Bob Casey

Mr. CASEY

Mr. CASEY. Mr. President, I ask unanimous consent that the order for the quorum call be rescinded.

Mr. CASEY. Mr. President, I rise tonight to talk about yet another healthcare debate we are having here in the Senate. As many people know and have been following this over the last number of months, we had a long debate and then a vote here at the end of July. At that point, despite all of the conflict and all of the debate and arguing about healthcare for not just months but for years, we moved to a new chapter, and that new chapter for a number of weeks has been very positive. When I went home to Pennsylvania, I went to 32 counties in the month of August, and in a lot of those counties, I tried to give a bit of good news on healthcare despite all of the conflict about it. I was able to say that since July 28, when the vote was held, we have had very positive bipartisan discussions. I was part of several of them. The chairman of the Health, Education, Labor, and Pensions Committee--the so-called HELP Committee--Senator Lamar Alexander from Tennessee, announced, in agreement with Senator Patty Murray of Washington, that they were going to preside over bipartisan healthcare hearings in that committee--probably the first bipartisan hearings in a long time. What that meant was that we were going to finally have hearings and a thorough examination of a few issues, not a sweeping bill that would repeal the Affordable Care Act and decimate Medicaid the way the prior bills would have but take elements or pieces of some of the challenges we have before us and try to fix those problems. That took place over the last 2 weeks and was among the most positive healthcare moments we have had in the Senate in a long, long time. What did we do? Well, we were focused on making sure that the cost- sharing payments were made--hoping we can get a bipartisan bill on that in the next couple of days--and focused on problems in the individual market, real problems, serious attention to serious issues--not a game, not a political exercise, not an ideological exercise; Democrats and Republicans sitting down and working together in the HELP Committee to solve some of--not all of but some of the problems in our healthcare system. It has been a very positive development for the committee, for the Senate, and for the Nation. There is a little more good news. Both parties have come together to make sure that the Children's Health Insurance Program continues. It is one of the most important programs in Pennsylvania. These are approximate numbers, but about 175,000 children in Pennsylvania get their healthcare that way. So both parties came together on that as well. It is very bipartisan. Since its enactment way back in the midnineties, CHIP has been bipartisan. There have been a couple of rocky roads here and there, but it has been mostly bipartisan for 20 years, and it will be again at this time in the Senate. It is very personal to me. My father was the Governor of Pennsylvania in 1992 when CHIP passed. I think we might have been the largest State with a children's health insurance program, and those kinds of State models became the basis for Federal legislation. It is deeply personal to families across Pennsylvania who, absent the CHIP program, would not have healthcare. The same is true of Medicaid, which, of course, is a much bigger number. A lot of children in the country have healthcare solely because of Medicaid, and some adults have healthcare solely because of Medicaid--millions of them. I think when we have these debates, we should remind ourselves about the value, the importance, the significance of these programs and the consequence of undermining them or wiping them out. In the case of Medicaid, what some earlier versions of the Republican healthcare bills would do would be to decimate Medicaid over time. Maybe not in year 1 or year 2, but over time they would have a terribly devastating impact on Medicaid. What is Medicaid? It happens to be the program through which 40 percent of all children get their healthcare and 60 percent of all children with disabilities get their healthcare. About two-thirds of nursing home care is paid for by Medicaid. Ask a family member who has a loved one with a disability what Medicaid means to that family. Medicaid is life or death. I know we have debates around here where people talk about Medicaid as if it is just another program, just another budget matter, just another healthcare talking point. Well, one of the reasons these bills have not passed is because a lot of Americans--Democrats and Republicans and Independents out there far away from Washington-- realize what would have happened if we passed some of these bills, what would have happened to the Medicare Program that covers more than 70 million Americans. No one here would lose their healthcare, by the way. No Senator, no House Member, or their families would lose their healthcare. But folks here were perfectly willing to support legislation that would result in millions--not a few million; double-figure millions--15 million, maybe, would have lost their healthcare and Medicaid if these bills had passed and several million more in the exchanges or otherwise. That is what we were debating, but, as I said, since July 28, we have had a lot of bipartisan moments and that is a good thing. Where are we right now? Well, here is where we are: with a piece a legislation--the shorthand is Cassidy-Graham, the two Senators who are leading the bill. What would it do? Well, it would do a couple of things that we should never allow to pass, in my judgment. It establishes a per capita cap on Medicaid. That is a bad idea. We should reject that. It ends Medicaid expansion as we know it, the part of Medicaid that now covers 11 million people. In the context of how difficult it is for States and counties and communities across the country to deal with the opioid crisis, I hope they don't say: We are going to pass a bill that will end Medicaid expansion as we know it, because we know that the biggest payer--the program that has the most impact on treating people who are in the grip of the opioid epidemic, who are gripped by that addiction--Medicaid expansion provides more help than any other program. At last count, 68,000 Pennsylvanians with an opioid issue got their help from Medicaid expansion. Solely because of Medicaid expansion, they can get help for opioids. So ending the Medicaid expansion as we know it is another bad idea. It rolls back protections for Americans with preexisting conditions. I thought we settled this, that this would be a guarantee going forward, that no matter what bill--Democratic, Republican, or otherwise--we would make sure that was a national standard, that no one had to worry about preexisting conditions again. Well, here we are again concerned about what might happen as a result of this legislation and what a State might do to take away the protections on preexisting conditions because they waive it, and they are allowed to waive it under these bills. It allows States to impose burdensome work requirements as a condition of coverage. That is another result of the bill. It takes coverage away from millions of Americans. We mentioned that, but it bears repeating. This isn't just a policy debate; this is about folks whom we all represent. I represent families in Pennsylvania, many of whom wrote to me, have contacted me telling me their stories. One of them was Pam Simpson. Pam is from southeastern Pennsylvania, Coatesville. Her son Rowan was diagnosed on the autism spectrum a number of years ago. Prior to having the protection of Medicaid--what we call in Pennsylvania Medical Assistance--that family had a big challenge. Challenges continue even after the coverage. What Pam said to me in a letter was how much benefit there was to her family in terms of getting the treatment and the help from Medicaid. She said: Without Medicaid, I am confident I could not work full-time to support our family. We would be bankrupt or my son-- Meaning Rowan-- would go without the therapies he sincerely needs. So here is a child who was 5 years old when he was diagnosed, and here is a mother telling me that their lives are a lot better because they have the protection of Medicaid because their son has a disability. And there are a lot of families in which a child might have more than one disability. And even some families who have wealth or very good healthcare coverage still need Medicaid if they have a child with a profound disability. So this isn't just about one group of Americans; this cuts across all incomes, all regions, all parties, all beliefs. That is what Medicaid does, because do you know what Medicaid is? It is an American program. We are the greatest country in the world. We have the strongest economy in the world. We have the strongest military in the world. And we can do all that and still have a program that says to any family who has a loved one with a disability: We are going to help you. We don't care where you live--we are going to try to help you because your family member has a disability. If you are low income, we are going to make sure your child has healthcare and gets all the excellent screening and diagnoses that take place early in a child's life to prevent disease, to prevent all kinds of challenges in the life of that child, because we are a great country. We are called America, and that is what America does--we take care of people who need help. And if it costs some more, we find the money to do it, just as we find the money to protect our security when we have a conflict. We all come together as a country, and we protect the country. Well, it is about time that Washington came together to protect people who have the benefit of a great program called Medicaid or other healthcare programs because that is what a great country does. If we do to Medicaid what some here have wanted to do, we will be diminished as a country. We will all be diminished. Do we want to live in a country where we just had 20 million people gain healthcare coverage and go backward, have more people without health insurance, have more children lose their Medicaid coverage? Is that the country we want to be? I don't think so. I don't think any Republican believes that, and I don't think any Democrat believes that--if you call yourself an American, because that is what America does. We take on big challenges and we solve problems. Medicaid is not the problem here. We have problems in our healthcare system; Medicaid is not one of them. Medicaid is helping a lot of people, and we are going to protect it. This idea that we have come together in the HELP Committee on fixing the parts of the system that we have to fix and doing a thorough examination and having hearings--isn't that a radical idea? I just heard in the last couple of hours that there is a healthcare hearing on Monday. Oh my goodness. Isn't that wonderful? So there will be a hearing on Monday, and I guess they want to pass the bill on Thursday. That is what counts for thorough examination or regular order on one of the most complicated challenges we have? Why don't they agree to do it the way Lamar Alexander did, as the chair of the HELP Committee? He said we are going to take these discrete, individual challenges and examine them closely, come together on a bill, and then pass the bill, and then we are going to move to the next problem and the next challenge and solve them one at a time or two at a time, not take a meat ax to Medicaid and hope it works out for people who don't have any healthcare coverage. That is what a great Senate would do. We would have months of hearings on this bill that some people want to pass by the end of September. But I will go back to the positive plane that we have been on. There has been good work on the HELP Committee on some issues, good work on the Finance Committee on the Children's Health Insurance Program getting reauthorized. While all of that collaboration is going on, all of those good discussions, all of that back-and-forth about policy, no yelling, no screaming, no finger-pointing, all the while, just in the last couple of days, this bill is moving through Washington quietly, but it is moving and it is starting to pick up momentum, like a snake in the grass. That is what this bill is--it is like a snake in the grass. You may not see it yet, you may not know much about it, but it is coming. And if they pass it next week, you may not feel the impact in 2017, you may not feel the bite of that serpent in 2018, you may not feel it in 2019, but you are going to feel it. And if we allow that snake in the grass to inject its venom into people--my analogy for losing your healthcare coverage--then we are not the Senate we should be. We are not the government we should be. We should be an institution--the U.S. Senate--that protects people from those kinds of adverse consequences. And this bill is that kind of a threat to people. It will bite, and that bite will have a lot of venom. Why do I say that? Well, think of what would happen to the Medicaid Program. By one estimate, starting in 2027, funding would be cut off completely, leaving 32 million Americans without access to health insurance of any kind and leaving States with zero Federal dollars to replace Medicaid expansion, marketplace tax credits, and cost-sharing reductions. So please don't make the argument that Medicaid is going to be just fine when you are block-granting it, which is a rather benign description of giving a block of money to a State and hoping that it works out, hoping that it is enough money or enough funding to pay for that State's Medicaid needs. What if you have more children with disabilities? What if that number grows? This bill basically says to the State: Good luck, State. The State has to balance its budget, by the way. The Federal Government doesn't have to do that. The State has to balance its budget, and they, by definition, will have to cap services and treatment to people with disabilities. So that is what this is all about in the end. It is about sending the problem back to the States and calling it flexibility. Isn't that a nice word? All these benign words--flexibility, block granting, per capita caps--all sound so benign. There is a lot of venom in those policies. What does it mean for one State? I will just give you one example. In Pennsylvania, we had more than 700,000 people obtain health insurance through Medicaid expansion--over 700,000 people. In the marketplace or the exchange, there are another over 400,000 people. So more than 1.1 million people got healthcare in one State through Medicaid expansion or through the marketplace. How about rural Pennsylvania? We have 67 counties. How about the 48 rural counties in my State? How many people living in rural Pennsylvania got healthcare? At last count, it was over 278,000 people--almost 280,000 people--and 180,000 obtained health insurance through the Medicaid expansion. The balance was through the exchanges. What are we going to say to rural Pennsylvania? I know 180,000 of your neighbors, friends, and family members got health insurance through Medicaid expansion, but we are going to wind that down, and you will be just fine. Don't worry; Washington will guarantee that you are just fine. That is a big lie, if you try to make that argument to rural Pennsylvania and to other parts of our State as well. What do we say to rural hospitals that have very thin margins already? Some of them are on the brink of having a major problem and depend upon the support they get from Medicaid. In rural Pennsylvania we have a lot of folks who have illnesses and challenges that maybe some of the rest of us don't have. They tend to be older folks who have those challenges, too. What do we say to them? Are we saying to them that we are just going to wind down the support that Medicaid provides in a State like Pennsylvania? So my plea to my colleagues is this. Don't allow this snake in the grass to get close to anyone and to bite them and to inject venom in them. Don't allow that to happen. Don't allow this bill to rip away healthcare from millions of people, just like the bill before that and the bill before that. Work with people in both parties to do what we are doing in the HELP Committee and, to a certain extent, although very limited, in the Finance Committee. I think we have a good model to work together, but I can't go back to Pam Simpson and say: Pam, you know what; I know that you are happy with the Medicaid that Rowan is receiving, and I know it is working out for you, but there are some people in Washington who just had a different idea for you. So you are on your own. You and your family are on your own. I don't think that is what we do as Americans. Forget being Senators; I don't think that is an American thing to do. We help people that need help. All of us in our lives need help at some point or another. No one is immune to some of these challenges. I will just read one or two sentences from the end of the letter that Pam Simpson wrote me months ago, in the earlier part of this year, when she talked about how important Medicaid was to her. She is pleading with me at the end of this letter to protect her son and to protect her family. I would just ask that my colleagues consider this when they are considering how to vote. Pam talked about all the benefits that Medicaid provides her son because of his disability and her family. She said: Please think of Rowan, my son. Please think of my husband and me, she said. But here is how she concludes: Please think of my 9-month-old daughter Luna-- That is Rowan's younger sister-- who smiles and laughs at her brother daily. She will have to care for Rowan later in her life after we are gone. Overall, we are desperately in need of Rowan's Medicaid assistance and would be devastated if we lost these benefits. I hope we can all say to Pam Simpson and her family and to any family who benefits from Medicaid or Medicaid expansion or the protections of the Affordable Care Act that we are guaranteeing that you are going to have those protections. We are going to guarantee that those protections are going to be there for you. Hopefully, every Member of the Senate can say that and vote in accordance with that promise. I would use an old expression and ask Members of the Senate to examine their conscience. Is this what you want people to remember you for--this kind of vote, where Rowan's mother has to worry, Rowan has to lose his Medicaid coverage, a poor child in a big city has to lose their healthcare coverage, or a child in a rural area or someone working at a rural hospital loses their job because of these massive ideologically driven cuts to Medicaid? I hope you can answer the call of your own conscience when you vote that way. I yield the floor.

