 
and to do everything we could.
  Some days we will not get it right; some days we will make mistakes. 
But on most days, a program like that is helping lots of families, tens 
of millions of them, and the bureaucrats or the elected officials or 
the administration officials in Washington who seek to make changes 
that will adversely affect even one of those families has to look those 
families in the eye--or should look them in the eye--and tell them why 
that is good, not just for that family but why that is good for 
America. How is that going to help us?
  I know what the argument will be. I hear it over and over again. They 
say that the program is unsustainable, right? We are not going to be 
able to afford this much Medicaid 10 years from now, 15 years from now, 
25 years from now. Well, when they say ``unsustainable'' around here, I 
want to translate for you. That means they are not willing to make 
people of means pay for it. Let me say it bluntly: If we have to charge 
someone else who has a high income to preserve Medicaid, sign me up for 
that too.
  Let's be very clear about this. This program is that important. I 
believe there are a lot of Americans of means--of high incomes--who 
would want to make sure this program is preserved. I know there are 
some politicians around here who are always talking about how you have 
to make sure that they have

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low tax rates, but I think a lot of those Americans want to preserve 
the Medicaid Program, want to strengthen it, want to make changes that 
are appropriate, want to make it more efficient where we can, but there 
are a lot of Americans out there of great means who want this program 
preserved. So we have a lot of work to do to make sure we move in the 
right direction.
  Let me make one or two more final points, and I will conclude.
  One of the other questions is, What happens if a block grant proposal 
goes through nationwide but even in more limited instances?
  Way back in November of 2016, one of the many organizations that 
track this kind of a program over time--the Medicaid Program or 
healthcare programs--issued a report. It has issued many of these 
reports, but here is just one for your consideration. The name of the 
organization is Center on Budget and Policy Priorities. It is here in 
Washington and has been around a long time. It was very helpful in the 
debate on healthcare and about the impact of various proposals.
  Here is what the Center on Budget and Policy Priorities said in 
November of 2016. The date was November 30, 2016. In order to save some 
space, I will not read the whole report, and I will not enter it into 
the Record. People can look it up, right?
  Here is the headline: ``Medicaid Block Grant Would Slash Federal 
Funding, Shift Costs to States, and Leave Millions More Uninsured.''
  Here is what some of the headlines say in the report. The first one 
reads ``A block grant would cap Federal Medicaid funding in order to 
achieve savings for the Federal Government.'' That is what the proposal 
is intended to do.
  No. 2, ``The likely magnitude of the Federal funding cuts and 
resulting cost-shift to States would be very large.''
  No. 3, ``Such a block grant would push states to cut their Medicaid 
programs deeply.''
  The last two are as follows: ``Medicaid is already efficient and 
innovative.'' That is true. We don't talk about that enough, but it is 
  The last headline is ``A Medicaid block grant would lead to draconian 
cuts to eligibility, benefits, and provider payment rates.'' What they 
didn't mention there is that cuts to Medicaid would also hurt a lot of 
hospitals, especially rural hospitals.
  Here is the number from the House Republican budget plan for fiscal 
year 2017. We are going back now to the latter part of 2016. Here is 
what the report concludes, and this is in the instance of being 
implemented as law: ``It would have cut federal Medicaid funding by $1 
trillion--or nearly 25 percent--over ten years, relative to current 
law, on top of the cuts the plan would secure from repealing the ACA's 
Medicaid expansion.''
  I realize that number is bigger than what we are talking about here 
because we are talking about a number of States changing their Medicaid 
Programs because of a block granting waiver that was granted to that 
particular State, but I am not too concerned about the overall number 
because that is impossible to predict.
