EXECUTIVE CALENDAR; Congressional Record Vol. 165, No. 115
(Senate - July 10, 2019)

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[Pages S4749-S4759]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                           EXECUTIVE CALENDAR

  Mr. BARRASSO. Mr. President, I ask unanimous consent that the Senate 
resume consideration of the King nomination.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The clerk will report the nomination.
  The senior assistant legislative clerk read the nomination of Robert 
L. King, of Kentucky, to be Assistant Secretary for Postsecondary 
Education, Department of Education.


                            Order for Recess

  Mr. BARRASSO. Mr. President, I ask unanimous consent that the Senate 
recess from 3 p.m. to 4 p.m. today.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The Senator from Wyoming.


                               Healthcare

  Mr. BARRASSO. Mr. President, I come to the floor because Democrats 
out on the campaign trail continue to spin their one-size-fits-all 
healthcare plan that they call Medicare for All. The name itself is 
misleading. I will state that as a doctor who has practiced medicine in 
Wyoming for 24 years.
  Even many Democrats in the first Presidential debate sounded confused 
about their own proposal. The candidates were asked a simple question. 
They were asked to raise their hands if they supported eliminating 
private health insurance. That is the health insurance people get from 
work. ``Just four arms went up over the two nights,'' but ``five 
candidates who kept their hands at their sides,'' the New York Times 
has now reported, ``have signed onto bills in [this] Congress that do 
exactly that''--take health insurance away from people who get it from 
work.
  On one point, though, they all raised their hands. That was on the 
question that was asked of all 10 Democrats in round 2 of the debate. 
They all endorsed taxpayer-funded healthcare for illegal immigrants. 
Every hand went up.
  It seems Democrats have actually been hiding their real, radical 
agenda. ``Most Americans don't realize how dramatically Medicare-for-
all would restructure the nation's health care system.'' That is not 
just me talking; that is according to the latest Kaiser Family 
Foundation poll. We need to set the record straight, and I am ready to 
do that right now.
  The fact is, Democrats have taken a hard left turn, and they want to 
take away your health insurance if you get it from work. The proposal 
abolishes private health insurance, the insurance people get from work. 
In its place, they would have one expensive, new government-run system. 
Still, Democrats know most of us would rather keep our own coverage 
that we get from work. Even the people on Medicare Advantage--20 
million people--would lose it under the Democrats' proposal. The Kaiser 
poll confirms Americans' top concern is, of course, lowering their 
costs or, as the Washington Post ``Health'' column put it, people 
simply want ``to pay less for their own health care.''
  That is what we are committed to on this side of the aisle.
  Many Democrats running for President continue to promote and support 
this radical scheme by Senator Sanders. The Sanders legislation would 
take away healthcare insurance from 180 million people who get their 
insurance through work, through their jobs. In addition, 20 million 
people who buy their insurance would lose coverage as well.
  You also need to know that the Democrats' proposal ends the current 
government healthcare programs. Medicare for seniors would be gone. 
Federal employees' health insurance would be gone. TRICARE for the 
military would be gone, and the children's health coverage also would 
be gone under this Democratic healthcare, one-size-fits-all plan. That 
is confirmed by the Congressional Research Service.
  The Congressional Research Service recently sent me a formal legal 
opinion. I requested it from them. It is a formal, legal opinion, 
stating: Medicare for All ``would . . . largely displace these existing 
federally funded health programs'' that I just mentioned--Medicare, 
Federal employees' health insurance, TRICARE, children's health 
coverage. It would largely displace these existing Federal health 
programs as well as private health insurance, the insurance people get 
from work.
  Mr. President, I ask unanimous consent to have printed in the Record 
the

[[Page S4750]]

Congressional Research Service memorandum, dated May 29, 2019.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                               Memorandum

     To: Senator John Barrasso, Attention: Jay Eberle.
     From: Wen S. Shen, Legislative Attorney.
     Subject: Effect of S. 1129 on Certain Federally Funded Health 
         Programs and Private Health Insurance.
       Pursuant to your request, this memorandum discusses the 
     legal effect of S. 1129, the Medicare for All Act of 2019 
     (MFAA or Act) on various public and private health care 
     programs or plans. Specifically, the memorandum analyzes 
     whether the MFAA would authorize the following programs or 
     plans to continue in their current form:
       Medicare (including Medicare Advantage and Part D);
       Medicaid (including the Children's Health Insurance 
     Program);
       TRICARE;
       Plans under the Employee Retirement Income Security Act; 
     and
       Individual, Small and Large Group Market Coverage.
       For reasons discussed in greater detail below, the Program 
     created by the MFAA would, following a phase-in period and 
     with some limited exceptions, largely displace these existing 
     federally funded health programs as well as private health 
     insurance. This memorandum begins with a description of the 
     key provisions of the MFAA before turning to its legal effect 
     on the programs and plans that are the subject of your 
     request.


                      Medicare for All Act of 2019

       The MFAA aims to establish a national health insurance 
     program (Program) that would ``provide comprehensive 
     protection against the cost of health care and health-related 
     services'' in accordance with the standards set forth under 
     the Act. Specifically, under the Program, every resident of 
     the United States, after a four-year phase-in period 
     following the MFAA's enactment, would be entitled to have the 
     Secretary of Health and Human Services (Secretary) make 
     payments on their behalf to an eligible provider for services 
     and items in 13 benefits categories, provided they are 
     ``medically necessary or appropriate for the maintenance of 
     health or diagnosis, treatment or rehabilitation of a health 
     condition.'' Except for prescription drugs and biological 
     products, for which the Secretary may set a cost-sharing 
     schedule that would not exceed $200 annually per enrollee and 
     meet other statutory criteria, no enrollee would be 
     responsible for any cost-sharing for any other covered 
     benefits under the Program. The bill would direct the 
     Secretary to develop both a mechanism for enrolling existing 
     eligible individuals by the end of the phase-in period and a 
     mechanism for automatically enrolling newly eligible 
     individuals at birth or upon establishing residency in the 
     United States.
       All state-licensed health care providers who meet the 
     applicable state and federal provider standards may 
     participate in the Program, provided they file a 
     participation agreement with the Secretary that meets 
     specified statutory requirements. The Secretary would pay 
     participating providers pursuant to a fee schedule that would 
     be set in a manner consistent with the processes for 
     determining payments under the existing Medicare program. 
     Participating providers would be prohibited from balance 
     billing enrollees for any covered services paid under the 
     Program, but providers would be free to enter into private 
     contracts with enrollees to provide any item or service if no 
     claims for payment are submitted to the Secretary and the 
     contracts meet certain statutory requirements.
       With respect to payment for covered pharmaceuticals, 
     medical supplies, and medically necessary assistive 
     equipment, the Secretary would negotiate their payment rate 
     annually with the relevant manufacturers. The bill would 
     further direct the Secretary to establish a prescription drug 
     formulary system that would encourage best practices in 
     prescribing; discourage the use of ineffective, dangerous, or 
     excessively costly medications; and promote the use of 
     generic medications to the greatest extent possible. Off-
     formulary medications would be permitted under the Program, 
     but their use would be subject to further regulations the 
     Secretary issues.
       With respect to the Program's administration, the bill 
     would authorize the Secretary to develop the relevant 
     policies, procedures, guidelines, and requirements necessary 
     to carry out the Program. The Secretary would also establish 
     and maintain regional offices--by incorporating existing 
     regional offices of the Centers for Medicare & Medicaid 
     Services where possible--to assess annual state health care 
     needs, recommend changes in provider reimbursement, and 
     establish a quality assurance mechanism in the state aimed at 
     optimizing utilization and maintaining certain standards of 
     care.
       To fund the Program, the bill would create a Universal 
     Medicare Trust Fund. Funds currently appropriated to 
     Medicare, Medicaid, the Federal Employees Health Benefits 
     Program (FEHBP), TRICARE, and a number of other federally 
     funded health programs would be appropriated to the new fund.
       The MFAA also includes a number of other provisions related 
     to the administration of the Program, including an 
     enforcement provision aimed at preventing fraud and abuse, 
     provisions relating to quality assessment, and provisions 
     concerning budget and cost containment.