Mr. CASEY

Mr. CASEY. Mr. President, I rise today to speak for just a few minutes about the Dreamers in our country, the young people about whom we have had a debate recently and will continue to debate about with regard to the so-called Deferred Action for Childhood Arrivals Program, known by the acronym DACA. The United States is a proud nation of immigrants, and ending this program does not make sense either morally or in terms of our economy. Rescinding the program will cost the United States jobs. It will hurt our national security, and it is a total betrayal of the trust of the Federal Government. Dreamers are young people who have lived in our country for a long time, since they were children. They have been law-abiding residents, they have learned English, and they pay taxes. They have secured jobs that support themselves and their families. Our Government promised them that they would be protected if they came forward, and now the administration is breaking that promise. President Trump's actions with regard to DACA are an insult to America and are an insult to American values. This action is unjust, it is immoral, and it is without regard for basic fairness. Tearing apart the lives of these young people will make our Nation less safe and will harm our economy. Ending DACA also does not make sense financially. In Pennsylvania alone, estimates are that ending DACA would cost Pennsylvania $357 million per year in GDP losses. Nationwide, the number is $460 billion from the GDP over the next decade. Ending DACA would remove approximately 685,000 workers from the U.S. economy. According to the Cato Institute, deporting DACA residents would cost more than $60 billion. Finally, the Institute on Taxation and Economic Policy estimates that 1.3 million young people enrolled in or eligible for DACA pay some $2 billion each year in State and local taxes. Let me just share one story of many about a Dreamer that I met. In this case, it was back in April of this year. I was proud to meet with this individual from Lancaster. Her name is Audrey Lopez. Audrey is one of those Dreamers. She came to the United States as a child with her parents, who were seeking a better life for her and for her family. She grew up in Pennsylvania and graduated from college. The United States is the only home she knows. When I met Audrey, she was worried about the debate about immigration and immigration policy. The debate that we have been having in Washington mostly since January of this year was causing great fear and uncertainty in her community. Audrey is obviously concerned about the immigration debate and, in particular, what happens with DACA. She has worked with Church World Services, an organization that helps resettle hundreds of refugees each year in Pennsylvania. They provide services to help new arrivals adjust to their new home and become successful members of their local neighborhoods. Audrey is now a student at American University, pursuing her master's degree in international development--of course, after getting a college education as well. This is America. This is who we are as a nation, where young people like Audrey have a chance to work hard and to succeed, to get an education and to contribute to the American economy and to the fabric of our society. We are a country in which hard-working young people who are working to better themselves and their community are given a chance to do so, in a sense, fulfilling or living that dream. This program, DACA, has allowed almost 800,000 young people whose stories are very similar to Audrey's to grow up and thrive in America. It makes no sense to heartlessly remove Dreamers from a country they call home. In response to President Trump's decision to end DACA, Congress should move immediately to pass a bipartisan Dream Act. This bill will allow Dreamers to become permanent residents if they meet the very stringent qualifications outlined in the bill. In Pennsylvania alone, 5,900 people have been granted DACA status. Passing the Dream Act will give these people the security they need and a future they can count on. We should be focused on humane and commonsense solutions that keep our Nation safe and allow it to thrive. I was proud to vote for the DREAM Act in 2007 and 2010. I hope we will have a clean vote on the Dream Act very soon. I suggest the absence of a quorum.

Mr. CASEY

Mr. CASEY. Mr. President, September marks National Senior Center Month. More than 11,000 senior centers across the country serve more than 1 million older adults every day. For many older Americans, senior centers are the heart of their communities, offering a place for everything from meals to recreational activities to health and wellness programs. Senior centers also create a sense of comity and community, giving older Americans a place to connect while reducing the social isolation that often burdens our older citizens. This summer, as ranking member of the U.S. Senate Special Committee on Aging, I visited numerous senior centers across the Commonwealth of Pennsylvania, in rural, urban, and suburban areas, to discuss the issues on the minds of older Pennsylvanians. At each stop, older Pennsylvanians told me about the important role that senior centers play in their daily lives, as a gathering place and a resource, providing not only necessary nutrition programs, but also benefits counseling, employment assistance, volunteer opportunities, transportation assistance, and so much more. Senior centers and senior center staff deserve our support. Communities piece together numerous sources to fund their senior center operations, including Federal, State, and local government resources, private-sector donations and grants, and the man-hours of countless volunteers. Many of the county commissioners who joined me during these visits expressed their support for the Community Development Block Grant, which regrettably is slated for elimination by the administration. Counties throughout Pennsylvania depend on the Community Development Block Grant program to fund important infrastructure in our communities. Now is not the time to scale back our investment in these needs. I stand with our community leaders in support of the Community Development Block Grant program, and I will fight to protect these vital resources from elimination. I am delighted to join with leaders from across the aging network in Pennsylvanian and throughout the country in honoring the work of senior centers and recognizing September as National Senior Center Month.

Mr. CASEY

Mr. CASEY. Madam President, I ask unanimous consent that the order for the quorum call be rescinded.

Mr. CASEY. Thank you, Madam President. I rise to speak in opposition to the nomination of Marvin Kaplan to serve as a member of the National Labor Relations Board. Mr. Kaplan has spent much of his career as a staff member in Congress, where he worked to undermine unions and the rights of workers to bargain collectively. A key role of the National Labor Relations Board is to preserve the right of workers to bargain collectively. The Board itself is charged with enforcing the National Labor Relations Act, which Congress passed in 1935 in the depths of the Great Depression. The act gave workers the right to join unions, and it encouraged and promoted collective bargaining as a way to set wages and settle disputes over working conditions. This law that passed in the 1930s--and is still in effect today--is not simply a benefit to workers; it also benefits businesses, and it also benefits the economy. Section 1 of the act says, in pertinent part: ``The inequality of bargaining power between employees . . . and employers . . . substantially burdens and affects the flow of commerce, and tends to aggravate recurrent business depressions, by depressing wage rates and the purchasing power of wage earners.'' There are a lot of important words there. When you have inequality of bargaining power, the findings of the Congress at the time said that would burden and affect the flow of commerce. So that tells you the impact on commerce. It also says that when you have inequality of bargaining power, that aggravates business depressions, and the result of that is depressing wages and depressing purchasing power. Everyone here knows that when we are measuring the American economy today--I am sure this has been true for many generations but especially today--the consumer plays a substantial role in our economy. So if that consumer, that worker has lower wages, that is not good for anyone. So giving workers the right to both organize and collectively bargain allows them to demand higher wages, thereby increasing their incomes and that purchasing power which is so critically important. That, in turn, of course, increases consumption and demand for goods, which, of course, increases production and employment. So all of these are tied together. Wages and benefits affect the economy, not just the worker and his or her family. I believe there is now a concerning trend to weaken the National Labor Relations Act and to tilt the Board against workers. Mr. Kaplan's nomination is another sign of this disconnect between the rhetoric of the administration claiming to be pro-worker and its actions that are of late anything but pro-worker. The administration claims it is here to support workers, but at every turn, we have nominees who have spent their careers working in the opposite direction. We know that in the 1950s and 1960s, the economy worked well for working Americans because 35 percent of workers were in a labor union. The decline of unions, the decline of the workers' voice, and the decline of collective bargaining have helped to lead us where we are today--stagnant wages over a long period of time, as well as power, wealth, and income, of course, concentrated at the top. So we know that unions helped workers to win higher wages, job security, and unprecedented benefits, including paid vacations, paid sick leave, and pensions that gave those workers and their families a measure of security, but it also increased their purchasing power, and it also, of course, strengthened the economy. American family incomes grew by an average of 2.8 percent per year from 1947 through 1973, with every sector of society seeing its income roughly double. We know now that in the last number of years, it has been a different story. Families across Pennsylvania and the United States know that the story is much different. It is not a coincidence that union membership has declined from its peak of 35 percent of private sector employment in the 1950s to less than 7 percent of private sector employment today. This is all the more reason to stop this assault on workers and labor unions. Nominees with a partisan history of working to undermine unions or undermine the National Labor Relations Act or undermine the National Labor Relations Board should not be confirmed to a position where they are supposed to act as an arbiter to protect the rights of workers to form a union and to bargain collectively. So I urge my colleagues to oppose the nomination of Marvin Kaplan to the National Labor Relations Board. Madam President, I yield the floor. I suggest the absence of a quorum.

Mr. CASEY

Mr. CASEY. Madam President, I intend to offer the following motion to H.R. 1628, and I ask unanimous consent that it be printed in the Record. The motion is supported by Senators Stabenow, Duckworth, Hassan, Van Hollen, Murray, Brown, Blumenthal, Carper, Durbin, Kaine, Baldwin, Wyden, Markey, Murphy, Harris, Cardin, Warren, Hirono, Reed, and Nelson.

