Home Health Care Planning Improvement Act of 2019

Mr. President, I was not next in the queue. Senator Gardner was, but since I don't see him, I am going to jump in, in great Senate fashion.

I rise today to educate my colleagues and the American people on actions that are currently being taken by the Food and Drug Administration. It deals with one specific thing that is familiar to all of us: combustible cigarettes. It revolves around a decision the FDA has just announced earlier this year: their plan to ban menthol combustible products. Their rationale for doing this is that menthol is the doorway for youth usage of tobacco products.

Let me start and end at the same point. I am going to start with this chart. This chart displays, from 2011 to 2017, the CDC's annual study of youth usage of tobacco products. Specifically, this one addresses the use of menthol cigarettes, where we have seen a reduction of 5.8 percent to 2.5 percent.

Somehow, as this chart displays, we have had a significant reduction in the use of menthol products for youth in this country. With this trend line, we are now making the case, as the Federal Government, that we have to ban this product because it is what is fueling an increase in youth usage.

Over the same period, youth usage of combustible cigarettes has dropped by 12.5 percent. By any standard we would look at, we would say that we have an education program in America that is actually having the right impact here. Between what we educate, parental guidance, and school pressures, the usage of our youth is going down.

This would be something that typically we would praise, but, no, an administration that came in primarily saying that we are here to reduce the regulation of the Federal Government, has picked one area that not only is it not reducing, but it is disregarding the trends that we see, and it is coming out with new regulations that, at the end of the day, are going to impact adults for whom we haven't either provided the tools to stop using combustible cigarettes or who have made a conscious choice that they want to use a legal product they know up front is harmful to their health.

To successfully talk about this, I have to hit rewind and go back 10 years, because it was 10 years ago, in 2009, that the Congress of the United States took up the Tobacco Control Act. I will say that it was a controversial debate. I spent hours on this floor.

Here are some of the points I made in 2009--that H.R. 1256, which was the Tobacco Control Act, did not provide a pathway to market for new tobacco products. New tobacco products were products that technologically we could create that provided a level of satisfaction for its users but didn't have the harmful effects of the combustion of tobacco. Innovative products--we see them in the market place today. They are there not because of the guidance of the Food and Drug Administration, with over 10 years of total control over the tobacco industry. They are there because the marketplace demanded it. Consumers said: Give me a tool to switch. We have gone from gum to patches, to now electronic cigarettes.

It was believed, at the time, that because we centralized tobacco regulation within an Agency that understands how to use scientific information to make decisions, they would look at trend lines like this and would make decisions that were consistent with it--that as technology became more available, we could determine how to put a heart valve in with it being less invasive through the use of technology. Over 10 years, we haven't figured out how to write a foundational rule to tell companies how they need to apply to get an e-cigarette approved.

When we went into this 10 years ago, HHS claimed that the Department would need $100 million to establish an Agency solely focused on tobacco products. We did them one better. We imposed user fees on the tobacco industry. For every piece of tobacco product that is sold, they paid to the FDA a user fee on that product. It is that user fee that has funded the FDA effort.

In 2019, the FDA received $712 million in user fees from the industry. Let me put that in perspective. Everybody who buys a tobacco product is paying a higher price today so that this money can go to the FDA so the FDA, hopefully, will create a foundational pathway that will allow them to approve and receive applications for reduced-harm products.

It is very consistent with this trend line of money we pumped into education to reduce youth usage and to encourage adults to switch, but until it is illegal in the United States, adults ought to have the freedom to choose the products they want.

Unfortunately, 10 years later, we are in no better position than we were 10 years ago, where the choices are combustible products or products that have yet to even have an established pathway by the FDA.

Those who are venturing out today offering e-cigarettes and alternatives are doing it with the understanding that tomorrow the FDA could walk in and say: We are going to pull this product off the marketplace because it hasn't been approved. Yet the FDA has never created the pathway and shown an individual or a company the application process to get a product like this approved.

Ten years ago, before TCA was signed into law, there were 14 Agencies that regulated tobacco in the United States. It was the Treasury Department, the Transportation Department, Commerce, Justice, the Executive Office of the President, HHS, Education, Labor, and the General Services Administration. It is now consolidated into one. You would think that we would do a much better job of doing it.