  Effect of the MFAA on Certain Federally Funded Health Programs and 
                        Private Health Insurance

     Federally Funded Health Programs
       The federal government currently funds a number of health 
     programs, including (1) Medicare, which generally provides 
     health insurance coverage to elderly and disabled enrollees, 
     (2) Medicaid, which is a federal-state cooperative program 
     wherein states receive federal funds to generally provide 
     health benefits to low-income enrollees, (3) the Children's 
     Health Insurance Program (CHIP), which is a federal-state 
     cooperative program that provides health benefits to certain 
     low-income children whose families earn too much to qualify 
     for Medicaid but cannot afford private insurance; (4) the 
     FEHBP, which generally provides health insurance coverage to 
     civilian federal employees, and (5) TRICARE, which provides 
     civilian health insurance coverage to dependents of active 
     military personnel and retirees of the military (and their 
     dependents). Following an initial phase-in period, the MFAA 
     would prohibit benefits from being made available under 
     Medicare, FEHBP, and TRICARE while also prohibiting payments 
     to the states for CHIP. These payment prohibitions would 
     effectively terminate these programs in their current form. 
     This reading is confirmed by Sec. 701(b)(2) of the MFAA, 
     which redirects funding for these programs to the national 
     Program.
       With respect to Medicaid, the MFAA would significantly 
     limit its scope. After the MFAA's effective date, Medicaid 
     would only continue to cover services that the new national 
     Program would not otherwise cover. Thus, Medicaid benefits 
     for institutional long-term care services (which are not 
     among the 13 categories of covered services under the MFAA) 
     and any other services furnished by a state that the Program 
     would not cover, would continue to be administered by the 
     states. The bill would direct the Secretary to coordinate 
     with the relevant state agencies to identify the services for 
     which Medicaid benefits would be preserved and to ensure 
     their continued availability under the applicable state 
     plans.


                        Private Health Insurance

       Currently, private health insurance in the United States 
     consists of (1) private sector employer-sponsored group 
     plans, which can be self-insured (i.e., funded directly by 
     the employer) or fully insured (i.e., purchased from 
     insurers), and (2) group or individual health plans sold 
     directly by insurers to the insured (both inside and outside 
     of health insurance exchanges established under Section 1311 
     of the Affordable Care Act). The MFAA would prohibit 
     employers from providing, and insurers from selling, any 
     health plans that would ``duplicate[]the benefits provided 
     under [the MFAA].'' Given that the benefits offered under 
     many existing private health plans would likely overlap 
     with--i.e., be the same as--at least some of the benefits 
     within the Program's 13 categories of covered benefits, those 
     existing health plans would likely ``duplicate'' the benefits 
     provided under the MFAA. Thus, this prohibition of duplicate 
     coverage would effectively eliminate those existing private 
     health plans. Employers and insurers, however, would be 
     allowed to offer as benefits or for sale supplemental 
     insurance coverage for any additional benefits not covered by 
     the Program. As a result, employers and insurers could offer, 
     for instance, coverage for institutional long-term care 
     services, which are not among the 13 categories of covered 
     services.

  Mr. BARRASSO. Mr. President, this report details how the bills cut 
off funding.
  The CRS memo concludes: These payment prohibitions would effectively 
terminate all of those programs I mentioned in their current form.
  The Congressional Research Service finds that Medicare for All 
actually terminates Medicare in this country. So Democrats want to turn 
Medicare, currently for 60 million seniors, into Medicare for None. It 
will become Medicare for None, not Medicare for All. Plus, 22 million 
people would lose Medicare Advantage. I know many of my patients who 
signed up for Medicare Advantage because there are advantages to doing 
it--coordinated care, working on preventive medicine. There are reasons 
for signing up for Medicare Advantage. That would all be gone under the 
one-size-fits-all approach that the Democrats are proposing.
  That is not all. This report says the Sanders bill ends Federal 
employee health insurance. There are more than 8 million Federal 
workers, families, and retirees who rely on this Federal Employee 
Health Benefits Program.
  The Congressional Research Service says that this bill, sponsored by 
over 100 Members who are Democrats in the House of Representatives and 
sponsored by a number of Democrats in this body, will abolish TRICARE, 
the insurance for the military. More than 9 million military members, 
their families,

[[Page S4751]]

and retirees rely on TRICARE for their healthcare.
  The report says the bill ends the Children's Health Insurance 
Program. Nine million of our Nation's children rely on the CHIP 
program.
  Interestingly, ObamaCare would end as well, according to the CRS 
report. After less than a decade, Democrats want to repeal and replace 
their failed ObamaCare healthcare law with a one-size-fits-all system.
  Again, the Congressional Research Service says the bill bans private 
health insurance. One hundred eighty million people get their insurance 
through work.
  To sum up, hundreds of millions of American citizens--American 
citizens--stand to lose their insurance, and I believe that is just the 
start of the pain for American families. In the new system, we would 
all be at the mercy of Washington bureaucrats. That means we would be 
paying more to wait longer for worse care--pay more to wait longer for 
worse care. The Democrats' massive plan is expected to cost $32 
trillion. That is trillion with a ``t.'' That is a 10-year pricetag.
  Guess who is going to pay for that mind-boggling bill--of course, 
every American taxpayer. Senator Sanders admitted in the Democratic 
debate the other night that his proposal would raise taxes on middle-
class families. His proposal will raise taxes, he said, on middle-class 
families.
  In fact, even doubling our taxes wouldn't cover the huge cost of what 
they are proposing. So Washington Democrats are planning to drastically 
cut payments to doctors, nurses, hospitals, and to people who are 
providing care. The bureaucrats would ration care, restrict care--the 
care you get that you need--and it would be restricted in terms of 
treatment as well as technology. People would lose the freedom to 
choose the hospital or doctor they want.
  As a doctor, I am especially concerned about the impact on patient 
care. Patients could wait weeks, even months, for urgently needed 
treatment. Keep in mind care delayed is often care denied. So the 
Democrats' grand healthcare vision is to force you to pay more to wait 
longer for worse care.
  As a Senator and a doctor, of course, I want to improve your care, 
make it less costly. You should get insurance that is appropriate for 
you and affordable. You should be free to make your own medical 
decisions. That is what it is like in America.
  No question, healthcare needs to be more affordable, and Republicans 
are working to lower costs without lowering standards. To me, that is 
the big difference. Democrats are proposing the reverse. Their plan 
would lower your standard of care and raise your costs. Democrats can 
keep campaigning hard left on healthcare. That is where they are 
headed.

  Republicans are going to stay focused on real reforms that promote 
more affordable healthcare, cheaper prescription drugs, protections for 
patients with preexisting conditions, and, of course, the end of 
surprise medical bills. President Trump recently took Executive action 
that increases price transparency to lower the costs that patients pay.
  You just need to know the facts about the Democrats' one-size-fits-
all healthcare. Don't let far-left Democrats fool you. Radical 
Democrats want to take away your current healthcare. There would be no 
more Medicare or private plans, just a one-size-fits-all Washington 
plan.
  Why pay more to wait longer for worse care? Instead, let's give 
patients the care they need from a doctor they choose at lower costs. 
That is our goal. That is our objective, and that is what we are going 
to accomplish.
  I yield the floor.
  The PRESIDING OFFICER (Mr. Romney). The Senator from Illinois.
  Mr. DURBIN. Mr. President, I ask unanimous consent to speak as in 
morning business.
  The PRESIDING OFFICER. Without objection, it is so ordered.


                        prescription drug costs

  Mr. DURBIN. Mr. President, just a few minutes ago, four young people 
from the State of Illinois visited my office. They were a variety of 
different ages, from 10 years of age to the age of 17. They all came 
because they had a similar life experience, and they wanted to share it 
with me. Each one of them had been diagnosed with type 1 diabetes.
  Ten-year-old Owen from Deerfield told a story--the cutest little kid; 
great reader; read me a presentation that he put together--and the 
young women who were with him all talked about how their lives changed 
when they learned at the age of 7 or 8 that they had type 1 diabetes. 
For each one of them, from that point forward, insulin became a 
lifeline. They had to have access to insulin, and they had to have it 
sometimes many times a day, in the middle of the night. It reached a 
point where, through technology, they had continuous glucose monitoring 
devices and pumps that were keeping them alive, but every minute of 
every day was a test to them as to whether they were going to get sick 
and need help.
  It was a great presentation by these young people, whose lives were 
transformed, and their parents, who were hanging on every word as they 
told me their life stories.
  They brought up two points that I want to share on the floor this 
afternoon. The first is the importance of medical research. As one 
young woman said--she is about 17 now. She has lived with this for 8 or 
9 years. She said she is a twin, and her brother told her when she was 
diagnosed that he hated the thought that, as an old woman, she would 
still be worried about her insulin every single day. She said: I told 
my brother ``We are going to find a cure before I am an old woman.''
  Well, I certainly hope that young girl is right, but she will be 
right only if we do our part here on the floor of the Senate and not 
just give speeches. What we have to do is appropriate money to the 
National Institutes of Health. It is the premier medical research 
agency in the world.
  We have had good luck in the last 4 years. I want to salute two of my 
Republican colleagues and one of my Democratic colleagues for their 
special efforts. For the last 4 years, Senator Roy Blunt, Republican of 
Missouri; Senator Lamar Alexander, Republican of Tennessee; and Senator 
Patty Murray, Democrat of Washington, have joined forces--I have been 
part of that team too--to encourage an increase in medical research 
funding every single year, and we have done it.
  The increase that Dr. Collins at NIH asked for was 5 percent real 
growth a year. That is 5 percent over inflation. Do you know what we 
have done in 4 years? NIH has gone up from $30 billion to $39 billion. 
Dramatic. A 30-percent increase in NIH research funding.
  We are going to have a tough time with this coming budget, as we have 
in the past, but I hope we really reach a bottom line, as Democrats and 
Republicans, that we are committed to 5 percent real growth in medical 
research every single year so that we can answer these young people who 
come in dealing with diabetes, those who are suffering from cancer, 
heart disease, Alzheimer's, Parkinson's--the list goes on and on--that 
we are doing our part here in the Senate; that despite all the 
political battles and differences, there are things that bring us 
together, and that should be one.
  The second point they raised--one of the young girls there, Morgan of 
Jerseyville, started telling me a story about the cost of insulin. As 
she was telling the story about the sacrifices being made by her family 
to keep her alive, she broke down and cried. What she was telling me--
her personal experience, her family experience--was something that 
every family with diabetes knows: The cost of insulin--charged by the 
pharmaceutical companies--has gone up dramatically, without 
justification, over the last 20 years.
  In 1999, one of the major insulin drugs--called Humalog, made by Eli 
Lilly--was selling for $21 a vial. That was 20 years ago. In 1999, it 
was $21 a vial. The price today is $329 a vial. What has caused this 
dramatic increase? There is nothing that has happened with this drug. 
It is the same drug. And, I might add, Eli Lilly of Indianapolis, IN, 
is selling the same insulin product--Humalog--in Canada for $39. So it 
costs $329 in the United States and $39 in Canada.
  These families told me they were lucky to have health insurance that 
covered prescription drugs. That sounds good, except they each had 
large copays--$8,000 a year. And what it meant was that for this young 
girl, this beautiful little girl who was in my office and who has 
juvenile diabetes,