Mr. CASEY. Mr. President, I know the Chair said I may speak for a few minutes before the vote. I spoke earlier so I will not reiterate every argument. Really, what we are doing with this particular amendment is sending this legislation to the Finance Committee so as to focus it as the motion itself says: When this bill would be recommitted to the Finance Committee, the Finance Committee could examine it from the perspective, in this case, of people with disabilities and to focus on changes that could be made in order to prevent harm to individuals with disabilities as defined in the Americans with Disabilities Act of 1990. The reason we mention that particularly is that is the seminal piece of legislation to protect people with disabilities who would be harmed by this legislation because you cannot just have rights that are guaranteed without the support for those rights. Medicaid provides that support so folks, if they want to live at home or if they want to live in a community-based setting, can do that, but they can only do that with the help of Medicaid. It is a pretty simple amendment to make sure there is some adequate review of the impact on Americans with disabilities. We have, in Pennsylvania, for example, over 720,000 people who have a disability and depend upon Medicaid. I want to make sure every one of those Pennsylvanians has all of the protections we say we are guaranteeing with disability legislation--with laws like the Americans with Disabilities Act and with the protections Medicaid provides. This is critically important. At a time when we are talking about freedom and liberty in the context of healthcare, I would hope we would take steps to guarantee that freedom and liberty apply to those with disabilities so that as the Americans with Disabilities Act has enshrined in our law, they may be able to choose the kind of places they want to live and choose the settings within which they want to live their lives, to be able to have the freedom to choose that by way of the support they can get from Medicaid. I hope that is something that is reasonable enough so as to get support from both sides of the aisle. I know my friend from Nevada is offering a sense of the Senate in the next vote. I just do not think that a sense of the Senate, in any way, is commensurate with the gravity of this problem. There is a time and a place for a sense of the Senate--when we are expressing a sentiment that is bipartisan--but we need more than sentimentality here. We need more than good wishes. We need to make sure we get this policy right as it relates to people with disabilities. Mr. President, I yield the floor.

Mr. CASEY. Mr. President, I have a motion to commit at the desk.

Mr. CASEY. Mr. President, first, I thank my friend from Indiana, Senator Donnelly, for his remarks this afternoon and also for his efforts to help to protect and preserve Medicaid so that hundreds of thousands of people in our States and across the country can continue to live in the community. I want to point out that today is the 27th anniversary of the signing of the Americans with Disabilities Act. This legislation, known as the Americans with Disabilities Act, is 27 years old. It is a piece of legislation that both recognizes and guarantees the rights of people with disabilities. It is, at its heart, a civil rights bill, one that promotes and promises liberty and freedom for people with disabilities--the liberty and freedom that all Americans are promised, that our founding documents guarantee, and that we in the Senate are charged with protecting for all citizens. We should be celebrating the liberty and freedom of people with disabilities, but instead of having a celebration of the Americans with Disabilities Act on this anniversary day, the Senate Republican bill-- which, I guess, is basically the House bill that we are on right now-- threatens that freedom and threatens that liberty that was accorded in the Americans with Disabilities Act with regard to those with disabilities. Now, I have heard a lot of speeches on this floor by my Republican colleagues about freedom and liberty in the context of healthcare--lots of speeches about both of those words. I would argue that, if you consider this legislation and the Senate versions of it that came after the House bill, all of these Republican healthcare bills were really, simply, about decimating Medicaid, limiting community-based care, and cutting long-term services and support, which will rob people with disabilities of their rights that the Americans with Disabilities Act advanced. I think everyone here knows the disabilities story. I will just do a quick summary. For centuries, people with disabilities have been placed against their will in institutions like this one. This is a building in Pennsylvania. When it was open and operating, it was known as Pennhurst. There were lots of places like this across the country, not just in one or two States. These institutions were, in fact, over time, warehouses, in which people had few, if any, rights. They were told what time to wake up, what time to go to bed, and when to eat. They were told they could never leave. That was the basic set of rules they lived by when they lived in institutions like that. These were places where choice was unknown and where freedom, liberty, and self- determination were also unknown. Over the past 50 years, we have made some improvements--slow improvements--with the voices of people with disabilities leading the way. Throughout those 50 years, individuals and families have fought for their freedom and have worked to create laws that protect their freedom. For example, the 1973 Rehabilitation Act Amendments and the Americans with Disabilities Act affirmed and protected the rights of people with disabilities to have access to all of society. The 1999 Olmstead Supreme Court decision reaffirmed the right of people with disabilities to live where they want to live and to be free of the confines of an institution. Let's take it from the institution down to the individual--to individuals like Jensen, who is pictured right here. People like Jensen, who were once forced to live in nursing homes, now live where they want to live and pursue their dreams. Yet we know that rights alone do not equal freedom and liberty for people with disabilities. Medicaid provides the supports that are necessary to live in the community and to have that full measure of freedom and that full measure of choice. Medicaid protects the hard-won rights of people with disabilities to have real choices. Medicaid home-based and community- based supports mean that people with disabilities can live in their own apartments, hold jobs, and contribute to their communities. Medicaid makes it possible to use the talents, skills, and knowledge of people with disabilities. Medicaid makes their rights a reality. Do not take my word for it. Just ask the people who were here today in the Gallery, the people who are outside this Chamber and are walking the halls of the Senate, walking throughout the buildings, marching, demonstrating, and greeting people on the streets, with some of them staying overnight at one place to make their voices heard. Ask the members of ADAPT. Ask the members of the National Council on Independent Living. Ask The Arc's 700 affiliates around the country. Ask the folks from Easterseals, the Association of University Centers on Disabilities, the Autistic Self Advocacy Network, and on and on and on--groups across the country that are telling us with one voice: Do not move forward with cuts to Medicaid as have been proposed in each of these bills. These Americans will tell you that their rights are not real without community supports. This bill will drive people back into those institutions that I just showed you a picture of. In the midst of voting on my amendment--which would basically say: Let's go back to the committee of jurisdiction--in this case, the Finance Committee--and spend some time to have some hearings, have some regular order, which some have called for here, and really consider this issue seriously--I know there will be talk that some will reject my amendment and will introduce and maybe have a vote on a sense of the Senate. There is a time and a place for that kind of measure when the Senate speaks with one voice on a matter. This is not one of those times. This is a time when we have to do more than just have a sense of the Senate. We have to be serious about a particular matter of public policy--in this case, of making sure that we protect people with disabilities so that they have all of the rights and all of the promises fulfilled in the Americans with Disabilities Act and other legislation. So we are hearing that there might be a sense of the Senate offered as a side-by-side to the amendment that I will offer. This is totally inadequate in terms of the serious issue that we are here to talk about--in this case, protecting people with disabilities. It is a totally inadequate response to that. The people with disabilities who are in the Gallery, who are in the reception area, or who are back at home in congressional districts and States--those folks in each and every community around the country--want to ensure that the promise that we made to them in the ADA and in other measures will be kept-- that we will keep our promise. If Medicaid community-based services are slashed, statements by the Senate will not help very much. What will we likely have in front of us in the next couple of hours or between today and tomorrow? I know it has been described in a lot of ways, if the Republicans want to get there. Here is the way I describe it. It is a congressional Republican scheme that they are working on to get to repeal--not repeal and replace. In this case, it would be repeal and decimate--decimating Medicaid, repealing the entire Patient Protection and Affordable Care Act. Some here will argue that they can support this because this next version--this scheme--will not include Medicaid and will likely not even include tax cuts for the very wealthy. Cuts to Medicaid have been the core part of every House version of healthcare and every Senate bill that we have seen so far. They will get to those cuts one way or another, and they will also get to the tax cuts for the superrich. The bill that we are debating, H.R. 1628, as you know, creates block grants in the context of Medicaid. Block-granting, in a sense, may be sending to the States a limited amount of money and saying: Good luck when you have to balance your budget and pay for Medicaid services. It will have per capita caps, which would, again, limit what States can do in terms of the dollars they have, or it would just continue to have cuts to Medicaid, as every bill has had, the likes of which we have never seen--sometimes over $800 billion, sometimes over $700 billion, but it is in that neighborhood of hundreds and hundreds of billions of dollars of cuts to Medicaid. This next version of the Senate bill will do the same. When you consider the cuts to Medicaid juxtaposed with the tax breaks given to the superrich--really giveaways--there is no other word that I can come up with other than ``obscene.'' There are probably other words, but that is, I think, a good description of what that is. That is one of the reasons that these measures have been so unpopular across the board with every income group. Those folks who would get those big giveaways--I think most of them would not want them if they knew the price of that tax giveaway to someone with a lot of money would be to decimate Medicaid. So passing this version of the bill--passing a scaled-down scheme-- means that Republicans have not abandoned their Medicaid cuts. They are going to get to that as soon as they can. This is simply what we are going to see over the next couple of hours--a back door to cutting and capping Medicaid--and anyone who believes otherwise is probably deceiving themselves. What we need are serious policies crafted to ensure long-term supports and services that provide and guarantee community-based services that promote choice and freedom for people with disabilities. This bill doesn't promise freedom or liberty. It doesn't promise the choice to live in a community and to be part of a family, like this family, where one member of that family has a disability and gets to live in a house with other members of the family. That is not possible for many Americans without Medicaid. For people with disabilities, this bill is anything but a bill that would enhance freedom or enhance choice. This bill would, in fact, be an anti-freedom bill when it comes to people with disabilities. It is not a key to liberty. It is really just a pathway to institutional care, where we were years ago and where we have come from, from whence we have made progress. It is a return to limited choices, a lack of rights, and a place where freedom is not possible. In conclusion, let me thank the Members of the Senate who have supported this motion: Senators Stabenow, Duckworth, Hassan, Van Hollen, Murray, Brown, Blumenthal, Carper, Durbin, Kaine, Baldwin, Wyden, Markey, Murphy, Harris, Cardin, Warren, Hirono, Reed, Nelson, Klobuchar, Warner, Shaheen, Coons, Bennet, King, Menendez, Whitehouse, Leahy, and Booker. I want to thank them for joining me in this effort. Mr. President, I yield the floor. I suggest the absence of a quorum.