  Even if just one State were to be granted this kind of a waiver in 
implemented block grants, a lot of people in that State would lose 
their Medicaid. I think we should be concerned if it were one person 
losing Medicaid because of that, let alone thousands or tens of 
thousands or hundreds of thousands or, in fact, millions. If block 
granting were to be granted for the whole country, you would be talking 
about double-figure millions losing that kind of coverage. Even if it 
were to be a much smaller number, we should be very concerned about 
  Here is another reason not to mess around with Medicaid in a way that 
adversely impacts people or undermines the program. I hear from a lot 
of politicians in Washington from both Houses and both parties. I 
think, in almost every instance--and there is probably an exception to 
this--they speak from their hearts and do truly care about what is 
happening in their communities and in their States because of the 
opioid crisis. It is everywhere. It is urban, rural, and suburban. It 
is everywhere, and it is devastating. We have never seen a public 
health problem like it in probably 100 years or at least not anything 
worse than it. It is a problem in Pennsylvania, and it is a problem in 
every State, as I am sure the Presiding Officer would agree. Yet here 
is the part they don't talk about. Sometimes the same people say, ``I 
really am worried about the opioid crisis, and I want to do the 
following to help people who are in the grip of that addiction, and I 
want to institute a program or provide funding or otherwise,'' and that 
is wonderful when they have that initiative. Yet sometimes those same 
Members of Congress, in the next breath, will say, ``But I want to 
block grant Medicaid'' or ``I want to cut or cap Medicaid'' or ``We 
need to cut back on what we spend on Medicaid,'' and they vote for 
budget after budget after budget and bill after bill to cut Medicaid.
  What do you think is the No. 1 payer when it comes to the opioid 
crisis, the primary payer for opioid treatment and recovery? You 
guessed it--Medicaid.
  If you are going to go down this road and talk about this program as 
if it were some far-off program for them, for someone else, you should 
look in the mirror because Medicaid is an ``us'' program, not a 
``them'' program and not a program for someone far away. It is for our 
neighbors. It is for our friends if they have opioid addictions and can 
only get treatment and services mostly because of Medicaid expansion--
actually, as part of the Affordable Care Act.
  Medicaid itself, the core program, of course, is a program that makes 
sure that a child has healthcare. Even if he is of low income and his 
mom or his dad or the person taking care of him is not working and 
doesn't have employer coverage, he gets the benefit of Medicaid. Guess 
what. When that low-income child gets Medicaid, we all benefit. That 
child is more likely to grow up healthy, and he or she will be more 
productive and will be a stronger part of our economy. So Medicaid for 
low-income children or children from low-income families helps all of 
us. It doesn't just help that child. It is not just a nice thing to do. 
It is the right thing to do, but it is also very practical.
  Medicaid helps people with disabilities whether they have profound 
disabilities or otherwise. They have to be eligible for it based upon 
their disabilities, but we have made a decision that that is a good 
thing to do for that individual and for society. The same is true of 
people making decisions about a loved one's going into long-term care 
and one's spending down one's assets, and there is usually a big gap 
after one spends down. Middle-class families--sometimes people above 
middle class--spend down. They can't afford the cost of nursing home 
care, and the State says and the Federal Government says: We want to 
help you.
  That is why Medicaid is so critical to nursing homes. If you look at 
the dollars spent, it would not be entirely inaccurate to say that 
Medicaid is a nursing home program with help for children and people 
with disabilities as well.
  I am just putting the administration on notice that if it wants to 
continue to pursue this, we are going to have a big fight about it, and 
it is a fight that will go on for a long time. It will go on in the 
courts. We will litigate it on this floor. We will litigate it in 
committees and fight about it in the House and in the Senate. We will 
fight in the streets of our States, and we will fight about it for a 
long time until we win because we have other things to do to lift 
people up around here. We have to do more on healthcare--lower the cost 
of healthcare, lower the cost of prescription drugs--and make sure that 
these programs work well. We don't have time for throwing millions of 
people off of healthcare or tens of millions off of healthcare. There 
is a broad, bipartisan consensus on a whole range of things we could do 
on healthcare. That is what we should work on.
  The administration, if it is doing the right thing, would abandon 
these reckless, extreme ideas on Medicaid and join us--join both 
parties in both Houses--in trying to do something positive and 
constructive and American on healthcare. I don't think it is American 
to say to a child, ``Yes, you had Medicaid before, but we couldn't 
afford it. You are not going to have healthcare any longer'' or to say 
that to someone with a disability or to a senior.
  If the administration wants to fight, we are going to be ready to 
fight, and

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we will punch hard in that fight--figuratively speaking, of course. We 
will fight every minute of every day against this.
  I yield the floor.