I am going to share with you the conclusion, and I will come back to this a couple of times.

There is an age restriction on the purchase of tobacco today. It is 18. We can have a debate as to whether it should be 21. We can have a debate about moving the age.

But when an agency that has the sole control of tobacco cannot enforce the age requirement for it to be purchased, you have to ask yourself, by taking away options that adults have, does that in any way, shape, or form affect youth usage when the youth are illegally accessing the product today?

You see, back when 14 agencies controlled it--and being a former Governor, the Presiding Officer may remember some of this--States actually enforced because the Federal mandate was to enforce the age requirements. They do it on alcohol today, and in some places, they do it on tobacco. But when we centralized all of the authority at the FDA, the FDA apparently gave up on the age requirement, and they only focused on things like this, where they can manipulate through government regulation, through onerous actions on the consumers, what they want to accomplish, which I would suggest to my colleagues and to the American people is not driven by facts or science; it is driven by politics. It is driven by those who want to see this product eliminated.

I will say what I said 10 years ago: I am ready for the debate. Let's bring it to the floor, and we can talk about it and debate it.

This is eerily similar to Canada a few years ago when they banned menthol products. How did they follow that up? This year, they legalized cannabis. Maybe that is the route we are on. We can have that debate at any point, but right now, that is illegal in the United States, and we put up with it with States that have legalized it. I am not sure it is a good move for adults, and I am not sure it is a good move for our youth. It certainly has the same combustible concerns we have with tobacco products. But there is a difference between the two-- this is legal. We have agreed that if you are over 18, you can choose to use it--with an extensive educational campaign to tell everybody why it is harmful to their health.

Also 10 years ago, I offered an amendment to create a department within HHS known as the Tobacco Harm Reduction Center, requiring public ranking of tobacco products according to their risk. That amendment would have allowed for the development of new products to encourage individuals to give up traditional tobacco products and turn to less harmful products.

I remember the debate well. My colleagues who were opposed to me in the debate said: If we centralize this at FDA, the natural reaction will be that they will migrate to not only the application being understood as to how to process it, but they will be inclined to approve those products quickly because of the alternative that we know today.

Here we are 10 years later, and we have no transitional, foundational pathway for a manufacturer to know how to apply to the FDA or what standards they have to meet. It is almost as if we are going to make it up as we go along. Therefore, these products are on the marketplace, but there is no application process at the FDA. They are susceptible to millions of dollars of investment being yanked tomorrow because somebody wakes up and says: My gosh. Youth have started using e- cigarettes. The Presiding Officer knows there is an 18-year-old age requirement on e-cigarettes as well. Is the answer to that to remove all of

that product for every American because we can't figure out a way to enforce an age limitation? I would suggest to my colleagues, if that is where we are headed, we are going to eliminate some products that will cause chaos in this country.

I suggest that this will not cause chaos, but this will be the wrong signal to send to adults who prefer to use this product, and we do it under the false pretense that we are doing this because of America's youth. America's youth are doing the right thing. They are reducing their usage of combustible products. They are not enticed by things like menthol. Yet they are the ones whom we are using to be the fig leaf of all this new government regulation that the Food and Drug Administration is proposing to do.

Within the office of tobacco control, there are 778 employees. There are close to 1,000 employees in the center for drug review. Put that in perspective--all the drugs that are out there, all the applications they are going through. We have almost as many people in the tobacco control agency as we do in drug review.

Well, the one thing I can assure you about drug review is that they actually do process applications. It is long. It is laborious. We would like to speed that up. Under the latest PDUFA reauthorization, the user fee for drugs, there is a 304-day average to process an application. Well, the review of a modified risk--if you change the risk of a combustible, if you have decided as a manufacturer that you are going to change the paper on the cigarette because there is technology that assures you that paper is not going to burn and somebody is not going to fall asleep and burn down a house--when they change that, that has to go through a modification review at the FDA. How long does a modification review currently take? It takes 360 days--56 days longer than that of a new drug application actually working its way through the Food and Drug Administration. They can't claim there are not enough people. There are ample people, and the FDA has hired 267 employees in tobacco control since 2017. The numbers may actually be identical now.