Mr. CASEY

Mr. CASEY. Mr. President, I rise tonight to speak about the healthcare legislation. I am grateful for the remarks of our colleague from Illinois, the great leader that he is, talking not only about the impact on his home State but on our country. I think a lot of us, especially in the last couple of weeks, have had an opportunity both to debate healthcare and, probably more importantly, when we go home to be on the road, to go to places where folks are thinking about it very intensively. Many people I had a chance to interact with and, really, to listen to on the road were folks in small towns and rural areas, especially, who probably didn't ever imagine they would have to engage in this kind of a discussion or debate. Coming into a conference room to have a discussion or a roundtable about healthcare is not what they do every day. They don't necessarily sit around to talk about a public policy issue. They usually have so much in their lives that keeps them busy and so many concerns and so many challenges that are weighing them down that they don't have any opportunity to have these kinds of conversations. Many of them felt obligated to have these conversations. Many of them were motivated to speak out because of what would happen in their lives and usually in the life of someone in their family. When I was in a number of counties the last couple of weeks, especially in rural areas, you would hear from a lot of moms and dads about their children, usually in this context: What will the Medicaid cuts mean for my child? In many cases, the child has a disability or more than one. Sometimes there is a series of complex disabilities-- plural--and the mom or the dad is there to talk about it. In these discussions, you hear a combination of sentiments and a combination of information. You hear sometimes a cataloging of what their daily life is like, what they do when they wake up in the morning and have to get that child or that young person ready for school if they have a disability or more than one disability. These parents become experts in all kinds of medical terminology and prescription drugs, and they become experts in assistive technology or equipment that allows their son or daughter to lead as full a life as possible. For these families, this is real life. This isn't some debate in Washington that we engage in here. This is about real life. That is why the issue of Medicaid, I think, has been so prominent. If we learned one thing over the last couple of months, it is that some people in Washington might have thought that Medicaid could be described as a ``them'' program. That is for someone else who is far away, and I don't have to worry about that. We found out that Medicaid is an ``us'' program. Medicaid is an American program. It is one of the ways we come together as a nation and say: You are up against something that I might not be up against. You have a challenge that I might not have, but I am going to do my part to support that program to give you a chance. If you are a child with a disability, we come together as a community, as a nation, and say we are going to help that child. We are going to do everything possible to make sure that child can lead a full life. For many folks who are low income--they are working, but they don't have a very high income and don't have employer coverage--we say in that instance: You are someone we should try to help with a program that provides healthcare--Medicaid. We say to seniors, if we believe, as we do, that you have given us so much--whether you fought our wars or worked in our factories or both, or taught our children, built the Nation, or built the middle class, and did all kinds of things for us--the least we can do is to make sure, if you need extra help getting into a nursing home or getting the benefit of long-term care, Medicaid will be there for you, without a doubt. It is only until recently that a lot of those same families have had to ask the question: Will that program called Medicaid--that ``us'' program, not a ``them'' program--be there for my child who has a disability? Will that program be there for me and my family, because our income is such that we qualify for Medicaid and we need that help? Will that Medicaid be there for that older citizen who has given us so much, given so much to their family, given so much to the Nation? Will that program continue to be there to give them that little bit of extra help they might need to get into a nursing home? Unfortunately for a lot of them, it is not a little bit. It is a lot, because they need that much help to have the benefit of long-term care. I have read a number of letters on the floor over the weeks and months, and I will continue to do that. It is remarkable, though, how people have put their own stories on paper or they have been interviewed by a local newspaper or they have been on local television, or even national television, talking about their lives, talking about their children, talking about their worries, and also giving us the benefit of their hopes and their dreams for their children. They are hopes and dreams that would be thwarted in some instances by a vote we could take here. They are hopes and dreams that in some cases would be absolutely shattered if we took the wrong step on Medicaid and the wrong step on healthcare. Obviously, I am not a supporter of the legislation before us. It seems like every time there is a change made, the legislation is either no better or a lot worse. The number of uninsured doesn't seem to budge. The latest Congressional Budget Office determination--this is dated July 20, last Thursday. It is a letter from the Congressional Budget Office, from Director Keith Hall to Senator Mike Enzi, the chairman of the Senate Budget Committee. I am quoting from page 4. The Congressional Budget Office says in this letter: According to CBO and JCT's estimates, in 2018, 15 million more people would be uninsured under this legislation than under current law. The increase in the number of uninsured people relative to the number under current law would reach 19 million in 2020 and 22 million in 2026. That is what the CBO tells us. Once again, we have that same number-- that stubborn number--22 million people uninsured, and 15 of the 22 becoming uninsured in 2018, next year. It is an immediate impact, the likes of which and the gravity of which we can't even begin to imagine. Imagine that, in the course of 1 year or maybe 1\1/2\ years, 18 million people in the country are losing their healthcare, just when we made the advancement of having 20 million people covered between the time the Patient Protection and Affordable Care Act was passed and just in the last year or so. We have made all that progress forward on coverage. One of the consequences--one of many but one of the consequences of this legislation--would be to wipe all that out. It is two or three steps forward and several steps backward. That alone makes no sense. As I said, when people come to meetings across the State about this bill, it is remarkable what they will tell you about their own challenges. It has to be very difficult to stand in front of a group of relative strangers--and sometimes with media there--and express to you or express to the people in the room or to the people listening in an interview or otherwise their innermost fears. That has to be disturbing. It must be difficult to do, but they feel compelled to do it because they have never had to worry like this--never had to worry in the course of their lifetimes about a direct threat to the healthcare of their children, a direct threat to the healthcare that their family has. I have notes here from a meeting just a couple of weeks ago. I will not say who the parents are; I don't have their permission. But I will say this: It was a parent in a county that is considered rural, a family that seems to be relatively secure in terms of their employment and everything else in their lives. After describing what Medicaid means to their family because they have a child with a disability, the mom talked about her own insurance. This is a common theme. The parent or parents have a good job or sometimes two good jobs, and they have insurance in most cases. Yet, because of the severity of the disability of their child, they have to have Medicaid. There is no choice. There is no way with 20 jobs that they could pay for the services that child needs--services, therapies, treatments. The good news is, we live in a country that has those available, but a lot of that will be ripped away if we pass this legislation. Here is what this mom said when talking about what she is determined to do for her child. She said: It is not negotiable. That is what she said about what is provided to her child. She said that these are necessities. These aren't extra things. These aren't just add-ons to some other healthcare. These are absolute necessities. Then she went through and itemized and cataloged all the ways and all of the tools and benefits that her family receives from Medicaid so that her child, who has a severe disability, might have a shot to lead as full a life as possible. The idea that this mother or anyone like her should have to come to a meeting in the United States of America and have to make an argument as to why those services should be preserved for her son or her daughter or any other member of her family--the idea that she should even have to make that argument is insulting to us as a country. We would be a different country if Medicaid were changed in the way some folks around here want to change it. I have used the word ``decimation.'' That is exactly what it is. It would be decimation, and a lot of families' lives would be destroyed. This is real life for these families. Even if someone could prove that a year from now or 5 years from now or 10 years from now, that mother and her family would be somehow walled off or protected--even if you could guarantee that, it is still wrong because she shouldn't have to worry for a minute. She should have no uncertainty about whether her child is going to have Medicaid going forward--her child with a profound disability. There should be no question. That child should get Medicaid today, tomorrow, and as long as they need it for the rest of their life because we are a great country. We do that in America. We can do it over and over again. We can have the strongest economy. We can have the strongest military, and we can take care of those families, no matter what, no questions asked, whatever it takes because that is who we are as Americans. But there are some people around here who just don't believe that. To use that mom's word, they think it is all negotiable--that if it is the right year and the numbers line up, maybe we can help you. We need a tax cut, apparently. That is what they argue. They need a tax cut for wealthy folks, so Medicaid is going to pay for that. To say that is insulting is a gross understatement. That is obscene. That is as close to uttering an obscenity as anything I can think of. So you bet we are going to fight when it comes to those kinds of decisions-- fight against those kinds of cuts. I mentioned that I had been on the road a good bit and have spent a lot of time in counties that are rural counties in Pennsylvania. Just to give you an example of the numbers, I live in a State that has 67 counties, and 48 of the 67 are rural. Those are our Pennsylvania counties. If you add up all of the individuals in those 48 rural counties in Pennsylvania who got insurance by way of the Medicaid expansion--or received insurance in the marketplaces in the intervening years between passage of the ACA and currently--just in those 48 counties, over 278,000 people have healthcare--278,266. I use a precise number because right down to the 66, it matters. Every single one of those individuals in those 48 rural counties should have an ironclad guarantee that no bill will pass the U.S. Senate that will rip away their healthcare, not for one person. That should be our promise to them. That is the number of people covered, right? With the Medicaid expansion plus the marketplace, 278,266 residents of rural Pennsylvania are covered. If the Senate bill passed, here is at least one estimate of what would happen to those rural counties: 151,000-plus people. I will not use the exact number because it is an estimate. The estimate is that around 150,000 people would lose their health insurance. You move forward in rural Pennsylvania by over 278,000 people; then you take two steps backward and rip healthcare away from 150,000 in rural Pennsylvania. I haven't gotten to the big population centers. That is the reality in Pennsylvania. Then if you break it down even further--these are just 11 rural counties that I visited in the month of July in addition to other counties. In 11 rural Pennsylvania counties--these are counties with very small populations. One of them, Forest County, which I was in this weekend, has a little more than 7,000 people in its total population. In these 11 rural Pennsylvania counties, 54,180 people have healthcare today because of Medicaid expansion, plus those who got it through the marketplace, so 54,180 get healthcare. What is the estimate of who would lose if the bill passed? It is 32,410. Let's call it 30,000, roughly, because it is an estimate. So 54,000 gain; then you rip it away from 30,000. Does that make any sense at all? Does that help the country? How are we stronger after that? How are we better off as a country or, in my case, as a State? How are the people of our Commonwealth better off when 30,000 in 11 rural counties lose their coverage--or 150,000 in 48 rural counties? I know I am over my time, and I will wrap up because we have colleagues here. This is a pivotal moment. To say it is a pivotal moment for the Senate is a big understatement, but it is also, I think, a pivotal moment for the country. We are going to be on a different path than we have been for a long time. Usually what happens over time is that you are expanding protections, enlarging the number of people who are the beneficiaries of protections of one kind or another. In this case, we would be going in the wrong direction. I hope our colleagues will think long and hard before they vote yes either to move forward to debate on a bill that is deeply flawed or to vote for the bill itself. I yield the floor.

Mr. CASEY

Mr. CASEY. Thank you, Mr. President. I rise to talk about an issue that some of us have talked about, but I think it is an issue that is barely breaking through now. There has been a lot of discussion in the debate so far about various aspects of the bill. We know the bill in its current form is about 142 pages, I guess, and more than 60 of those pages deal with one topic--Medicaid. So this is basically a Medicaid bill and a tax cut bill, and the two are not just referred to on a regular basis in the text, but I would argue they are actually in conflict with one another. I was on the floor last night showing a chart that indicated that the top 400 households in the country would get a tax cut of $33 billion. Just imagine that. Four hundred families get $33 billion out of the bill--the House bill, but it hasn't changed substantially at all when it comes to tax cuts--and then on top of that, the Medicaid cuts in just four States add up to the same number. So we have $33 billion in cuts on Medicaid for 4 States and $33 billion in tax cuts for 400 families. If you are within the sound of my voice and you are one of those 400 families, sorry, but I don't think you deserve a tax cut. Here is another way of looking at it. This is the same basic information, but now, instead of looking at four States, as we did last night--those four States were Alaska, Arkansas, Nevada, and West Virginia--where the total Medicaid cut was just below $33 billion, here is just one State, the State I represent, Pennsylvania. The cuts over time come up to $35 billion. The Senate bill might move that one way or the other by a little bit, but basically that is what it is. But we still have this number we just referred to--$33 billion in tax cuts for the 400 highest income households in the country. Nothing about that is fair. In fact, I think that is obscene. There are other words we could use, but we shouldn't use those words on this floor. That is obscene. In the same bill, they are ripping away Medicaid over time, and, as we know from the CBO report we saw last night, the House bill has a Medicaid cut of 14 million people losing their Medicaid coverage over the course of a decade. In the Senate bill, the number goes up to 15 million. So 15 million of the 22 million who lose their healthcare coverage are from Medicaid. As my colleague from New Jersey just outlined, low-income folks, folks with disabilities, and folks who need to get into a nursing home--that is basically the Medicaid population. They are low-income children and adults, adults and children with disabilities, and, of course, seniors. That is the basic inequity here. I don't think anyone around the country, if they were looking at that comparison, would really say that is fair. How could that be fair in a healthcare bill, that a small group of Americans gets a tax cut? By the way, it doesn't end there. It is not just the top 400 Americans, it is a lot of other people as well. So if you are in any way wealthy, this bill is a bonanza for you. This is a once-in-a- lifetime injection of revenue that you are rarely, if ever, going to see. But why should a single family get millions and millions of dollars--under this scenario, potentially tens of millions for one family--why should they get that kind of a break while others are losing their healthcare by way of the Medicaid cuts or otherwise? So if we are going to have a real process here that leads to a bipartisan conclusion, we have to get serious about the issue of healthcare. This is not a serious attempt to change our healthcare system for the better. A third-grader could rip healthcare away from a lot of people and give away the store to very wealthy people. That is an exercise anyone could do. That is simple. But to fix problems in our healthcare system, to make sure that if you are living in a rural area and there is only one insurer, that we work to create some competition--to fix that requires some work. To fix that requires bipartisan support. It is not this exercise we have been going through so far. I hope folks on the other side can defend this and go home and say: I voted for this bill--or the updated version of the bill in a couple of days or weeks--and I am here to tell you that I not only voted for the bill, but I am asserting that it is fair to give $33 billion to 400 households and tear $35 billion out of the Medicaid Program just for Pennsylvania--just for Pennsylvania, one State, and it gets worse when you add other States. I know our time is short and others are waiting to speak, but we have a long way to go to make sure we are focused on some of the real challenges we have in our healthcare system, not just ripping coverage away from vulnerable Americans in order to enrich people who need no help, need no injection of a tax cut. In fact, they don't even want the tax cut. I was at a townhall the other day, and a doctor stood up and said--if the House version of the healthcare bill went through, this one doctor in Pennsylvania would get $20,000 in a tax cut. He said: I don't need that. I don't want it. We want to fix the system. We want to make sure the people on Medicaid still get coverage. I yield the floor.