[[Page S4752]]

they would spend $8,000 a year at the beginning of the year for 3 
months of insulin before the health insurance kicked in and started 
paying for it. Of course, there are families who aren't so lucky--they 
don't have health insurance to pay for their drugs.
  So what are we going to do about it? It happens to be something the 
Senate is supposed to take up. We are supposed to debate these things 
and decide the policy for this country. We will see. Very soon, we will 
have a chance. A bill is coming out of the Health, Education, Labor, 
and Pensions Committee, and we will have a chance to amend it on the 
floor and to deal with the cost of prescription drugs. I will have an 
amendment ready if my colleagues want to join me--I hope they will--on 
the cost of insulin, and we will have a chance if Senator McConnell, 
the Republican leader, will allow us--it is his decision. We will have 
a chance to decide whether these kids and their families are going to 
get ripped off by these pharmaceutical companies for years to come.

  It isn't just insulin; it is so many other products. It is time for 
us to stand up for these families and their kids, to put money into 
medical research, and to tell pharma once and for all: Enough is 
enough. Insulin was discovered almost 100 years ago. What you are doing 
in terms of increasing the cost of it for these families is 
unacceptable and unconscionable.


                            Border Security

  Mr. President, in the last 2\1/2\ years of this administration, we 
have seen an incredible situation when it comes to immigration and our 
border. We have seen, unfortunately, some of the saddest and most 
heartbreaking scenes involving children at the border between the 
United States and Mexico.
  The pattern started with the President's announcement shortly after 
he was sworn in that he was imposing a travel ban on Muslim countries. 
That created chaos at our airports and continues to separate thousands 
of American families.
  Then the President stepped up and repealed DACA, the Executive order 
program created by President Obama that allowed more than 800,000 young 
immigrants to stay in this country without fear of deportation and to 
make a life in the only country many of them had ever known.
  Then the President announced the termination of the Temporary 
Protected Status Program, a program we offer--and have throughout our 
modern history--for those who are facing oppression or natural disaster 
in their countries. President Trump announced that he was going to 
terminate it for several countries, affecting the lives of 300,000 
immigrants.
  Then came the disastrous separation of thousands of families at the 
border--2,880 infants, toddlers, and children separated from their 
parents by the Government of the United States. This zero-tolerance 
policy finally was reversed by President Trump after the public outcry 
against it.
  Then what followed was the longest government shutdown in history 
over the President's demand that he was going to build a border wall, 
even at the cost of shutting down the Government of the United States 
for 5 weeks.
  We've also seen the tragic deaths of 6 children apprehended at the 
border and 24 people in detention facilities in the United States.
  The President then announced that he was going to block all 
assistance to the Northern Triangle countries--El Salvador, Guatemala, 
and Honduras, the source of most of the immigrants who come to our 
border--and that he would shut down the avenues for legal migration, 
driving even more refugees to our border.
  Now, on President Trump's watch, we have an unprecedented 
humanitarian crisis. We have seen that crisis exemplified by the 
horrifying image of Oscar Alberto Martinez Ramirez and his 23-month-old 
daughter, Valeria, who fled El Salvador and drowned as they tried to 
cross the Rio Grande 2 weeks ago.
  We have seen this crisis play out in the overcrowded and inhumane 
conditions at detention centers at the border.
  In April, I visited El Paso, TX. What I saw in the Border Patrol's 
overcrowded facilities was heartbreaking.
  In May, I led 24 Senators in calling for the International Committee 
of the Red Cross and the inspector general of the Department of 
Homeland Security to investigate our Border Patrol facilities. I never 
dreamed that I would be asking the International Red Cross to 
investigate detention facilities in the United States. They do that, 
but usually you are asking them to look into some Third World country 
where inhumane conditions are being alleged.
  After being in El Paso, after seeing what is going at our border, I 
joined with 23 other Senators in asking the International Red Cross to 
investigate the U.S. detention facilities.
  Later that same month, the inspector general of the Department of 
Homeland Security released a report detailing the inhumane and 
dangerous overcrowding of migrants at the El Paso port of entry. The 
Inspector General's Office found that overcrowding is ``an immediate 
risk to the health and safety'' of detainees and DHS employees.
  One week ago, the Inspector General's Office issued another scathing 
report, this time about multiple Border Patrol facilities in the Rio 
Grande Valley. The Inspector General's Office asked the Department of 
Homeland Security to take immediate steps to alleviate the dangerous 
overcrowding and prolonged detention. They stated: ``We are concerned 
that overcrowding and prolonged detention represent an immediate risk 
to the health and safety of DHS agents and officers, and to those 
detained.''
  Congress recently passed legislation 2 weeks ago that included $793 
million in funding to alleviate overcrowding at these CBP facilities 
and other funding to provide food, supplies, and medical care to 
migrants. The bill also includes critical funding for the Office of 
Refugee Resettlement to care for migrant children.
  We must now make sure that this money is spent effectively by the 
Trump administration. We gave them over $400 million in February, and 
they came back to us within 90 days and said: We are out of money. I 
would like to know how they are spending this money, and I want to make 
sure it is being spent where it is needed.
  There is a gaping leadership vacuum at the Trump administration's 
Department of Homeland Security. Think of this: In 2\1/2\ years, there 
have already been four different people serving as head of that 
Department. Every position at the Department of Homeland Security with 
responsibility for immigration or border security is now being held by 
a temporary appointee, and the White House refuses to even submit 
nominations to fill these positions.
  Two weeks ago, I met with Mark Morgan, one of those temporary 
appointees. In May, President Trump named him Acting Director of U.S. 
Immigration and Customs Enforcement. Mr. Morgan was asked at that time 
to carry out the mass arrests and mass deportations of millions of 
immigrants the President had threatened by his infamous tweets.
  Shortly before I met with Mr. Morgan to ask him about the mass 
arrests and mass deportations, there was a change. They took him out of 
that position and named him Acting Director of U.S. Customs and Border 
Protection. He went from internal enforcement to border enforcement. 
Now he is in charge of solving the humanitarian crisis that President 
Trump has created at our border.
  The Trump administration can shuffle the deck chairs on this Titanic, 
but we must acknowledge the obvious: President Trump's immigration and 
border security policies have failed. Tough talk isn't enough. We need 
to do better.
  This morning, I met with Dr. Goza, the president of the American 
Academy of Pediatrics. She came to give me a report about her visit to 
several border facilities that has been well documented and reported in 
the press. She said that it was hard for her, as a doctor for children, 
to see these things and realize they were happening in the United 
States.
  Yes, children are being held in caged facilities with wire fences and 
watchtowers around them, some of them very young children. As a 
pediatrician, she told me those things have an impact on a child--on 
how that child looks at the world and how that child looks at himself.
  She said that she took a lot of notes as she went through these 
facilities, but it wasn't until she got on the airplane on the way home 
that she read