As I said earlier, in 2019 the FDA will receive $712 million in user fees from the industry. Of the $582 million in user fees collected by the FDA in 2018, which we have just completed, $205 million originated from the sale of combustible menthol cigarettes. So this one proposal is going to reduce by one-third the amount of money that the regulatory agency has.

I might share with the Presiding Officer--because I think he would find this of great interest, having left the State of Florida as Governor--that there is a tax revenue piece tied to this. A ban on the sale of menthol cigarettes will generate a significant revenue loss for State, Federal, and local governments. Last year, menthol sales brought in $4.1 billion in Federal excise tax, it brought in $9.1 billion in State and local excise tax, and it brought in $1.8 billion in State and local sales tax. That is a total of $15.2 billion. Two-thirds of it is--State and local governments will lose over $10 billion in revenue from this one decision, the elimination of a choice for adults--all under the belief and sales pitch to the American people that this is going to stop youth usage of tobacco. Bull. We are not going to stop youth usage until we enforce the age limit, whether it is 18, 20, 21, wherever we set it. We eliminated enforcement of the age when 10 years ago we consolidated all of this into one entity at the Food and Drug Administration.

So my suggestion to my colleagues is we have gotten no benefit out of this. If anything, we have lost because we don't enforce age. We have gotten no new innovative products. We are not even on the horizon looking at a proposed pathway. There is not a pathway. I question whether there is even one perceived, even though we have 1,000 people working at CTP--soon to be cut by one-third by their own proposal that is going to eliminate user fees based upon the loss of sales of menthol products.

So I say to my colleagues, it is extremely important that you understand that when Commissioner Gottlieb announced his reform initiative for the regulation of tobacco on July 28, 2017--and I recognize the fact that we move from administration to administration, we move from Commissioner to Commissioner, and most come in and say: The last guy did it all wrong; I am going to do it differently. I hold him to his word on July 28 when he said that. He said in that announcement: The goals of the new approach will include the development of foundational regulations to provide the rules of the road for the review of tobacco product applications and a path to market for less harmful products as part of the solution to end the cycle of disease and death.

Let me repeat what I said earlier. The FDA has yet to issue a single foundational rule as called for in July of 2017. The proposed version of one SE rule is currently under review at the OMB.

If you are now the single agency in charge of the regulation of tobacco and you are looking at how to reduce the harm of the product, wouldn't your focus first be on how you approve technological products that meet the threshold of reduced risk? If you saw an increase in youth usage, would you not look at a period of time, like 7 years, and ask yourself, is this an anomaly?

We will have a report next month from CDC of their annual tobacco survey. There must be something alarming in it relative to youth usage of e-cigarettes alone, and I don't dispute what they found. If, in fact, we find that menthol took a spike up and they say 11 percent of our youth are using it, I will question the science of their survey, with the trend that has consistently built over the last 7 years.

But I would also make this point: If there is an age limitation on e- cigarettes, just as there is on combustibles, are we not smart to first go in and find an enforcement mechanism for age if, in fact, our concern is that our youth are using the product?

In essence, what they have done with the menthol rule is they suggested: We don't want to enforce the age thing. That is hard. What is easy for us to do is to do something that is political. It doesn't change much, but we can go out and say ``Look at what we did. We eliminated access to this product.''

The majority of the people who use this product are adults. The tax revenues at the State, local, and Federal levels are huge.

As a matter of fact, one of the settlements that were made prior to the Tobacco Control Act was the Master Settlement Agreement. That was before the Presiding Office was Governor and before some in this room might have been born. It was in 1998, and it was a significant change for an industry. They agreed not only to defray Medicaid costs at the State level; they agreed to an annual payment. That annual payment was more than $200 billion in manufacturer funds to defray the cost of healthcare to States through Medicaid resulting from the use of tobacco products and to develop cessation programs to get Americans to quit smoking.

Let me suggest to you that it is not the industry that is fighting this; it is the industry that is fueling this. They are funding it. They are the ones funding the CTP. They are the ones funding the education programs. They are actually the ones that are supplementing Medicaid funding in States.

Well, let me say to Commissioner Gottlieb and to those bright folks over at CTP: When you do this, you are eliminating a portion of that $200 billion that is calculated based upon the sale of products in the marketplace, and you are reducing the shared cost of Medicaid. For many States that have diverted that money to other things, you are reducing economic development. I think one State was building sidewalks with tobacco money in one large city.