Mr. CASEY. Mr. President, I seek recognition to continue this discussion on healthcare, and I ask unanimous consent to speak in morning business.

Mr. CASEY

Mr. CASEY. Mr. President, I rise, as well, to talk tonight about the issue of healthcare. I thank my colleague from Connecticut for looking down the road to when, maybe, we can actually work together on this issue. We are in conflict this week, and that is not a place any of us want to be. We are in conflict because of the elements of this bill. I will make two basic points in my remarks tonight, one about Medicaid and then one point about another provision in the bill that I think is particularly insulting. A lot of our discussions start with policy and data, and that is important. That is obviously part of the debate about the bill and what is in it and what impact it will have on programs and people over a long period of time, but part of this debate, of course, is about the people we represent. I know the Presiding Officer understands this, and I am heartened that he is paying attention to our arguments because sometimes--I have done it myself--when you preside, sometimes you are doing something else. So we are grateful for his attention. I have talked on this floor a couple of times over the last couple of weeks--even months--and I will not repeat the stories because they have been told a number of times, but Rowan Simpson is a young man whom I recently just met. His mom had sent me a letter. Rowan is on the autism spectrum, and his mom is very worried about his future because of the potential impact on Medicaid and the benefits he is getting today from Medicaid. I just referred the other day--I guess it was Thursday on the floor-- to a letter from a dad about his son Anthony, who has a number of challenges, one of them being that he is on the autism spectrum. I have another letter, as well, which I will not go through tonight, but it is from a mom in Northeastern Pennsylvania, who wrote to me about two of her children--principally, her son who has Type 1 diabetes and what the loss of Medicaid coverage will mean for that child, who, in this case, is just 4 years old. Everyone in this Chamber in both parties has stories like this to tell--stories about people who are, because of a disability, totally dependent upon Medicaid. That is not unique to one State, and, of course, it is not unique to one party. One of the more egregious and objectionable parts of this 140-plus page bill is the impact it will have on Medicaid--the Medicaid expansion, which many people now know represents probably on the order of 11 million people who got healthcare coverage since 2010 and got that coverage because Medicaid was expanded. But the bill also speaks to the Medicaid Program itself by the so-called per capita cap, capping the dollars the Federal Government would provide in the future with regard to the Federal-State partnership on Medicaid. These are big stakes when it comes to a program that has been with us for 50 years. As everyone knows, Medicaid is principally about individuals with disabilities, and that is obviously those children I mentioned. It is about folks who need some help getting into a nursing home, senior citizens. Of course, it is about kids from low-income families who have no other healthcare, absent Medicaid. In our State, there happen to be 1.1 million kids on Medicaid who are from low-income families. The disability number in both children and adults is, by one estimate, more than 722,000 people. These are big stakes, even if it is just involving one of those individuals or hundreds or thousands. But as I will refer to later, some of the numbers are, of course, a lot higher than that. So those stories and those pleas for help from those families obviously do not just inform us, but they inspire us to keep working, to keep fighting. I will be fighting against this bill as long as it takes. It is likely that we will have a vote this week. I am assuming we will, so we have only hours and a few days to fight and point out what we believe to be the defects. One of the things that is significant about this debate is that we have had people not just writing those stories and telling us their story but also telling us and giving us ideas about how to conduct the debate and how to fight and how to oppose it. I have in my hand--I will describe it first before I offer a consent request. I have in my hand several pages that list almost 600 names from people in Pennsylvania who have written to me over the last number of weeks and months, actually. What they are urging me to do is to pursue a legislative strategy to protect their healthcare. Why are they doing that? It is not because they have nothing else to do. They are worried. These people are really worried. They are worried about those kids like Rowan and Anthony, whom I just mentioned, and a 4-year-old with Type 1 diabetes or a whole long list of other disabilities a lot of kids have. They are worried about their parents, who may not be able to get the long-term care they need if Medicaid is capped and cut and decimated. They are worried about their friends and their families. They are, in a word, as worried as anyone has ever been about the healthcare of those they love and the healthcare of those they care about. That is why they have been writing and going to meetings and making phone calls and engaging in such a robust way, all these weeks and months. Mr. President, I ask unanimous consent that this list of almost 600 names from Pennsylvanians be printed in the Record.

Mr. CASEY. Mr. President, I will make two final points about Medicaid and then juxtapose Medicaid with another part of the bill. If you look at the bill--it is about 140, I guess, 142 pages--more than 60 pages deal with Medicaid. So this is principally a bill about Medicaid. There are some other issues, obviously, addressed on the exchanges and the fundamentals of healthcare. But it is mostly about Medicaid and tax cuts, unfortunately; and that is particularly objectionable to me that you have a small group of very wealthy people who are going to make out in ways we can't even imagine, like a big bonanza for the superrich. Now, let me just talk about the Medicaid part of it first, and then I will refer to a chart. I am holding in my hand the Congressional Budget Office report from today, which came out. It, of course, is a document produced by the Congressional Budget Office as well as the Joint Committee on Taxation so it is a joint effort. On the CBO--so-called CBO Congressional Budget Office report, recently--a couple weeks ago now--on page 17 of that document, there was an assessment made of the number of people who would lose Medicaid as a result of the House bill, and that number was 14 million Americans would lose Medicaid over the decade up until 2026. Well, unfortunately, as of 4 p.m. or something this afternoon--I guess about 4 p.m., 4:30--we got the Congressional Budget Office assessment of the Senate bill, the Senate bill that was unveiled last week. Not on page 17 of this report but actually on page 16, here is what the Congressional Budget Office and the Joint Committee on Taxation says about enrollment in Medicaid. I am quoting from the bottom of page 16: Enrollment in Medicaid would be lower throughout the coming decade, with 15 million fewer Medicaid enrollees by 2026 than projected under current law in CBO's March 2016 baseline. Then, they refer to a figure in the report. So the House bill CBO assessment says 14 million will lose Medicaid coverage. The Senate bill, analyzed by CBO, which is supposed to be a more moderate bill, a better bill in the eyes of some Republican Members of the House and the Senate, that was supposed to be better, but here is what we know now: 15 million people will lose Medicaid. That alone should cause any Senator to be very concerned about the impact of this legislation. That alone should, I hope, require some people to use an old expression: Examine your conscience about what will happen if you vote for this legislation. Let's say someone says: Do you know what? I can put that into context, and I think actually that will not happen or I have another explanation or whatever justification or rationale you use for voting for a bill that will result in 15 million people losing Medicaid coverage. People are very vulnerable. Let's just say you can analyze that a different way and come to a different conclusion. We will see how people deal with that number this week when they go home and when they have to talk about this legislation over time. Here is where it gets a lot worse. This is a chart that is rather simple. Even though it has a lot of data on it, it is rather simple. Here is what it says at the top. First of all, this isn't my chart; it is the Center on Budget and Policy Priorities' chart. You can go to cbpp.org to see it. This is based upon the House bill, but I just told you that the Medicaid enrollment number is 1 million higher--or that the number losing Medicaid is 1 million higher under the Senate bill, and the tax cuts that are in the Senate bill are almost identical. You can just go down and count them. The House and Senate bill are virtually identical on tax cuts. Here is what the headline is: Tax cuts for the top 400 roughly equal to Federal spending cuts from ending Medicaid expansion. Now, remember, I said before that Medicaid expansion is one problem I see. The per capita cap is another. This chart just deals with one of the Medicaid problems--Medicaid expansion--so ending Medicaid expansion in Nevada, West Virginia, Arkansas, and Alaska, just four States, right? Alaska, they project, will lose $2 billion worth of Medicaid over the decade, Arkansas would lose $7 billion, West Virginia would lose $12 billion, and Nevada would lose $12 billion. That adds up to $33 billion Federal Medicaid cuts from ending Medicaid expansion. So $33 billion dollars just for States. By the way, these are not really high-population States. There is no California, New York, Texas or big States like that. So $33 billion lost in Medicaid in just those four States. What does this orange bar graph show? The same number, $33 billion tax cut for the 400 highest income households in the country. It is the same number. So 400 households get a tax cut of $33 billion, not in some other bill down the road, not in some other year, not in a budget bill or a tax bill. They get this massive tax cut in what is called a healthcare bill. At the same time, it is equivalent to the total Medicaid lost in just four States. It gets worse if you add more States. Guess what. If you add up about 30 States in a different chart, it is about the same as all the tax cuts together, but here we are just talking about four States and 400 families. I hope I am not offending anyone if they are in those top 400 households who are making either billions or, by one estimate, the average might be $300 million. I know it has been difficult to make ends meet. You have been struggling and trying to pay the mortgage and the light bill when you are one of the top 400 richest households in the country. But this chart, when you juxtapose this chart--and especially the orange part, the tax cut for 400 families, the giveaway to families who don't need it. Frankly, they don't even want this tax cut. I haven't found one person who came up to me in the last couple of years and said: You know what, I wish my taxes didn't go up. I wish those taxes didn't go up while you were trying to help people on Medicaid. Not a single person said that. Most people who will get this tax cut would rather that we make sure we take care of those children I mentioned with the disability or those families who need the protection of Medicaid. When you put this chart next to the policy and those 60-plus pages of the decimation of Medicaid, there are a lot of words we could use that we are not allowed to use on this floor, but one of the words we should use is ``obscene.'' That is an obscenity. When you match these cuts for 400 families next to the cuts to Medicaid, that is obscene, obnoxious, and bad policy. If there was ever a reason to take this 142-page bill and throw it in the trash, throw it in a garbage pail as fast as we can, it would be this chart because that is not what the American people are asking for. They actually think some people in the Senate are actually working on a healthcare bill. That is what they believe. A lot of people don't know about this yet, but they are going to know. They are going to know by the end of the week, at least, if not sooner, that the 400 richest households in the country are getting that much money--$33 billion. Maybe in the Senate bill it is only $32 billion or $31 billion, so we will stand corrected if it goes down, but that is really an abomination. That is an insult to the American people. People should be ashamed this is part of that bill. I get it. We can have a debate about Medicaid. I get that, but when you are taking Medicaid dollars and transferring to wealthy people, no one should support that kind of a policy, but that is what we have. That is what we are up against. If there was ever a reason to fight to the ends of the Earth against a piece of legislation, it is this. We are going to continue to fight this. We are going to continue to point out this basic inequity, this insult for the rest of this week. We hope folks on both sides of the aisle will not only be listening, but we hope our Republican friends will take another look at this bill and understand how objectionable this is to so many American families. All of that worry I talked about before is made worse, is aggravated by this kind of result when it comes to tax cuts. We can do all that as a great nation. We can make sure wealthy folks who need a break once in a while--they have gotten a lot of them in the last 25 years--that they can get a fair tax code. We could also make sure kids with disabilities, seniors, and kids in rural areas and big cities and small towns can get the healthcare they need from Medicaid. We are a great country. We can do that. We can have a growing economy and still support a critically important program like Medicaid. I yield the floor.

Mr. CASEY

Mr. CASEY. Mr. President, I ask unanimous consent that Christopher Friese, a congressional fellow on my staff, be granted floor privileges for the duration of the debate on the Better Care Reconciliation Act.

Mr. CASEY

Mr. CASEY. Mr. President, I ask unanimous consent to speak as in morning business.