[[Page S4753]]

through them. She said: Then I started crying. I am supposed to be a 
professional who can take this, but I couldn't imagine what we were 
doing to these children at the border. There just aren't enough medical 
professionals there--not nearly enough.
  The United States is better than that. We can do better than that. We 
can have a secure border and respect our international obligations to 
provide a safe haven to those who are fleeing persecution, as we have 
done on a bipartisan basis--Democrats and Republicans--for decades.
  I stand ready, and I believe my party stands ready, to work with 
Republicans on smart, effective, and humane solutions to the crisis at 
our border. I suggest that the following be included:
  Crack down on traffickers who are exploiting immigrants. That is 
unacceptable.
  Provide assistance to stabilize the Northern Triangle countries. That 
is long overdue.
  Provide in-country processing and third-country resettlement so that 
migrants can seek safe haven under our laws without making the 
dangerous and expensive trek to our border.
  Eliminate the immigration court backlog so that asylum claims can be 
processed more quickly.
  We have authorized more than 100 immigration court judges, and this 
administration can't find people to fill them. They want more judges. 
They have authority to hire 100 more, and they have been unable to do 
it.
  We need to ensure that children and families are treated humanely 
when they are in the custody of the U.S. Government.
  Eventually, the history of this period will be written, and there 
will be accountability, not just for the officials in government but 
for all of us--those of us in the Senate and the House and those in 
journalism and other places. We are going to have to answer for the way 
these people have been treated. Whether or not they qualify for legal 
status in the United States, I hope we can hold our heads up high and 
say that, at least from this point forward, we are going to show them 
that we are humane and caring people. No matter where they come from, 
no matter how poor they may be, we will take care that children are 
treated in a merciful way and a compassionate way; that the adults are 
given appropriate opportunities to exercise whatever rights they have 
under the laws of our country; and that at the end of the day we can 
hold our heads high because we have done this in a fashion consistent 
with the values of the United States of America.
  We haven't seen it yet. It is time for the President to acknowledge 
that get-tough, bizarre tweets just aren't enough. We have to have a 
policy that makes sense to bring stability to our border.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Iowa.


                        Prescription Drug Costs

  Ms. ERNST. Mr. President, I recently received a letter from a 
gentleman living in Cedar Falls, IA, who suffers from Parkinson's 
disease. As I speak, he is going without his $1,450-per-month LYRICA 
prescription in order to keep a roof over his head. That is right, 
folks. He must choose between making a mortgage payment and getting his 
prescription.
  Here is another story a woman from Davenport, IA, shared with me. 
Last October, she was able to get a 3-month supply of blood pressure 
medication for $17, but when she went to the pharmacy for her refill in 
late December, she was told the price had nearly tripled to $55. She 
wrote to me and said:

       Thinking this was a mistake, I refused the refill and 
     checked online about the change in price and found I couldn't 
     get it cheaper anywhere else. So I went back in ten days and 
     thought I would just have to pay the new cost [which was 
     $55]. In that time . . . the prescription had gone up to 
     $130!

  Whether I am talking to folks back home in my townhalls and other 
events on my 99 County Tour or in meetings right here in Washington, 
DC, the cost of prescription drugs is the No. 1 issue I hear about from 
Iowans. Every day, I hear stories just like these about the outrageous 
costs associated with their prescription medications.
  For too long, hard-working Iowans have borne the brunt of 
skyrocketing prescription drug prices. Stories like the man from Cedar 
Falls and the woman from Davenport have become the norm. We have to 
change that, and that is exactly what we are doing here in the Senate.
  We have been hard at work in advancing bills to drive down drug 
prices, increase competition, and close costly loopholes that are being 
exploited by those bad actors. I am proud to lead on three such bills 
that were recently approved in committee.
  First, I have teamed up with Senator Cotton on a bill that aims to 
eliminate an egregious loophole in the patenting process. This loophole 
allows drug companies to take advantage of the well-intentioned concept 
of sovereign immunity for Native American Tribes in order to dismiss 
patent challenges and unfairly stifle competition.
  Our legislation would put an end to this manipulative practice and 
actually provide Iowans with access to cheaper options for their 
prescription drugs. That is not all we are doing in the Senate to make 
more low-cost generic drugs available to folks in Iowa. We have also 
been working across the aisle on a bipartisan bill that would put a 
powerful check on drug companies seeking to keep generics off the 
market.
  The bill would empower the makers of generic drugs to file lawsuits 
against brand-name manufacturers if they fail to provide required 
resources, such as drug samples, needed for generics to clear the 
regulatory process. In turn, we would see cheaper alternatives 
available for my folks in Iowa.
  I am also working with my fellow Iowan, Senator Grassley, on a bill 
that focuses on the middlemen behind some of the prescription drug 
price hikes we have seen recently. The bill would direct the Federal 
Trade Commission to examine anti-competitive behavior in the 
prescription drug market. As mergers push drug prices higher and 
higher, this bill will be instrumental in helping Congress develop 
policies to increase competition and lower those costs for both 
patients and our taxpayers.
  Make no mistake. The rising cost of prescription drugs is an issue 
that significantly impacts hard-working Iowans. We in Congress have a 
responsibility to take action, to give folks a voice, and to make sure 
no family is ever forced to choose between making a mortgage payment 
and purchasing their medications.
  That is what we are doing. We have some great bills in the Senate--
bills from both Republicans and Democrats--that can help lower those 
drug prices, increase competition, and close loopholes. Let's build on 
this effort and continue working together in a bipartisan way to get 
these bills and others across the finish line and signed into law. 
Iowans are counting on us.
  I yield the floor.
  The PRESIDING OFFICER (Mr. Perdue). The Senator from Florida.
  Mr. SCOTT of Florida. Mr. President, as is now obvious to everyone, 
ObamaCare made healthcare even more expensive. Premiums are up. Copays 
are up. Deductibles are way up. ObamaCare has been a disaster, and even 
the Democrats are admitting it.
  Let's all remember, ObamaCare was sold and based on a bunch of lies. 
You didn't get to keep your doctor, your health plan, and your premiums 
didn't go down.
  The Democrats want Medicare for All, which will absolutely ruin the 
Medicare system and throw 150 million people off of the employer-
sponsored health insurance they like. That would be a disaster. There 
is something we can do and must do right now to help American families: 
We must lower prescription drug costs.
  This is very personal to me. I grew up in a family without 
healthcare. My mom struggled to find care for my brother who had a 
serious disease. Eventually she found a charity hospital 4 hours away 
for his treatment. I remember asking my mom how much lower drug costs 
would have to be for her to consider changing pharmacies. Without 
missing a beat, she said: a dollar.
  This story is not uncommon. All over my State I hear the same thing: 
Drug prices are rising, and we are having trouble affording the 
lifesaving medication we need.
  I recently met Sabine Rivera, a 12-year-old from Naples, FL, who was 
diagnosed with type 1 diabetes more than 2 years ago. She is 12 years 
old, and she is already worried about how she will

[[Page S4754]]