I could be critical of how they have done it and what they have used it for, but I do know this: I went far enough in math to know that if you reduce the amount of sales and if the payment is figured based on sales, then you reduce the take States and cities are going to get from taxes or from the settlement.

So I say to my colleagues, concentrate on this number--2.5 percent was the last number the CDC came out and said that of our youth, this is the percentage that use menthol products.

We should not quit until that number is zero. If you want to make that number zero for youth under 18 today for all tobacco products, I have the answer: enforce the law. Hold retailers

accountable. Do the same raids on tobacco that you do with alcohol. We probably will never get to zero, but we might do better than 2.5 percent of menthol or 8.5 percent of overall tobacco usage.

I want to summarize because I know there are other colleagues who wish to speak. I assure my colleagues, and I assure Commissioner Gottlieb and all the individuals who work at the CTP at the Food and Drug Administration, I am going to be down here every week. These speeches are going to get longer and longer and they will get more and more detailed because I want my colleagues who aren't here to understand the debate we went through, the decisions we made, and the assumptions that were made for consolidating these Agencies into one Agency versus multiple Agencies, and what they said would happen. I can give my own report card, and I am giving it to you. They have done zero. All of these matters about reduced-harm products that the FDA was going to set up, transitional, foundational rules don't exist.

It is 10 years later. It is 2 years after the current Commissioner got in and said: We are going to do this.

Well, I am still waiting. Rather than produce things which adults can take advantage of--tools to get off of combustible cigarettes--what is the action all of a sudden they take? To everybody's amazement, they said: We are going to ban menthol from the marketplace.

I mentioned Canada earlier. They banned menthol and, 3 years later, they approved cannabis as a legal product. I am not accusing the administration of having that pathway, though it does raise suspicion because it is not the administration of reduced regulation and onerous government when you see what the FDA is proposing to a legal consumer product, but I will state that the Commissioner announced not long ago that they were beginning to review products that were derived from cannabis, oils, and other things that they thought they could safely approve for use in the United States.

Well, Mr. Commissioner, you are only fueling my fears that you are following the roadmap Canada followed; that this is all a bait-and- switch situation. Not only is it not valid to suggest we are doing this because of our youth, you are doing it to prove that the Food and Drug Administration can overreach and not be slapped and that somewhere down the road you may come to the same conclusion Canada did; rather than enforce cannabis and illegal drugs, let's just approve them. Let's make them legal. Boy, that is a sad day. It is shocking to me as one who has been engaged in this debate for now 25 years.

We are extremely worried about the combustible impact of cigarettes-- and we should be--but States don't have any concerns about the combustible nature of cannabis. There are no filters on it. There are no regulations on the paper that is used, even though it is legal in some States. As a matter of fact, we have less research on cannabis in this country than any legal product that exists, including bandaids.

There is more research and development and approval that goes into bandaids than goes into cannabis in the States where it is legal for either recreational or medical use.

So I would state to Commissioner Gottlieb, in the insane world you have created, if you are going to head down this road, No. 1, expect Congress to weigh in but, No. 2, understand that if you begin to loosen up the legal use of cannabis, then we are going to hold you to the same standards you display for everyone else, everything that you hold a drug manufacturer to, that you hold a drug device manufacturer to, and, quite honestly, that you hold the tobacco industry to. Don't think you are going to slide this by and there are not going to be regulations or that we are going to adopt the Canada model or we are going to continue letting States do what they are doing.

If you are worried about somebody burning a product and inhaling it into their lungs, there better be as much concern about that as it relates to marijuana use. Why is there no effort--given that this is legal from a recreational and medical standpoint--from the FDA to study this and put the science out?

It only suggests to me that science is not important. Yet this is the institution that is the gold standard for the use of science. There is a scientific reason for why it takes 304 days to get a new drug approved. There is no scientific reason that it takes 360 days to approve as acceptable changing the paper on a combustible cigarette.

I am not creating this pathway, the FDA did. It started with the U.S. Congress providing this much authority to one Agency, an Agency they believed could do everything. Because they are not funded by the U.S. Congress for this piece--they are funded by the industry--do you know what? They think Congress has no say in it.