Mr. CASEY. Mr. President, I rise to discuss, for just a couple of minutes this afternoon, the issue of healthcare and, in particular, the legislation that was unveiled today, what is referred to as a ``discussion draft.'' It is legislative text, but it is not the final word on this issue. So we have to begin in earnest to engage in debate because we are going to be very limited in the time that we have. I think the best way to describe this legislation can be very simple, actually, in terms of the impact on a lot of Americans. Unfortunately, I don't think this is really an effort to improve the healthcare system. I think it is a scheme. It is a scheme that sells out the middle class. It hurts seniors and children and devastates the protections and healthcare for individuals with disabilities over time, and all of that is done to finance tax breaks for the very rich. There are other ways, of course, to describe it, but I will focus mostly on Medicaid. As it relates to Medicaid, this isn't a repeal and replace, or repeal and improve, or repeal and reform. This is repeal and decimate when it comes to Medicaid. The cuts may be stretched out, but they are, in fact, deeper over time. So if you are one of the 1.1 million children in Pennsylvania who receives Medicaid or one of over 720,000 Pennsylvanians with a disability who benefits from Medicaid, your healthcare could be at risk. My test would be that if any of those individuals lose their Medicaid benefits, it is a bad bill. I would hope that would be the test for every Member of the Senate. The other adverse consequence of this legislation is that it will cripple efforts to battle the opioid addiction in our country. We just had a great consensus at the end of last year where both parties came together on two pieces of legislation--one that dealt directly with the opioid epidemic, the so-called CARA bill, or the Comprehensive Addiction and Recovery Act. Then later in the year, there was another bill that provided some additional funding. All of that would be compromised, undermined, or degraded, at least, if this legislation went through because the biggest payer--certainly, in the top two, in terms of our paying for opioid treatment and services--is, of course, the Medicaid Program. So what we have here before us is a bill that is a tax giveaway to the wealthiest. The top one-tenth of 1 percent would receive thousands and thousands, if not tens of thousands, of dollars. One estimate of the earlier version of the House bill said, if you were in the top one- tenth of 1 percent, you would get $197,000 each. Those people don't need $197,000 from a tax break from a so-called healthcare bill. They would, I think, expect that we would take care of the people that need healthcare: Vulnerable children. Some 40 percent of the children in America get Medicaid. Almost half the births in the country are paid for by Medicaid. People with disabilities are disproportionately dependent upon Medicaid, and they should have a right to expect--and their families should have a right to expect--that, if you have a disability, you should get Medicaid today, tomorrow, years from now, decades from now, and as long as you need it. You should have that guarantee. This bill takes away that guarantee for those families with a loved one with a disability. One of the many stories that we get from back home are from parents. Many of them are writing because their child has a disability or multiple disabilities, and they are dependent upon Medicaid. Here is just one: My son, Anthony, was born at 25 weeks and he weighed one tiny pound. We were overcome with medical bills which Medicaid thankfully paid for us. Since his birth he has had multiple health crisis, seizures, sleep disorders just to name a few. Most recently, Anthony was diagnosed with Autism spectrum disorder, Tourette's syndrome, severe obsessive compulsive disorder and Dyspraxia. He has suffered the most physically and mentally because of his Tourette's. It's severe and he is frequently unable to attend school due to his ``tics.'' They are painful and debilitating. They make him unable to eat, breathe and see at their worst. Far from what is commonly depicted in the movies and on TV. Then, this father goes on to say: Two years ago I was forced to quit my job of twenty years as a therapist to stay at home and care for Anthony because of the amount of doctors' appointments he has and the number of days of school he misses every year. Luckily with medical assistance-- That is the Pennsylvania version of Medicaid-- covering his services I am still able to do so. If we lost coverage, we would not be able to provide the support he needs. We are sure of that. I truly realize that unless you are actually living this kind of life, it's easy to turn a blind eye. I can assure you that my story is much like thousands of others that DEPEND-- And he has that word ``depend'' in all capital letters-- on funds from medical assistance to cover doctors, medications, therapies and durable medical equipment that children with disabilities require. Families of children with disabilities are desperate to not lose those benefits. My son Anthony is currently attending school almost regularly and functioning the best he has for a very long time thanks to the services he received from medical assistance. That is otherwise known as Medicaid. So that is the reality for a lot of families. Now, I can hear some folks in the Senate saying: Well, maybe Anthony will not be affected because the Medicaid provisions are going to be up to the States, and the States can handle that. We are just going to put a cap on the dollars, and we are going to wind down the Medicaid expansion that covered 11 million Americans at last count, and the States will handle it. So we are sending back these challenges and the disproportionate burden that States will have to bear to make sure that Anthony--who has all those challenges in his life--has the coverage of Medicaid. The Federal Government will just wash its hands of that responsibility. No, Medicaid is a guarantee now, based upon your eligibility. That guarantee should remain. We are a great country. We have the strongest economy and the strongest military in the world, and we have the Medicaid Program. We don't have to sacrifice those kids or sacrifice the healthcare for one child who depends on Medicaid. We don't have to sacrifice that child in order to have another part of our budget funded appropriately. That is an insult, and anyone who is going to choose to support legislation that would fund tax cuts for the wealthiest, while at the very same time and in the very same bill would result in others losing coverage--and I am not only talking about children with disabilities. I am talking about adults who have coverage--20 million people in the last couple of years. Any Member of the Senate who chooses tax cuts for the wealthy over those children and over those individuals, I think, should examine their conscience, to use an old expression, because this kind of policy that results in the most vulnerable among us losing their healthcare coverage is obscene. There are a lot of other words we could use--words we can't use here--because that is the definition of an insult to our values and to our country. We are a better country than what we will become if this Chamber votes in favor of a bill that will decimate Medicaid, the way this bill will. I realize it might take a long time. I realize it might be another Presidency or many Congresses from now, but the deed will be done here that will lead to that kind of misery. We have no sense of the misery that will be imposed upon those families because we have never had this before. We had a program in place for 50 years, and it has helped a lot of kids with disabilities. It has helped a lot of families to be able to hold down a job while their child gets the benefit of Medicaid because of a disability. It has helped a lot of poor children rise up from poverty and overcome terrible poverty because when they were kids--when they were very, very young--they got early periodic screening diagnosis and testing--the kind of early intervention and good healthcare that children get on Medicaid. A lot of seniors get into nursing homes. A lot of middle-class seniors from middle-class families get into nursing homes solely because they get the benefit of Medicaid, in addition to Medicare. The last thing I would say is that I think Senators in this Chamber should think about the basic inequity when they have healthcare. Everyone here has healthcare. All the families here have healthcare. All of our loved ones who are dependent upon us have healthcare. Yet some will vote to take away healthcare from some, and, in the very same bill, vote for gross, obscene tax cuts for the wealthiest among us-- most of whom, I would bet, don't want those tax cuts. They would rather see us take care of the vulnerable. So it is a basic choice. This isn't complicated. This is a very simple choice. I hope that in the course of this debate, some will come forward with some courage, some guts, and some compassion and do the right thing and vote this bill down. I yield the floor.

Mr. CASEY

Mr. CASEY. Mr. President, today I wish to commend Cheryl Bullock as she retires from public service. Cheryl has honorably served the people of Pennsylvania for 9 years through her role as my southeastern Pennsylvania regional director. She has been a valuable asset to my office, the city of Philadelphia, and the Commonwealth. Prior to joining my office, Cheryl spent the majority of her career with WPHL-TV. Cheryl spent over 20 years with the station handling media buys and marketing for local and national advertisers, including sports sponsorships and advertising with the Philadelphia Phillies, Flyers, and 76ers. Her tenacity and infectious laugh made her a natural at WPHL. She was later appointed governor of the Philadelphia Advertising Club from 2012 through 2014 after they recognized her strong leadership and dedication to her work--in and outside of the office. Upon her departure from WPHL-TV, Cheryl transitioned to the public relations team within the Community College of Philadelphia. From 2007 to 2008, Cheryl managed strategic messaging, communications, and campus activities and events--skills she later utilized throughout her work for the people of Pennsylvania. Due to her creative nature and way with words, she was trusted to write multiple articles for three community college publications. In addition to her professional pursuits, Cheryl has held leadership roles in several organizations geared towards community empowerment and service. Cheryl served as the vice president of Philadelphia Chapter of the Links, Incorporated, as well as president of the National Coalition of 100 Black Women. The National Coalition of 100 Black Women was created to establish a leadership forum for Black women from all geopolitical and socioeconomic groups. Cheryl's service within these organizations is a clear demonstration of her long-standing commitment to improving the lives of others. Over the course of the last 9 years, the Commonwealth has benefited from Cheryl's thoughtful guidance, driven attitude, attention to detail, and overall leadership. We will all miss her passion for service and commitment to helping others. I wish Cheryl well in her retirement as she plans to spend more time with her husband, George, and son Jordan.