afford the rising cost of insulin--something no 12-year-old should ever 
have to stress about.
  Patients want to shop for better coverage and lower costs, but too 
often they can't or don't know how. At the same time, pharmaceutical 
companies are charging low prices for prescription drugs in Canada, 
Europe, and Japan but charging American consumers significantly more. 
Why? Because for too long politicians have done nothing.
  American consumers are subsidizing the cost of prescription drugs in 
Europe and Canada and all over the world. Why should we be doing that? 
That certainly is not putting America first, and that is not putting 
American families first. That is why I am working with President Trump 
and Republicans and Democrats in Congress to fix this problem.
  I recently introduced the America First Drug Pricing Plan with 
Senator Josh Hawley to take real steps to lower costs for patients and 
put the consumers back in charge of their healthcare decisions. Part 
one of my bill focuses on transparency.
  First, pharmacies must inform patients what it will cost to purchase 
drugs out of pocket instead of using their insurance and copays. If 
patients choose to pay out of pocket, which is sometimes cheaper, the 
total cost would be applied to their deductible.
  Second, insurance companies should, and must, inform patients of the 
total cost of their prescription drugs 60 days prior to open 
enrollment. This allows patients to be consumers and shop around for 
the best deal.
  Finally, my bill would simply require that drug companies cannot 
charge American consumers more for prescription drugs than the lowest 
price they charge consumers in other industrialized nations.
  I have found that provision to be controversial in Washington. Do you 
know where it is not controversial? Everywhere else. In Tampa and 
Orlando, Miami and Panama City, all over Florida, this just makes 
sense. I don't spend a lot of time outside of Florida, but I would 
wager and say that across the country my bill would make a lot of sense 
too.
  Why would we as American consumers, who make up 40 percent of the 
market for prescription drugs, pay two to six times more for drugs than 
consumers in Europe or Canada or Japan? That needs to change. My bill 
takes real steps to change this, and I believe it should have 
bipartisan support.
  I also led seven of my colleagues in a letter to pharmaceutical 
companies asking them to work with us on solutions to lower the cost of 
prescription drugs. We are still waiting to hear back.
  American consumers are facing a crisis of rising drug costs, and we 
can't wait any longer. I will not and cannot accept the status quo of 
rising drug costs. We need to get something done this year, and I am 
fighting every day to make sure we do.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from West Virginia.
  Mrs. CAPITO. Mr. President, I am pleased to join my colleague on the 
Senate floor to talk about an extremely important topic--that is, 
lowering the cost of prescription drugs in this country. Just a few 
weeks ago, on June 20, West Virginia celebrated our 156th birthday. 
There is plenty to celebrate about West Virginia, from its breathtaking 
beauty and wonderful families to our kind and hospitable West Virginia 
spirit.
  Unfortunately, West Virginia has its challenges, too, including 
health challenges. We have some of the highest rates in the Nation for 
heart disease, diabetes, cardiovascular disease, cancer, and arthritis. 
While there are many nonpharmaceutical steps people are taking to 
prevent and control diseases, for many, their prescription medicine is 
the difference between wellness and illness or even between life and 
death.
  That is why it is so important that West Virginians are able to 
secure their medications and that we as a Congress make sure they are 
not paying too much for those medications. Of all the issues that my 
constituents come to me with--whether it is a phone call, a letter, or 
casually running into them at the grocery store--this is the issue I 
hear most about because it is something that affects so many West 
Virginians' way of life, and it is something that affects them every 
day. If it doesn't affect them, it affects somebody in their family.
  The same can be said for Americans across this country, and that is 
why it has become one of our Nation's top priorities, one that is 
shared by Republicans and Democrats and one that is a significant 
bipartisan focus of this administration and this Congress. It is a far-
reaching problem with many different factors contributing to it, and 
that is why we have to address it on many different fronts.
  The chairman of the HELP Committee is here today. He has worked 
through his committee diligently, and I applaud him for his efforts and 
look forward to joining him on the floor in support of those efforts.
  As we all know, the path a medication takes from the manufacturer to 
the patient is very complex, with many factors impacting the price a 
consumer pays. While making changes to this pathway is very important, 
my constituents really don't care about the pathway. They are more 
concerned with the total on their bill that their pharmacist is ringing 
up. That is why I have focused a lot of my personal efforts on the 
important role that our pharmacists play in lowering drug costs.
  In many small towns and rural communities--which is my entire State--
pharmacists are the healthcare providers people go to quite regularly, 
and they are often some of the most trusted, friendly, and welcoming. 
It is essential that patients, especially seniors, are able to access 
the local pharmacy.
  West Virginians and Americans across the country should be able to 
trust that their pharmacist is not being restricted about telling them 
how to get the best prescription drug prices. They need to know they 
aren't facing higher cost sharing for drugs and being accelerated into 
the coverage gap or the doughnut hole phase of Medicare Part D due to 
an overly complicated system of fees and price concessions that nobody 
really understands--certainly not at the pharmacist's desk.
  In order to ensure that seniors have access to a pharmacy of their 
choice, Senator Brown and I introduced the Ensuring Seniors Access to 
Local Pharmacies Act last Congress. We will be reintroducing this bill, 
which requires that community pharmacists in medically underserved 
areas be allowed to participate in the Medicare Part D preferred 
pharmacy networks.
  Why is this important? If a local pharmacy is not included in a 
preferred network, a senior must either switch to a preferred network 
pharmacy, which could be a lot farther away or less convenient, or pay 
higher copayments and coinsurance to access their local pharmacy. In 
some cities and towns, you can find a pharmacy on nearly every corner. 
In rural areas, that is just not the case, and accessing a preferred 
pharmacy could require significant time and difficult travel.
  Additionally, many seniors rely on their local pharmacies not only to 
access prescription drugs but also to receive those needed services 
like preventive screenings and medication therapy management.
  As important as access to a local pharmacy is, it is also essential 
that patients can trust their pharmacists to let them know which 
payment method provides the most savings when purchasing their 
prescription drugs.
  I was proud to join Senator Collins last year as a cosponsor of the 
Patient Right to Know Drug Prices Act. This commonsense bill, which the 
President signed into law in October, bans the use of the pharmacy gag 
clause. It was hard to believe this still existed. These clauses were 
put into place by insurers and pharmacy benefit managers, and they 
prevented our pharmacists from proactively telling consumers that their 
prescriptions could cost less--less--if they paid out of pocket rather 
than relying on their insurance plan.
  I am also currently working with Senators Tester, Cassidy, and Brown 
on legislation that would help improve transparency and accuracy in 
Medicare Part D drug spending. Our bill would reform the application 
process of pharmacy price concessions, also known as direct and 
indirect remuneration, or DIR fees, in the Medicare Part D Program. It 
sounds complicated, but it is driving up the cost of our 
pharmaceuticals.

[[Page S4755]]

  This will ensure that our seniors are not facing higher cost sharing 
for their drugs or, again, being accelerated into the coverage gap. It 
will also help ensure that local pharmacies are able to stay open. This 
is critical. We have to keep our local pharmacies open for a vast 
majority of rural America and have them continue to stay open and 
continue to serve Medicare beneficiaries and other communities that 
rely on them. It would provide needed financial certainty for these 
pharmacies, which are often small businesses.
  My colleagues and I hope to see this legislation included in the 
soon-to-be-released Senate finance package. These are just a few 
examples of how we are working to lower prescription drug costs.
  I have been listening to my colleagues and have heard a lot of other 
ideas. They are small but much needed steps that can be, and already 
are, making a real difference in our constituents' lives, but our work 
is far from over. We have to continue looking at both commonsense and 
complex solutions to the problem. This is a complex problem. While as a 
Congress and a country we may not agree on the best way to do that, we 
do all agree that it is a problem that needs to be solved.
  I look forward to continuing to work with Senator Alexander and 
Senator Lankford, who are on the floor here today, and my other 
colleagues and the administration to find that pathway forward to 
lowering the cost of prescription drugs.
  I yield back.
  The PRESIDING OFFICER. The Senator from Tennessee.
  Mr. ALEXANDER. Mr. President, I thank the Senator from West Virginia 
for working to reduce the cost of prescription drugs. That is the 
question I hear most often in Tennessee: How can I reduce what I pay 
for out of my own pocket for healthcare costs? The most obvious way to 
reduce what you pay out of your own pocket for healthcare costs is to 
reduce the cost of prescription drugs.
  Shirley, from Franklin, TN, is one of those Americans who asked me 
that question. This is what she said:

       As a 71 year old senior with arthritis, I rely on Enbrel to 
     keep my symptoms in check. My copay has just been increased 
     from $95.00 to $170.00 every ninety days. At this rate I will 
     have to begin limiting my usage in order to balance the 
     monthly budget.