Do you know who funds 75 percent of new drug applications that are filed, reviewed, and approved? The drug industry. Seventy-three percent of applications they review and approve for the medical device industry are funded by the medical device industry.

With regard to generic drugs, which we all want more of because they drive down the cost of drugs in America, all of a sudden the FDA has a backlog that is years-long for approving generic applications. They said, if only we had a user fee agreement for generic drugs, and that user fee agreement is over 60 percent of the cost of approving a generic drug. What has happened? The backlog is every bit as big today as it was when the user fee was created. So if my colleagues wonder why I am standing in the way of a user fee agreement for over-the-counter drugs, it is because I figured this out.

They get funded by the industry. Their actual work goes down. The American people pay the tab for the user fees that are sent to the FDA, while the price of drugs, devices, cigarettes, and over-the-counter drugs goes up. When Congress stands up and says explain this, they look at us--and we control 25 percent of their budget for any given center-- and they say: We are going to go talk to the people who pay 75 percent of our budget, not to you.

The last thing I will share is that 25 years ago it wasn't like this. Twenty-five years ago, we appropriated everybody's budget in the administration. One hundred percent of the money for the FDA was appropriated by Congress. When I, as a Member of the U.S. Senate, picked up the phone and called the FDA, they didn't want to answer my question over the phone. They wanted to come to my office that day and answer it. They wanted to actually solve the problem.

I just went through a period of time where I gave FDA 2 weeks to respond to letters and, in some cases, it took a month to get a response.

They don't think we play a role in this. Yet we set legislation priorities for the country. I would suggest to my colleagues that this is an isolated example, that is true, but it is an example of a much bigger problem within the Food and Drug Administration and this Commissioner; that Congress is insignificant to them; that you can be called up to provide oversight in front of a committee, and you can say whatever because we have no clarity and no transparency inside the system. So they can tell me the review time has gone down 47 days since last year. I don't know whether it is accurate. I can only tell you this. I don't see it in the numbers of third parties that do reviews. I see actions such as this with no science to substantiate it, and I have to question the science they use across the landscape of products they review.

The Food and Drug Administration regulates 25 cents of every dollar of the U.S. economy. This ought to be something that not just my colleagues but the American people should be concerned with.

If you believe my argument is half accurate and this is ill-advised, for God's sake, pick up the phone and call the White House switchboard and tell the President, who came in to reduce regulation, that there is an Agency that is not listening.

Not only is there an Agency that is not listening, the President has a Commissioner that went on Twitter, and there was a tweet that said the President's numbers are going down, and the Commissioner ``liked'' the tweet. Maybe I will say that a few more times so the President will see it or hear it, but maybe somebody is listening who will tell him.

I am not interested in a single individual's political goal. This has to be an individual political goal because

there is no science to substantiate what they are doing, and the losers are the localities and States in taxes and States in settlement payments but, more importantly, adults who choose this product because it is legal.

Now the FDA says, with the strike of a pen: We can eliminate it. It is no longer a choice you have.

That is not the America I signed up for, but I did sign up to come here and fight for things I thought weren't in the best long-term interests of the country. This is at the top of my list right now. You will hear me often.

I yield the floor.

Mr. President, all across our country--in Vermont, in Illinois, in California--all across this country, people are asking a very simple question. That question is, How does it happen that in the midst of the extraordinary wealth that exists in our country--how does it happen that so many people continue to hurt financially and struggle desperately to keep their heads above water economically?

Today, despite unemployment being relatively low, some 40 million Americans continue to live in poverty. We don't talk about poverty very much here in the Senate, but we have 40 million Americans living in poverty. Many of them are struggling to adequately feed their kids. Many of them are forced to go, despite working, to emergency food shelters just to stay alive.

Despite the United States having a GDP--gross domestic product--of more than $20 trillion, we in this country embarrassingly continue to have the highest rate of childhood poverty of almost any major country on Earth. We don't talk about that either. Children are obviously the future of America, and we continue to have one of the highest rates of childhood poverty of any major country, and that includes 29 percent of African-American children who live in poverty.

How does it happen that in a so-called booming economy--and we hear from President Trump every other day about how the economy is booming-- the bottom 40 percent of our population does not have $400 in cash in order to address a financial emergency? Think about that. The bottom 40 percent--almost half of Americans--don't have $400 in their pocket, in the bank to address a financial emergency. Maybe the car breaks down, maybe the kid gets sick, maybe one loses one's job, maybe one undergoes a divorce; something happens, and 40 percent of the American people don't have $400 in the bank to address that crisis.