Mr. CASEY

Mr. CASEY. Mr. President, I want to thank my colleague from Oregon for bringing the passion and the determination that he brings to his work, especially when it comes to healthcare. I spoke earlier tonight about the potential impact of any Senate bill, but of course the impact that we know already with regard to the House bill, because the House bill is legislation that passed and legislation that we can analyze as it relates to the impact on children, especially children with disabilities. Of course, when it comes to healthcare generally, but, in particular, Medicaid and what Medicaid provides to children, we know the impact nationwide. In my home State of Pennsylvania, we have 1.1 million children who are covered by Medicaid. So I am very concerned about any effort that would undermine or ultimately extinguish the ability of Americans--especially children--to have the benefit of Medicaid expansion, but, of course, the Medicaid program itself. It is especially insulting when some would support cuts to the Medicaid Program that would undermine or even threaten to undermine healthcare for children with disabilities. I spoke earlier of two children in particular. I will come back to children in a moment, but I wanted to go to the other end of the age scale--older Americans. So many people think of healthcare for people over the age of 65 to be solely limited to Medicare, not Medicaid. But, of course, we know that Medicaid plays a role as well. One of the parts of our healthcare infrastructure that may not be as well known is the impact that Medicaid has on supporting aging older adults, in particular, with regard to supports and services. We know Medicaid is critical to supporting aging older adults, providing them dignity and choice as they age. Medicaid covers long-term services and support for low-income, older adults and adults with disabilities, including nursing home and home community-based programs. Generally, health insurance does not cover long-term supports and service costs. Medicare coverage for those services can be limited, and private, long-term care insurance is unaffordable for many Americans. So spending on long-term supports and services for older citizens accounts for almost two-thirds of all Medicaid spending. I said Medicaid, not Medicare. A lot of people don't know that we spend that much in terms of long-term supports and services. To give this perspective, in 2016, the median annual cost for a year of home health aide services was over $46,000--for home health aide services. The median cost for a semiprivate room at a nursing facility was $82,000--a much greater cost. So we know the impact of those numbers. About a third of the people turning 65 will require nursing home care at some point during their life. So these are big costs, and we have to make sure that as we move forward, we can provide this kind of care for aging adults. Three-fourths of nursing home residents will eventually be covered by Medicaid. So if you are going to a nursing home and you spend down, the only option for you in most instances is Medicaid. We know that in about a 1-year timeframe, between July of 2015 to June of 2016 in Pennsylvania, 123,000 Pennsylvanians aged 55 and older received long- term supports and services through Medicaid. One group of about 80,000 Pennsylvanians received those long-term supports and services at a nursing home. Another group of about 50,000 Pennsylvanians 55 and older received Medicaid home and community-based services. There are lots of numbers there and lots of data, but the key thing is, we know the great dependence folks have on the Medicaid Program in addition to the obvious benefits provided by Medicare. So cuts or per capita caps on Medicaid would have a devastating impact on older Americans. I know the closed-door secret discussions taking place in the Senate between among only a small group of Republicans so far--we know those kinds of discussions are taking place. What will they do with regard to Medicaid? Will they cut it outright or will they put a per capita cap on it or will they send it back to the States and tell the Governors and State legislatures they have to balance their budget: It is up to you to provide most of the Medicaid services. The Federal Government is getting out of that business or at least transferring substantial responsibility to the States. So we have to be vigilant about that and make sure we do everything we can to put the interests of older citizens and the priority of taking care of them at the front of the agenda. Research also shows that Medicaid dollars play a role in supporting a lot of good-paying jobs in a State like Pennsylvania. We are told that over a quarter of a million jobs in the long-term care field--meaning long-term supports and services--are Pennsylvania jobs right now. So any change there could have an adverse job impact. The Commonwealth Fund and George Washington's Milken Institute released a report projecting 942,000 fewer jobs in 2026 and that nearly every State would experience an economic downturn if the Republican bill were to become law based upon the House bill as we know it. As we were told most recently by a Republican Senator, the Senate bill will reflect the House bill about 80 percent. So we have a sense of the outlines of the Senate bill, if not all the details yet. In Pennsylvania, this same report by George Washington University's Milken Institute said that just in Pennsylvania, the job impact would be 85,000 fewer jobs by 2026, and of those 85,000, more than 52,000 of those jobs would be healthcare jobs which would be lost if the Republican bill were to be enacted into law. We get a sense of the job impact, we get a sense of the healthcare impact when it comes to cuts to Medicaid that are substantial. As we know, the Congressional Budget Office told us that were the House bill to be enacted into law, in that decade, 14 million folks on Medicaid would lose their coverage. That is on page 17 of the CBO report. When we look at it by county in Pennsylvania, we can see the impact in this age category of 55 and up. Allegheny County--our second largest county by population--over 10,000 Pennsylvanians over the age of 55 receive care in a nursing home or at home because of Medicaid. That generated nearly $360 million in payments to providers in the county, a huge impact in addition to the impact on the care people receive. I will not go through every county, of course, but just to give a sense of it. Cambria County, a much smaller county by way of population--where Johnstown is in the southwestern corner of our State--1,100 individuals in Cambria County age 55 and older receive care in a nursing home or at home because of Medicaid. That is about a $36 million impact on that county. In my home county, Lackawanna County, where Scranton is located, 2,500 Pennsylvanians over the age of 55 receiving nursing home care because of Medicaid, a $96 million impact just in Lackawanna County. I will not go through all the counties, but we can see the impact on both care and jobs when it comes to the impact of Medicaid on long-term care, support, and services. We talked earlier about Medicaid and the impact on children. I don't think it has been at all clear until recently the reach and scope of Medicaid when it comes to children. Forty percent of every child in the country is covered by Medicaid. I mentioned earlier tonight, and I will say it again: Sixty percent of all children with disabilities ranging from autism to traumatic brain injury, and a lot of disabilities on that list in between, rely upon Medicaid. I said the Republican plan at the bare minimum should guarantee every child with a disability who has Medicaid coverage today would in fact have that coverage going forward for whatever time they need it because I think that is part of who we are as a country. When a child has a disability that is so substantial in terms of the impact on that child and his or her family and they have Medicaid, nothing the U.S. Senate should do should undermine that in any way. I would hope, at a minimum, our Republican colleagues would ensure that. I think it is insulting to even create doubt or uncertainty or create any degree of anxiety for a family to have to watch this bill proceed--either the House bill that was passed or the Senate bill which is in formation right now. For any family who has the benefit of Medicaid and has a child with a disability to in any way be anxious or uncertain because of what might happen here, I think is an insult to them and to our values as Americans. We are a great country. We can make sure children with disabilities have the benefit that comes from the early periodic screening and diagnosis, preventive care, the quality care that comes from services provided by Medicaid for kids with disabilities. We are a great country. We can pay for that and still be a growing economy, still have the greatest military in the world, still have the strongest GDP in the world. We can do all of that and still take care of the children. I guess some believe the only way to prosperity is to say we have to substantially cut back on Medicaid, to the point where 14 million Americans lose their coverage over 10 years, but we still, at the same time, have to give tax cuts to the very wealthy. One estimate showed the original House bill--the one that didn't get a vote but was substantially similar to the one that did get a vote--the first bill gave to 400 Americans a tax cut of some $7 million each. How does that make the country stronger when you are cutting back on Medicaid and giving gross substantial tax cuts to people who already are worth hundreds of millions of dollars or maybe even billions of dollars? I don't see how that moves the country forward to shortchange folks on Medicaid, especially if it were to adversely impact a child with a disability. We mentioned all of those impacts, but I think it is especially devastating when it gets down to an individual family. I talked earlier about Rowan Simpson whose mom wrote to me months ago. I had the chance to meet Rowan and his mom and dad just last week for the first time in person, but the idea that Pam Simpson--or any parent--would be at all uncertain or worried about what would happen here in the next couple of days or weeks is really an insult to who we are as a people. I hope those who are behind closed doors making decisions as we speak--maybe they are done for the day now, but I hope they will be thinking about Rowan and his mom and their family. I mentioned the overall impact of Medicaid on children. In particular, we know the Medicaid Program, of course, in addition to covering children with disabilities, covers adults with disabilities as well. In my State, by one estimate, it is over 720,000 people. Across the country, in 2015, there were 15 million people with disabilities who were Medicaid beneficiaries. Through Medicaid, those 15 million people receive assistance with their healthcare. They get the benefit of durable medical equipment, such as wheelchairs or assistive speaking devices. They get long-term supports for daily living, such as personal care attendance because of their disability. So Medicaid is now the primary payer for healthcare services for those with disabilities. It is also the primary payer for long-term supports and services that help people with disabilities live independent lives. In many cases, these long-term care supports and services also make it possible for a person with a disability to hold down a job because of the support they get from Medicaid. We know that in 2014, across the country, the average spending for a person with a disability enrolled in Medicaid was a little more than $19,000. In Pennsylvania, it was a little more than 18,300. The average annual growth in enrollee spending for persons with a disability between 2000 and 2011 was 4.5 percent. In my State, it is a little more than that almost. It is almost 5.7 percent, and we have seen the outline of a proposal that would limit that annual growth to about 2.4 percent. I would hope those who are working on the Medicaid provisions would take into account the reality of what it costs to provide help to someone with a disability and not come up with some arbitrary number to cap or limit what an individual with a disability would have available to them, especially by way of Medicaid or otherwise. They are dependent upon and have a right to expect that kind of healthcare would continue to be provided. We will see what happens. I know those who are behind closed doors have a sense of those numbers. I hope they would be very determined to make sure no one with a disability is worse off as a result of their efforts, but that is the reality people with disabilities live with. I think when we consider what some families are up against right now, many families have just barely come out of the last recession. Some families lost their home, some families lost their home and their job or even if they lost a job and have since recovered because they are employed or partially recovered, sometimes the job they have isn't the job they had prior to the recession. I can only imagine what it is like to have the kind of economic stress some live with because they have lost a job or the job they have now doesn't pay what their old job paid. On top of all that, if your son or daughter or someone in your family has a disability and the only thing that has kept you above water or allowed you to get from one day to the next to make ends meet is the availability of Medicaid for that individual and the family who needs that kind of help--we will see what the bill drafters come up with. Every indication so far has been very negative and very much adverse to the interests of those families-- those millions of families who depend upon Medicaid for basic healthcare, especially the basic healthcare that would be connected to a disability, whether that disability is a physical disability of one kind or another or whether it is a disability because that child or adult is on the autism spectrum or whether it is a child with Down syndrome who is dependent upon Medicaid or is dependent upon some other healthcare program that would be adversely affected. We can debate the outlines and the broad numbers of this legislation, but what I hope would not be up for debate is that those who now have the benefit of Medicaid because of a substantial burden in their life-- meaning a disability because of circumstances that require one individual to have the benefit of long-term care, where the family has spent down their assets to such an extent that only Medicaid can allow that loved one to get into a nursing home--I would hope that it would not be much of a debate that we should continue to help those families and those individuals. At a minimum, I think we can agree between the two parties that vulnerable Americans who depend upon Medicaid and other healthcare programs will be protected. I think that is something on which both parties should be able to agree. Unfortunately, the House bill in no way agreed with that assertion. That is why it was particularly objectionable, and that is why you have an array of organizations across the country that came out against the bill, those who have experience delivering healthcare to the vulnerable, those who have experience making sure people with disabilities are given that kind of help and that kind of care. If the Senate bill is substantially similar to the House bill, those with disabilities will be substantially and adversely and, I am afraid, irreversibly impacted to such an extent that we wouldn't be the same country we are today if those individuals lost their healthcare and lost the benefit of those healthcare services. Mr. President, with that, I yield the floor.

Mr. CASEY

Mr. CASEY. Madam President, this past Friday, when I was back in Pennsylvania, I had the opportunity to meet a family whom I have referred to very often on the floor--the Simpson family. Rowan Simpson, their son, is on the autism spectrum. I have talked a lot about Rowan's disability in the context of the healthcare debate. We have now the beginnings of a debate about what will be in the Senate bill, if one emerges. If we are going to be up front about what happens to families and individuals like Rowan, I think it would be important to know what happens to a family who has a loved one with a disability in the context of both the Senate bill and the House bill merging. Madam President, on behalf of Rowan and families who have loved ones with disabilities, I ask unanimous consent that no motion to proceed to calendar No. 120, H.R. 1628, the American Health Care Act, be in order until the bill is jointly referred to the Committee on Finance and the Committee on Health, Education, Labor, and Pensions.

Mr. CASEY

Mr. CASEY. Mr. President, I will start tonight with one of the questions that we have, and this will be a procedural question. I want to alert the Chair, I am going to pose this question initially before I make my remarks about the debate we are having on healthcare. Is the Chair able to confirm that the Committee on Finance considered S. 1796, the America's Healthy Future Act, which was ultimately incorporated into H.R. 3590, the Patient Protection and Affordable Care Act, in executive session on eight separate calendar days prior to reporting the bill favorably?