  There has never been a more exciting time in biomedical research, but 
that progress is meaningless if patients can't afford these new 
lifesaving drugs.
  Last month, as Senator Capito mentioned, our Senate Health Committee 
passed legislation by a vote of 20 to 3 that included 14 bipartisan 
provisions to increase prescription drug competition as a way of 
lowering generic drug costs and biosimilar drugs that reach patients.
  Here is what that includes: The CREATES Act--the Senator from Iowa, 
Mr. Grassley, is on the floor. He, Senator Leahy, and many others have 
proposed the CREATES Act, which will help bring more lower cost generic 
drugs to patients by eliminating anticompetitive practices by brand 
drugmakers. That is in the bill we approved. It also includes helping 
biosimilar companies speed drug development through a transparent, 
modernized, and searchable patent database. That was proposed by 
Senators Collins, Kaine, Braun, Hawley, Murkowski, Paul, Portman, 
Shaheen, and Stabenow. This legislation we have was approved 20 to 3. 
There are 55 different proposals by 65 different U.S. Senators--about 
the same number of Republicans and Democrats--all to reduce healthcare 
costs.
  Here are some other examples. The bill improves the Food and Drug 
Administration's drug patent database by keeping it more up to date to 
help generic drug companies speed product development, a proposal 
offered by Senator Cassidy and Senator Durbin.
  Another provision is it prevents the abuse of citizens' petitions. 
These are used to unnecessarily delay drug approvals. This was proposed 
by Senators Gardner, Shaheen, Cassidy, Bennet, Cramer, and Braun. 
President Trump included that in his 2020 budget.
  Another provision is it clarifies that the makers of brand biological 
products, such as insulin, are not gaming the system to delay new, 
lower cost biosimilars. That came from Senators Smith, Cassidy, and 
Cramer.
  Another provision is it eliminates exclusivity loopholes. These allow 
drug companies to get exclusivity and delay patient access to less 
costly generic drugs by just making small tweaks to an old drug. That 
came from Senators Roberts, Cassidy, and Smith, which President Trump 
also proposed in his budget.
  Another provision prevents the blocking of generic drugs. This is 
done by eliminating a loophole that allows a first generic to submit an 
application to FDA and block other generics from the market. Again, the 
President included this in his budget.
  Another provision in our bill prevents delays of biosimilar drugs by 
excluding biological products from compliance with U.S. Pharmacopeia 
standards. That sounds pretty complicated, but what it means is that it 
could delay patient access and lower the cost of drugs. Again, that is 
another proposal by President Trump.
  Another provision is it increases transparency on price and quality 
information by banning the kind of gag clauses Senator Capito talked 
about. These are gag clauses in contracts between providers and health 
plans that prevent patients, plan sponsors, or referring physicians 
from seeing price and quality information.
  Another provision bans pharmacy benefit managers from charging more 
for a drug than it paid for the same drug.
  Instead of remaining stuck in a perpetual partisan argument over 
ObamaCare and health insurance--and I can guarantee you that is going 
to continue to go on for a while--we have Senators on that side of the 
aisle and Senators on this side of the aisle working together to lower 
the cost of what Americans pay for healthcare out of their own pockets.
  Since January, Senator Murray and I have been working in parallel 
with Senator Grassley and Senator Wyden of the Finance Committee. They 
are continuing to work on their own bipartisan bill. Last month, the 
Senate Judiciary Committee also voted to lower the cost of prescription 
drugs. In the House, the Energy and Commerce, Ways and Means, and 
Judiciary Committees have all reported out bipartisan bills on the cost 
of prescription drugs.
  As I have mentioned, President Trump and Secretary Azar have been 
focused on this. Last year, the administration released a blueprint on 
steps the President would take to lower prescription drugs. Last year, 
the Food and Drug Administration set a new record for generic drug 
approvals. Generic drugs can be up to 85 percent less expensive than 
brand drugs.
  So I believe the cost of prescription drugs is an area where 
Democrats and Republicans in Congress and the administration can find 
common ground to help Americans reduce the cost of healthcare that they 
pay for out of their own pockets.
  I am very hopeful that our bill, with 55 proposals from 65 Senators, 
which has been reported to the Senate floor, will be placed by the 
majority and minority leaders on the Senate floor before the end of the 
month. We can pass it, the House will do their job, and we can send it 
to the President to lower prescription drug costs.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Oklahoma.
  Mr. LANKFORD. Mr. President, I rise to talk to this body again about 
healthcare and the cost of healthcare. This has been an issue and an 
ongoing dialogue for a long time around the Senate and around Congress.
  It is an issue that was supposedly settled when the Affordable Care 
Act was passed, but, ironically enough, my Democratic colleagues have 
now joined Republicans in saying they want to repeal and replace the 
Affordable Care Act. They are not using the term ``repeal and 
replace''; they are just saying they want to do Medicare for All. Built 
into that is completely taking out the Affordable Care Act and 
replacing it with something different.
  So, ironically, in some ways, we are in the same spot. We have both 
come to the same realization that the Affordable Care Act didn't pass--
it actually did pass, but it is not working. So now the challenge is 
what to do with healthcare.

[[Page S4756]]

  We are now trying to break into pieces what we can actually do 
together to get this done, beginning with the cost of prescription 
drugs.
  I continue to hear from Oklahomans all over the State about how hard 
it is to deal with the cost of prescription drugs, how rapidly the 
costs are increasing, and how sporadic the cost changes really are. 
They will have a drug that costs a small amount one month and come back 
a month later and find a dramatic increase for the exact same drug. 
They can go pharmacy to pharmacy and find a different price for the 
exact same drug or find that the pharmacy closest to them doesn't offer 
that drug, and a different pharmacy is the only one that is allowed to 
have that drug. The complexity is driving them crazy and rightfully so.
  As we peel back the layers on pharmacy issues, we are finding that 
the complexity is that cost overruns being built in are too high.
  For the past few months, we have looked at every step in the drug 
process, from the approval to research and development, to try to 
figure out how the cost is actually getting to the consumer.
  Along the way, several things have occurred. The administration has 
aggressively been approving generics. In fact, the administration has 
approved a record number of generics. Those generic pharmaceuticals are 
much less expensive than the branded pharmaceuticals. Many of those 
have been waiting a very long time at the Food and Drug Administration 
to actually be approved. The Food and Drug Administration is rapidly 
getting those out the door, and that helps consumers.
  Something else we have done in Congress is to try to address 
something called the gag clause. The gag clause is one of those things 
that was behind the scenes that no one knew about except for the 
pharmacists because, if you came in with your insurance card to pick up 
your prescription, the pharmacist knew the actual cost you would pay if 
you paid in cash. Often, you could get that same prescription for less 
by paying in cash than you could if you were to pay with your insurance 
card, but the pharmacist was prohibited from actually telling you that. 
We have addressed that in Congress, in a bipartisan way, to release 
that gag clause and allow pharmacists to actually tell people their 
options on pricing.
  You might say: That is an absolutely crazy thing. Who put that gag 
rule in?
  Well, the system, and the structure behind the scenes that negotiates 
all of it, said: If you want to be a pharmacy that sells these drugs, 
you have to submit to these rules. As we found, the culprit behind many 
of these issues is a group called pharmacy benefit managers. You will 
hear it referred to as just the PBMs.
  Those pharmacy benefit managers are supposed to negotiate between the 
manufacturers and the insurance plans to lower the prices. In many 
areas, they have lowered prices, but they have also given preferred 
formulary placement to some of their preferred pharmacies so some 
pharmacies get that drug and other pharmacies that are competing with 
them don't get access to that drug. Often, it is the drug that is the 
highest margin drug only their pharmacies will get and other pharmacies 
will not.
  It has become an anti-competitive piece in the background, when it 
was supposed to be something that was a highly competitive piece to 
actually help the consumer.
  Unfortunately, PBMs have created one of the most elaborate, complex, 
and opaque system of pricing, which has a tremendous amount of market 
distortion and at times has limited patients' access to those drugs. 
Oftentimes, it is a system they have been able to take advantage of and 
have created financial incentives to help their bottom line in the 
process rather than actually help the consumer.
  Many consumers have heard about rebates, but they wonder who is 
getting a rebate. They go to their pharmacy to pay for their drugs, and 
they are not getting the rebate. There is a rebate going somewhere, 
just not to them.
  Here is the challenge. We are trying to peel back with greater 
transparency what is happening in the pharmacy benefit manager world 
and figure out how a small group--it is actually three companies that 
have 90 percent of the market nationwide, how that middleman in the 
process actually handles pricing and negotiation.
  If you talk to any pharmacist anywhere in the country--and certainly 
across my great State--who is an independent pharmacist, they will all 
express their frustration with pharmacy benefit managers and their 
access to some drugs and not others and the stipulations they 
deliberately put there to hurt them and help others.
  I have joined my colleague Senator Cantwell in trying to shine some 
light on the operations of PBMs within the drug chains. Consumers 
deserve greater transparency. That will help us understand the actual 
cost of drugs and how those costs are actually getting to consumers or 
not to consumers in the process. The PBMs need greater examination, and 
we are finally taking that up to walk through the process.
  On the Finance Committee, we are dealing with several issues. Led by 
Senator Grassley, we are walking through Part B of Medicare, Part D of 
Medicare, and trying to examine what can be done to help the actual 
consumer. Our goals are how do we actually increase the options in 
drugs that are out there, how do we stop the cost increases, and how do 
we decrease out-of-pocket costs for pharmaceuticals.
  In Part B--these are drugs that are often intravenous, but they are 
done in a hospital setting or in an inpatient setting. As we are 
working through that process, we are trying to find the perverse 
incentives that are built in because, right now, physicians are 
actually paid a percentage of the medicine they prescribe in Part B. 
That means if there are three medications that are out there, if a 
doctor prescribes the highest cost medication, they get a much higher 
reimbursement. It is not a flat amount. Now, all three may be 
intravenous, but whichever is the most expensive actually helps the 
doctor the most. I am not challenging doctors and saying they are 
always prescribing the branded drugs and the most expensive in the 
process--that is between the doctor and the patient to determine--but 
there is no doubt a perverse incentive is built into this; that if they 
prescribe a more expensive drug, the doctor and his office actually 
benefit from it. We need to fix that.
  In Part D, there are reforms that can actually slow the growth in 
cost increases and allow people to have greater access to drugs. We are 
not interested in some kind of formula where we are actually going to 
decrease the patients' options of what drugs they can actually get in 
their formulary. That is a great thing about being an American; that we 
don't have limited formularies. It is very open in the process so 
Americans can try different pharmaceuticals to see which one works best 
for them. That is not chosen by government; it is chosen by them and 
their doctors. The Part D definitely needs a redesign of the benefit 
structure because right now things like the doughnut hole drive up 
costs for consumers. We are exploring a way to limit the out-of-pocket 
costs for beneficiaries so there is a lifetime cap sitting out there. 
There is an opportunity to know that if I end up with cancer or some 
other rare disease, I am not going to have these out-of-control costs 
on the pharmaceutical side and know there is not a doughnut hole 
waiting for me, where when I get a couple thousand dollars in, I am 
suddenly going to have a very expensive time. So I can afford my 
insurance in January, February, and March, but from April to August, I 
can't afford prescriptions anymore. We can't have that. We have to 
address those issues because that dramatically affects the out-of-
pocket costs.