In other words, today--and we saw this in the recent government shutdown; today in America, many, many millions of families live paycheck to paycheck in order to survive. That should not be happening in the wealthiest country on Earth, and it is time we begin to talk about that. It is not good enough to talk about a so-called booming economy, forgetting about tens of millions of families who are not seeing that booming economy but, in fact, are living under incredible financial stress.

How does it happen that, in the so-called booming economy, tens of millions of American workers today are working for wages that are so low they cannot afford the escalating cost of housing? Some of them are spending 40, 50 percent of their limited incomes on housing. For many of these people, there is no health insurance available; the idea of a vacation for the family is something not even to be thought about; and the idea of being able to send one's kids to college is something that is also not on the table. By the

way, many of these individuals are working two or three jobs, 50, 60, 70 hours a week, just to survive.

This, again, is the wealthiest country in the history of the world. Yet 30 million Americans today, as we speak, have zero health insurance--no health insurance at all; 41 million people are underinsured--which means their deductibles and their copayments are so high that even though they have insurance, they still can't afford to go to the doctor, and one out of five Americans today cannot afford the prescription drugs their doctors prescribe.

In my view--a view I have held for a very, very long time, and it is a view shared by people not only in this country in wide numbers, but all over the world--healthcare is a human right, not a privilege. Whether you are rich or whether you are poor, you have the right to go to a doctor when you get sick, and you have the right to know that if you end up in a hospital, you are not going to go bankrupt or suffer from financial distress.

We are an aging population--no great secret there. We are an aging population. In this Congress, instead of dealing with government shutdowns precipitated by the President, we should be talking about how we respond to the reality of an aging population. Yet what we don't talk about is that about half of older Americans--half of older Americans, those 55 and older--have no retirement savings and no idea about how they will retire with dignity.

Think about what that means. Somebody is 60 years of age, they are coming to the end of their work-life, and they have no money--or virtually no money--in the bank. Maybe all they are going to get is Social Security. They turn on the TV, and they hear folks around here talking about cutting Social Security. Talk about why people in this country are angry and why they are stressed out.

Here is the bottom line. We are the wealthiest country on Earth. In fact, we are the wealthiest country in the history of the world, but despite that wealth, a significant percentage of our population--our children, our elderly people, our working men and women--struggle each and every day to keep their heads above water economically. Not only are they struggling, I think the pain they are feeling has to do with the worry they have about the future for their kids because they know, as many of us know, that unless we make some bold changes in our economy, the younger generation today will have a lower standard of living than their parents.

Imagine that--a so-called booming economy, yet we are looking at a situation where the younger generation may well have a lower standard of living than their parents.

I want to also say a word about another reality that currently exists. While so many of our people are struggling, while so many of our children are living in poverty, while 20 percent of folks on Social Security are trying to live on less than $13,000 a year, there is another pervasive reality in American society today; that is, the people on top--the very wealthiest people in this country--have never had it better, and the gap between the very, very rich--I am not just talking about the rich; I am talking about the very, very rich--is growing wider.

Here is the simple truth, a truth that we virtually never talk about here in the Senate, a truth that is not heard much in the corporate media; that is, the United States of America today has the most unequal distribution of wealth and income of almost any major country on Earth, and that level of inequality is worse today than at any time since the 1920s, the so-called Gilded Age of American society.

Today, if you can believe it, the three wealthiest people in this country--three--own more wealth than the bottom half of America, 160 million people. Let me repeat that. The three wealthiest people in this country own more wealth than the bottom half of America, 160 million people. Today, the top one-tenth of 1 percent--not 1 percent; one-tenth of 1 percent--own almost as much wealth as the bottom 90 percent. Today, and since the Wall Street crash in 2008, about 46 percent of all new income goes to the top 1 percent. Roughly speaking, half of all new income goes to the bottom 99 percent, and half goes to the top 1 percent, and our great task here in the U.S. Senate is to keep the government open while Trump tries to shut it down. Maybe, just maybe, we should be talking about those issues. Maybe, just maybe, we should be talking about an economy that works for all of us, not just the people on top.