Mr. CASEY. Thank you. Mr. President, I rise tonight to provide some context about what is at stake for children in the United States with regard to the debate we are having on healthcare and, in particular, what would happen--some of the adverse impacts on children with disabilities. I will start with the broad view, but I think it is important to frame our discussions. Sometimes our debate on healthcare comes down to a discussion of big numbers. How many people will be impacted? For example, the Congressional Budget Office told us that 23 million people would lose their healthcare coverage over the course of a decade if the House bill were to become law. So healthcare coverage would be ripped away from 23 million people or we hear about the impact on the deficit one way or the other or we hear about broad numbers. Probably the best way to think about the impact of these policies is, if the House bill were to become law or some version of it because of what a few Senate Republicans are working on right now--maybe the better way to think about it is in terms of a couple of individuals, children. I will give you two examples for now. Angelica and Rowan--two different children, two different stories. We received a letter in the last couple--I am sorry. Angelica is the parent. I should have said Amaya. Amaya is the child whom her mom wrote to us about. Her mom is Angelica. She wrote to us and said: I am writing to you because I am appalled by all that is happening to this country. I have an amazing story about my daughter Amaya. She was basically born with no bones and she received a miracle drug that regrew her bones. She will have to take this medicine for the rest of her life but the fact that she is doing so amazing has to do with all the help that she received from Medicaid. She is the youngest patient in the U.S. to take the drug. I don't only want to talk about her but I am concerned about the future of our party. Looking forward to hearing from you. So said Angelica. Then, later on, she talks about what happened in her case to her child. She says she decided with a counselor to check with the Allegheny County officials about whether or not Medicaid expansion would cover Amaya's treatment. She said they made an inquiry. She said by the next day, ``Someone from the State had called me, and later that week her treatment was approved. Thanks to the Medicaid expansion, my daughter receives her lifesaving treatment.'' So I make that reference to one letter about one child, Amaya. Then, of course, there are so many other letters. I will just highlight one I received months ago now from Pam Simpson. She is from Coatesville, PA-- Southeastern Pennsylvania just outside the city of Philadelphia. Now you are talking about Rowan in Southeastern Pennsylvania and Amaya in Southwestern Pennsylvania, two corners of the State--two children facing challenges that most of us can't even imagine. In this case, Pam Simpson wrote to me about her son Rowan and talked about his life before a diagnosis of autism and before he was getting the help he is getting now. Pam talked about all of the challenges she and families like her face. She talked about the fact that he was having all kinds of difficulties, but then they finally got the word that Rowan would be covered by Medical Assistance. That is the Pennsylvania version of Medicaid at the State level. She said she applied in January of 2016. After Pam got the word that Rowan would be enrolled, she said: We were able to obtain wraparound services, which included a behavioral specialist consultant--so-called BSC--and a therapeutic staff support worker. The wraparound services have been a godsend-- Referring to the services provided to her son Rowan. Then she goes on later in the letter and says: Without Medicaid, I am confident I could not work full time to support our family. We would be bankrupt or my son would go without the therapies he sincerely needs. Here is how Pam concludes her letter: Please think of my dear Rowan and his happy face, his big blue eyes, and his lovely strawberry blonde hair. Please think of me and my husband, working every day to support our family, and please think of my 9-month-old daughter Luna. I will stop there just to explain. She is talking about Rowan, who is a couple of years older. The reference here is to his younger sister Luna. Please think of my 9-month-old daughter Luna who smiles and laughs at her brother daily. She will have to care for Rowan later in her life when 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 Pam Simpson wrote to me months ago. After referring to her story and Rowan's story over the last couple of months, I finally had the chance to meet her and to meet Rowan and his dad and his sister Luna. So I met this family--four people in a family. I met them on Friday. It is one thing to read about it and to get a sense of what a family is up against every day, and it is another thing to meet them. Right now, the Simpson family has what they need for Rowan. That doesn't mean they don't have challenges. It doesn't mean it will not be difficult in the years ahead, but they have the benefit of Medicaid right now--Medical Assistance, as we call it in Pennsylvania. Rowan now, because he has autism, has the benefit of those behavioral specialists and Medical Assistance. There was a person with them the day I met them, to work with Rowan every day so the parents can work and have the peace of mind to know they can go to work, and they can raise their family with the benefit of the kind of healthcare every child should have. Some might say: You know what. If the Republicans get their way on this bill, maybe the Medicaid provisions will not apply to Rowan. Maybe he will be protected or maybe in Allegheny County, maybe Amaya will be protected. Maybe it will not reach that far. Maybe when the Congressional Budget Office--I will read directly from page 17 of the report by the Congressional Budget Office analyzing the House bill when it says: Medicaid enrollment would be lower throughout the coming decade, culminating in 14 million fewer Medicaid enrollees by 2026, a reduction of 17 percent relative to the number under current law. That is what the Congressional Budget Office says about the impact of the House bill on Medicaid--14 million people lose their Medicaid. Some might say: Let's assume for purposes of this argument that those two children we just spoke about might be protected from those cuts. We don't know that, of course, and they can't guarantee that because what they are doing when they go at these Medicaid provisions is taking away the guarantee that has been there for 50 years and, over time, eliminating the Medicaid expansion. That is what we expect to happen. That is certainly what the House bill did. Let's assume for the sake of argument that they could come in here and make an ironclad guarantee that those two children, Rowan and Amaya, won't be affected. You know what. That is not good enough. That is not good enough because there are a lot of other children who will be affected, children who might have a disability. Sixty percent of children with disabilities are enrolled in Medicaid. We know that. We know that millions of other children who come from low-income families get the benefit of Medicaid. We know that a lot of seniors depend upon Medicaid to get into a nursing home. But no family who has a child with disabilities who benefits from Medicaid should have to worry for 15 minutes about what would happen in this Chamber-- because a small group of Republican Senators are meeting in secret, and they are supposed to produce a bill that we are all supposed to consider in a short timeframe--no product of that secret process should in any way give any parent who has a child with a disability any concern at all that that benefit will be taken away. That is not who we are as a country. We are America. We take care of people who need those kinds of services, that kind of benefit. So if a child like Rowan, who is receiving the benefits of Medicaid today because of his disability--if a child like that is receiving those services today, we should guarantee that he will receive those benefits for as long as he needs those benefits. Even if it goes the length and breadth of his life, we should guarantee that, take it off the table so that family doesn't have to worry. That, I hope, would be the result of this process undertaken by a small group of Republican Senators. I have been waiting to hear that, waiting to hear whether they will guarantee that to that child, to give that family some peace of mind with all the challenges they have, even with Medicaid, even with the great support they get. It is not easy. It is a very difficult life many families lead when they have a child with a disability. But we should do everything we can to make sure that if a child with a disability--just one category of people who benefit--any child with a disability who gets the benefit of Medicaid should have that protection for as long as they need it. And I will be waiting to hear that from our colleagues when they finally emerge from this secretive process with the bill. So I hope that is what they are working on in their meetings because we know that it affects a lot of children. As I said before, Medicaid covers 60 percent of all children with disabilities, ranging from autism, like Rowan, to traumatic brain injuries. We know that children on Medicaid receive what many consider the gold standard for children's healthcare--early and periodic screening, diagnostic and treatment options, so-called EPSTD--so they can get the screenings they need, so they can get preventive healthcare when they need it. All of these protections should be not just a goal, they should be guaranteed for those children. I am hoping our friends who are working on this right now will consider Rowan and Amaya and children like them. We will come back to it later. We will have other stories to tell about children and what they are up against. But on a night like tonight, I am thinking of those children and worried about some of the headlines we are seeing on some analysis. I will wrap up with this: The Center for American Progress report dated May of 2017 is titled ``Cuts to Medicaid Would Harm Young Children With Disabilities.'' That is one report. Another report is from the Center on Budget and Policy Priorities, May 18, 2017: ``Medicaid Cuts in House ACA Repeal Bill Will Limit Availability of Home- and Community-Based Services.'' That is another headline. We won't get into the details of those reports now. We have a lot to work on here to make sure that nothing that happens in this process will rip away healthcare from children with disabilities. I yield the floor.

Mr. CASEY

Mr. CASEY. Mr. President, I wish to start this afternoon with a reflection on what happened yesterday. We are thinking today of the individuals who were hurt in the attack during the baseball practice in Virginia, and, of course, we are praying for those who were injured. I will list them. Many of the names we already know, but it is important to list them. Of course, Representative Steve Scalise from the State of Louisiana-- we are thinking of his family and praying for them, and we hope for his speedy recovery. Matt Mika, who works for Tyson Foods, was also a shooting victim like Representative Scalise. Zack Barth, who works for Congressman Roger Williams, was a shooting victim, and Special Agent Crystal Griner, of course, of the Capitol Police, who exhibited such courage in the line of duty. We are thinking of Crystal at this time as well. We know there were individuals injured at the scene, including Special Agent David Bailey of the Capitol Police, who was not shot, apparently, but suffered an injury and was released from the hospital. We are happy to hear he has been released. Representative Roger Williams, who was hurt at the scene as well--not a shooting victim but hurt--and, of course, two of our colleagues were there at the time, Senator Rand Paul and Senator Jeff Flake. We are thankful they were not injured in any way. On these days, we come together as a family to remember those who have been the victims, and we are thinking of them and their families and praying for them.

Mr. CASEY

Mr. CASEY. Mr. President, today I wish to honor the life of William G. Sesler, Esq., 89, who passed away peacefully on May 22, 2017. Bill's exceptional service to our country in the U.S. Air Force, his dedication as a public servant in Pennsylvania, and his unwavering commitment to underserved communities throughout his career are worthy of recognition. His contributions to the Commonwealth will never be forgotten. I ask that the obituary from Gregory P. Sesler from May 26 be printed in the Record. The material follows: Thank you to the hospital care takers, physicians, pastors, friends, relatives, church community and family. I was on my way home from the hospital last week after having just left my father and after the decision had been made by the family to put him on palliative care. It was hard, my mother was awesome. A wave of sadness swept over me as I began to think of all of the things I would soon not be able to with him again in this world. But then I thought of all the things we had been able to do together and what a blessed life he had lived. Maybe we wouldn't climb Mount Washington together again, but we did it once. No longer would we sail the Chesapeake, go iceboating, travel on the German autobahn, see the Reformation Wall in Geneva, go to Africa to Ngorongoro crater, or go transatlantic on the QE II, but we had had a chance to do them all before. We had travelled thousands of miles and done dozens of business deals together, eaten lunch together at the Maenerchor Club hundreds of times. No he wouldn't drive my Jaguar way too fast again, or sail our Catalina sailboat or visit Civil War Battle Fields or see the wild horses of the Outerbanks, or see the Northern Lights in Alberta or the great cathedrals of Europe, or return to Kenyon College for another reunion or read his letters to the Editor. But we had been able to do all of those things together. We got the chance to shoot pheasants in South Dakota, geese in North Dakota, go to Mexico with his grandchildren, see the cliffs of Western Ireland, listen to Pavarotti at the Warner, smoke cigars on the back porch, banter about an article in the New York times, argue about business decisions, drink too much wine on a fishing trip in Canada, and enjoy over 50 Christmas parties together. Although I will never again have to endure his criticism or crave his praise or chase a bear out of our campsite within the Smokey Mountains, I have been able to do all of those things with him. Although he won't be bursting into my office on December 23rd and having me accompany him to buy an apartment's worth of furniture for a refugee family, or feeling the pride of seeing my aged parents volunteer in the homeless shelter, I did get to do that with him once. There may be no more deer hunting or trout fishing trips to Potter County or camping on the Outer Banks, or horseback riding in the Allegheny Forests, or watching World War II documentaries or going to James Bond movies on my birthday, but not everybody gets the chance to create this wealth of memories and for that chance I have been very blessed. But while Dad loved to travel and do and experience life in a very full way, and to share those experiences with his children and grandchildren generously, it was his transfer of character, drive, and confidence to us that was his greatest gift. He also instilled in us an innate curiosity of the world. We both thank him and curse him for our restless discursive minds. My mother once said that one of the reasons she married my dad 59 years ago was because she knew her life would never be boring. She was right. My dad was a non-politically correct liberal. He cared for people and believed in government as an agent of good, but he wasn't shy about criticizing the slothful or undisciplined. He wasn't afraid to refer to sloppy or vague thinking as BS. He admired the great planners who got things done. General George Marshal was one of those. He was not an admirer of Donald Trump. After William had been in the ICU for four days and we were able to wean him from the ventilator, he asked for his New York Times. His first comment when opening the paper was ``He fired Comey? What the hell!'' I had a special relationship with my dad. After returning to Erie from law school in 1984 we worked together for 33 years. Logged thousands of miles together, built 15 office buildings together, had many triumphs and losses, made money and lost money. We had fights, we had love, and I wouldn't trade any of it. Thanks Dad. Thanks for helping with my kid's college tuition, thanks for helping me buy a house, thanks for teaching me about the law and making me a better lawyer. Thank you for making me a more careful thinker, thank you for being my business partner, for being the family patriarch and also a great dad. He was a man who was confident, direct, capable, and precise, who valued careful thinking, reasoning and planning, he could be a tough dad and a demanding boss, and even though he was often a critic you didn't want to hear, you often knew in the back of your mind that the criticism was justified. You were also a patriarch who greatly loved and cared for your family and were so generous to all of us, monetarily, intellectually, spiritually, and emotionally--you gave us so much. You made our lives and the lives of many people who we will never know so much better with this love, your public service and the resolve to get things done. And so, we thank the Lord this day for the life of this man, my dad, and ask God to hold him in the palm of his hand, to keep him safe, to care for him, to love him and to welcome him into eternal life.