  There are lots of other options we are looking at while working 
through this process, like the rebates, as I mentioned before, actually 
getting to the consumer, not to the companies behind the scenes, and 
dealing with how to take greater advantage of biosimilar drugs--very 
similar to the generic drugs but just in a different category and at a 
reduced cost--to allow them to have opportunities to get to those drugs 
faster. We have to deal with some of the patent issues to make sure 
drug manufacturers can't hold on to their patents abnormally long so 
the generics can't actually get out to people or bundle them together 
to restrict their patents.
  We have to end this practice of surprise medical bills. Some folks 
have no

[[Page S4757]]

idea what that is, and other folks know all too well. They look at 
their insurance. They go to a hospital that is in network, and their 
doctor is in network. So they go to a hospital that is in network, and 
they go to a doctor who is in network, but they get a giant bill from 
an out-of-network anesthesiologist, or the lab is out of network and 
the hospital is in network, and they get a giant bill from the lab. We 
are working to end the practice of having labs that are out of network 
or certain specialists a doctor has sent them to--the patient assumes 
they are in network, but then they find out that certain individuals 
who have taken care of them are out of network.
  We are also dealing with the issue of air ambulance surprise bills, 
which has been a great challenge for those folks in rural America who 
are having to be transferred long distances to get to a hospital and 
then are getting an enormous bill for an out-of-network air ambulance 
as a surprise billing. There are ways we can address this to deal with 
the out-of-pocket costs.
  We are focused on areas where we can find agreement and things we can 
do to work through this process.
  There is much to be done in the area of prescription drugs and in the 
area of in network, out of network, and surprise medical bills. We 
should be able to find common ground, and I am grateful I am part of 
this dialogue to help try to find ways we can come together, get this 
resolved, and get a better situation for American consumers and 
patients in the days ahead.
  With that, I yield the floor.
  The PRESIDING OFFICER. The Senator from Iowa.
  Mr. GRASSLEY. Mr. President, I want to update my colleagues and the 
American people about efforts to reduce the cost of prescription 
medicine.
  Last week, our country and the American people celebrated 
Independence Day, marking 243 years of self-government. As elected 
representatives, it is our job to make the government work for the 
people, not the other way around.
  For more than two centuries, our system of free enterprise has 
unleashed American innovation, investment, and ingenuity. Robust 
competition incubates advances in science and medicine. It leads to 
lifesaving cures and promising treatments for cancer, Alzheimer's, 
diabetes, and other debilitating diseases.
  However, prescription medicine too often smacks consumers with 
sticker shock at the pharmacy counter. The soaring prices leave 
taxpayers with a big tab--particularly under the Medicare and Medicaid 
Programs--and they weigh heavily on the minds of moms and dads all 
across the country.
  Last week, I held meetings with my constituents in 12 counties across 
Iowa. The cost of prescription drugs comes up at nearly every single Q-
and-A county meeting that I hold. Iowans want to know why prices keep 
climbing higher and higher. They want to know why the price of insulin 
keeps going up and up and up--nearly 100 years after the lifesaving 
discovery was made. They want to know what can be done to make 
prescription drugs more affordable.
  I am chairman of the Senate Finance Committee, and in that position, 
I have been working with Ranking Member Wyden from Oregon on a 
comprehensive plan to do just that. We have held a series of hearings 
to examine the drug price supply chain. We are working on a path 
forward. We are taking care to follow the Hippocratic Oath: ``First, do 
no harm.'' In other words, let's be sure we don't try to fix what is 
not broken. Americans don't want to give up high-quality lifesaving 
medicine. That is why I support market-driven reforms to boost 
competition and transparency, because with transparency brings 
accountability and the marketplace working more free of secrecy.
  Congress needs to get rid of perverse incentives and fix problems 
that undermine competition in the drug pricing system, including 
withholding samples by brand-name pharmaceutical companies, pay for 
delay, product-hopping, and rebate-bundling. There is too much secrecy 
in the pricing supply chain. Consumers can't make heads or tails of why 
they are charged what they pay for their medicine.
  President Trump has made reducing drug prices a top priority of this 
administration, and they have taken several steps under various laws--
including even under ObamaCare--to do things that give more freedom to 
consumers of medicine and on other healthcare priorities.
  In another instance, on Monday, the Federal court took a negative 
move, knocking down a rule that would require drug companies to 
disclose the price of their drugs in television ads. This is very, very 
disappointing. Senator Durbin and I worked on this in the last 
Congress, and I am going to continue to work with Senator Durbin to get 
this job done. Congress must correct what the Federal court said the 
administration didn't have the authority to do. I disagree with the 
court, but Congress can fix that. Big Pharma is already required to 
disclose side effects in their ads. Consumers ought to know what the 
advertised drug will cost. Today, I call upon my colleagues to climb 
aboard that effort Senator Durbin and I will be pursuing.
  Let's pass the bipartisan healthcare bills thoughtfully crafted in 
various committees. The previous three speakers spoke to some of those 
issues. Let's get these various bills correcting some of these problems 
over the finish line. Working together, we can drive down the price of 
prescription drugs without derailing quality and without derailing 
innovation, all of which saves lives and improves the quality of life 
for the American people.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Indiana.
  Mr. BRAUN. Mr. President, Senator Grassley and I attended the rollout 
of President Trump's Executive order to get the healthcare industry on 
the move. The chairman of the Finance Committee, the chairman of the 
Health, Education, Labor, and Pensions Committee, and Senators like 
me--I am a mainstream entrepreneur--came to the Senate to discuss 
issues just like this.
  I have probably been on the floor more than any other Senator, and 
every time I do it, I tell the industry: Wake up. I took you on 10, 11 
years ago, in my own business, to give good healthcare coverage to my 
employees. Year after year, it was a litany of, you are lucky your 
premiums are only going up 5 to 10 percent this year. You have all 
heard it before. It took risk, and it took some novel thinking, but it 
can be done. Most entrepreneurs aren't going to put the time I put into 
it to make it work for my own employees.
  When you hear Democrats, Republicans, three or four committees, and 
the President of the United States talking about a healthcare system 
that is broken, you should get it through your thick head that there 
need to be changes made. It shouldn't be coming from Congress, even 
though it will keep coming.
  I think the message is out loud and clear: Wake up and start fixing 
these things, or you are going to have a business partner whose name is 
Bernie Sanders and another idea of Medicare for All that we would 
regret once we got it. But, like most things here, like most big 
problems in this country, we wait too long to solve the issue.
  To give you a few things on what led me to be passionate about it, 
when I had to give up my own company's good health insurance, I had a 
very generic prescription that I needed to get renewed. There were 
eight pharmacies in the little town of Jasper, roughly, so I knew I 
would be able to get quotes. I had no health insurance. I was in 
between being a CEO of a company and a Senator. I said, I am going to 
try to see what this is going to be like. I knew it should cost 20 or 
25 bucks, maybe a little less.
  The first place I called, they stumbled around and couldn't even give 
me a quote on a common prescription. Finally, after about 3 to 4 
minutes, they said $34.50. I called another place that I thought would 
be a little quicker on its feet. It took 10 seconds, I got a quote for 
$10, and they said: By the way, you can pick it up in 10 minutes.
  That is more the way the rest of the economy works, but healthcare 
consumers have gotten used to not doing any of that heavy-lifting 
themselves. And believe me, the industry has evolved from Big Pharma, 
to big hospital chains, to the health insurance industry, which is in 
the middle of all of it. There are pharmacy benefit managers, and the 
drug companies give

[[Page S4758]]

them $150 billion worth of rebates, and through their costs and 
profits, less than half of that makes it to the consumer or to the 
pharmacy.
  The case is out there. We, as Senators and Congressmen on the other 
side, shouldn't need to be going to the floors of our Chambers to tell 
you the obvious: If you don't do these things, I don't believe we 
here--at the speed at which we normally operate--can do it quickly 
enough for you to save yourselves from that other business plan, which 
is Medicare for All.
  So what do we do to prevent that? No. 1, the industry should be out 
there doing what all other companies do--be transparent. In any other 
part of our economy, where do you not ask for and have plenty of 
information to work with. What does it cost, and what is the quality? I 
know that where I live, people would drive 60 miles to save 50 bucks on 
a big-screen TV that costs a thousand bucks.
  When I instituted a plan in my own business that encouraged my 
employees to do that, to have skin in the game, amazing things 
happened. Every time you pick up the phone or get on the web and look 
for that comparison, it is kind of hard to find, but it is there. The 
industry just needs to give more of it and not hide behind a system 
that has benefitted them. When we created that in my own business, 
people shopped around for prescriptions and routinely saved 30 to 70 
percent, as they do on MRIs, CAT scans, and most other procedures.
  I put the time and effort into it. Most CEOs--and you always hear 
about how employees are happy with their employer-provided insurance. 
That is because the employers are generally paying for anywhere from 85 
to 100 percent of it. So folks working somewhere don't really have skin 
in the game.
  Consumers of healthcare need to do what they do in all other 
industries and in all other things that they buy--take the time to ask 
how much it costs, what is the quality, and then the industry get with 
it so that we can fix the system before the other option actually takes 
place. There aren't enough CEOs and there aren't enough legislators to, 
I think, get the industry in shape, and the industry itself knows what 
these problems are. Get with it before you have a different business 
partner whom you won't like.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Louisiana.
  Mr. CASSIDY. Mr. President, I, too, come to speak today regarding 
pharmaceutical costs and what we can do to make lifesaving 
medications--and sometimes these medications make our lives a little 
bit better--more affordable to the average American.
  I happen to be a doctor, and I will approach these remarks as a 
fellow who has seen medicine evolve, who has seen the incredible, 
positive benefits of pharmaceutical innovation, but also as a doctor 
who sometimes saw that patients were unable to afford innovation. The 
question in my mind is, How do we give the patient the power to afford 
these innovative medicines, because if she cannot afford them, it is as 
if the innovation never occurred, and for her, it never did occur. So 
give the patient power.
  Let me make some remarks about pharmaceutical companies. There are 
some incredible examples.
  When I was in medical school, cutting away a part of one's stomach--
not the belly but part of the stomach; as I would tell patients, where 
the food goes after you swallow it--cutting away a part of the stomach 
because of ulcerative disease was one of the most common procedures 
done in surgery. Then histamine blockers came along, H2 blockers. 
Cimetidine was the first. All of a sudden, a surgery that was done 
multiple times a week was scarcely ever done. Those medicines are now 
sold over the counter.
  This morning, I got a little bit of arthritis, so I took my 
nonsteroidal anti-inflammatory, which used to be sold by prescription 
and now is over the counter, along with my H2 blocker, my Pepcid, which 
used to be sold by prescription but now is over the counter. I take 
them in the morning, and my back feels better. All of these are 
medicines that are generic, routine, and we almost--in fact, we indeed 
take the innovation for granted.
  I can go on. I am a liver doctor. Hepatitis C used to be an incurable 
disease which, in a certain percentage of those affected, would lead to 
cirrhosis, vomiting blood, liver cancer, and death. Now hepatitis C is 
cured by taking pills for several weeks. Amazing.
  Human immunodeficiency virus, AIDS. When I was in residency, if you 
got HIV, you died. There was no cure whatsoever. Now people live with 
it for decades. It is a disease you live with but do not die from. We 
speak of actually now developing cures for HIV.
  That is the promise of a vibrant pharmaceutical industry--people who 
not only live when otherwise they would have passed away but who also 
have a better quality of life.
  Now, that said, if the patient doesn't have the power, the patient 
has no leverage in this situation.
  I was recently with others in a conversation with the new head of the 
Congressional Budget Office. The CBO head said: You know, everybody has 
leverage in the healthcare marketplace except the patient. Everybody 
has leverage but not the patient.
  That is so true. Let me give some examples of how the patient lacks 
leverage in the pharmaceutical marketplace.
  First, I will say, if I go to church--and I do go to church 
regularly--and there is a Bernie Sanders supporter yanking on this 
lapel and a Donald Trump supporter yanking on this lapel and they are 
complaining about the same thing, they are talking about either 
surprise medical bills or the high cost of drugs. It is something that 
touches each American, but it doesn't have to be that way.
  Consumer Reports did an article over 1 year ago now in which they 
sent secret shoppers out to retail pharmacies to buy five generic 
medications, a prescription for each type--again, generic, like the 
over-the-counter pills I am taking. They went, and they paid anywhere 
from $66 to $900 for the same five drugs. Now, we can assume that the 
acquisition cost was about 60 bucks, because you could buy it 
someplace--an independent pharmacy or online--for $66, but three or 
four chain pharmacies were charging $900 for medications that they 
could acquire for less than $60.
  You could argue, why did the patient pay? Because we have so little 
advertising, if you will, cost competition, on what a generic medicine 
would cost. So imagine you have a health savings account, and you are 
going to buy your prescriptions, and you get charged $900 for something 
that should cost $60. This is the situation in which the patient has no 
leverage.
  By the way, you can ask, why didn't insurance cover it? It is because 
these patients were posing as uninsured. So the chain pharmacy figured 
out that it is the uninsured who do not have somebody working on their 
behalf who are going to be the most ripe for the picking for the high 
prices. The uninsured are the ones we are going to exploit, the ones 
paying cash. That is wrong. That is not the patient having the power; 
it is the patient being used as a victim.
  There are other things we can see. One is called evergreening. You 
have a drug, and you make just a little bit of a tweak to it that 
doesn't improve its importance or the efficacy of the drug--no clinical 
benefit--but it extends the intellectual property protections. Now laws 
that were conceived of and passed by Congress to reward innovation and 
to encourage creativity are instead being used to stifle competition 
and to extend patent lives so that we, the patients and the taxpayers, 
have to pay more--not for innovation but, rather because, somebody 
figured out how to evergreen it.
  So on the one hand, I am going to praise pharmaceutical companies for 
lifesaving drugs that have meant so much to me, my family, and everyone 
who is listening today, but I must also ask, why should we reward that 
which is not innovative but which is merely arbitraging laws meant to 
encourage innovation? We should not encourage arbitraging laws.
  There are other issues, such as patent abuse, where companies file 
large numbers of patents on parts of their drugs that are not 
innovative but are byproducts of the production process in order to 
keep out competition; citizen petitions, which typically come on 6 
months before a drug is about to become generic, so all of a sudden, we 
have all these petitions that must be navigated by the companies 
seeking to

[[Page S4759]]

introduce the generic; and the rebate system, which works to preserve 
market share but also to increase prices and to keep them high so 
patients do not benefit from competition.
  If we are going to say the patient should have the power in order to 
have lower prices, we can say right now that the system seems to be 
aligned against the patient.
  What can we do? Well, my office and others have several proposals in 
the current pieces of legislation going through, such as the so-called 
real-time benefit analysis. A prescription is ordered for a patient. 
The patient scans a barcode, and it would say: At this point, with your 
deductible and your copay, this is how much this drug is going to cost 
you, but there is a generic available, and you can get that generic 
instead. That would be a real-time benefit analysis that would save the 
patient money.
  We just talked to the folks at Blue Cross California. They are coming 
up with so-called gainsharing. If a patient selects a lower cost 
medication, the patient receives some of the savings that would 
otherwise have all gone back to the insurance company--another great 
idea. Senator Braun was speaking about the patient having skin in the 
game. In this case, there will be skin in the game because the patient 
shares the benefit with the payor for being cost-conscious. That is the 
patient having the power.
  We can also add value-based arrangements, which pharmaceutical 
companies, to their credit, have proposed. If you are the 
pharmaceutical company, you get paid only if the medicine works. If the 
medicine doesn't work, you don't get paid. If it does work, you do. 
That is a value-based arrangement. We have a bill with Senator Warner 
that would do that.
  I would also mention attempting to cap Part D exposure. If there is a 
senior citizen who is in the catastrophic portion of her policy, then 
you can cap the amount the senior might be exposed to. Under current 
law, she might be paying 5 percent of $100,000 worth of medicine. She 
is taking an essential drug to treat cancer, and she is paying 5 
percent of that $100,000, in addition to 5 percent of the other 
medications she is receiving. This is something many seniors cannot 
afford and this is something we as Congress can find mechanisms by 
which we can cap that exposure but still hold taxpayers whole.
  We have to enhance existing markets. As you might guess, my theme is 
that we should enhance it in terms of giving the patient the power, but 
we also have to preserve the innovation that has led to the great drugs 
I spoke about earlier. If all we do is steal intellectual property from 
the pharmaceutical companies, we will lose these innovative drugs. But, 
again, we need to have the drugs affordable for the patients. This is 
the tension--promote innovation but ensure affordability.
  We have a number of solutions, such as those I have just mentioned, 
in the HELP Committee and now in the Finance Committee. Republicans 
have solutions. My office continues to work on those. I look forward to 
working with my colleagues on their implementation.
  Mr. President, I yield the floor.

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