Today, the top 25 hedge fund managers on Wall Street--25 hedge fund managers--earn nearly double the income of all 140,000 kindergarten teachers in America.

What all of the psychologists tell us is that the most important years of a human being's development are 0 to 4. Those are the most impressionable years in terms of how we develop intellectually and emotionally, and our childcare workers, our kindergarten teachers play a very important role. Does anybody think it makes sense that you have 25 hedge fund managers on Wall Street who, today, earn nearly double what 140,000 of our kindergarten teachers make? By the way, public teachers in America are falling further and further behind other occupations.

Having stated that reality--the fact that the middle class is struggling and the fact that the people on top are doing phenomenally well--I think it is fair to ask what the views are of the Republican leadership here in the Senate--Republicans control the Senate--and what our Republican President, President Trump, is proposing to address these massive levels of injustice and inequality. Three people own more wealth than the bottom half of America. What does the President and what does Leader McConnell have to say about that? The sad truth is that the Republican leadership today wants to make an embarrassingly bad situation even worse.

After passing a $1 trillion tax giveaway for the top 1 percent and large corporations last year, Republican leadership is coming back and saying: Hey, we only gave 83 percent of the tax benefits to the 1 percent. That is not good enough. That is not good enough. We have to do even better for our billionaires and corporate sponsors.

This time, the Republican leadership and the President want a tax break of hundreds of billions of dollars that would go exclusively to the wealthiest of the wealthy. I am not talking about the wealthy; I am talking about the wealthiest of the wealthy--the top one-tenth of 1 percent, the wealthiest 1,700 families in America.

We have 127 million families in our country--a population of some 320 million people. As I have indicated, many of these families are struggling. Many of these families are hurting. Today, many of these families are wondering how they are going to pay their rent, pay their mortgage, keep their lights on. Yet the legislation to repeal the estate tax that Senator McConnell and President Trump are proposing would benefit less than the top one-tenth of 1 percent of them--99.9 percent would see no tax reduction from the legislation.

Can anyone actually imagine bringing forward a piece of legislation that does not help the bottom 99.9 percent? Can you imagine that? The middle class are struggling. The gap between the rich and the poor is growing wider. There are 30 million people without health insurance. Our infrastructure is crumbling. And they come forward with a piece of legislation that is designed to protect and benefit the top one-tenth of 1 percent. The legislation would be of no benefit to 99.9 percent of the people of this country.

I think it is clear that when the people of this country look at Congress and say ``Those folks in Washington are not representing me. They are representing their wealthy campaign contributors. They are representing the billionaire class,'' there can be no clearer example of that reality than this proposed legislation.

Once again, with all of the economic problems, all of the inequality we face, imagine legislation that comes forward from the Republican leadership and the President that benefits the top one-tenth of 1 percent--the 1,700 wealthiest families in this country.

It is no secret that our infrastructure--our roads and our bridges, water systems, airports, wastewater plants--is crumbling all over this country. All over this country, there are major infrastructural problems. But I hear over and over again: We don't have the

funding to rebuild our crumbling infrastructure and put millions of Americans to work at good-paying jobs rebuilding that infrastructure. We just don't have the money.

Our schoolteachers are underpaid, but we don't have the money to provide attractive salaries in order to get the best and the brightest to do the most important work in this country; that is, teaching our young people.

Today, we have veterans--people who put their lives on the line-- sleeping on the streets, but we don't have the money to house them.

Families in America cannot afford childcare, and public schools are underfunded.

We don't have the money to address those crises, but somehow we do have hundreds of billions of dollars available to provide tax breaks for the top one-tenth of 1 percent.

We apparently have enough money to provide the Walton family--the wealthiest family in America, the folks who own Walmart, the people who pay their own employees starvation wages--by repealing the estate tax, as Senator McConnell and President Trump would like to do, we have enough money to provide the Walton family, the wealthiest family in America, with a tax break of up to $63 billion. Veterans sleep out on the street, teachers are underpaid, and 30 million Americans have no health insurance. We can't address those issues, but we do have legislation that would provide up to $63 billion in tax breaks for one family.

We have, apparently, enough money available to provide the Koch brothers--a family who spent some $400 million during the midterm election to help elect Republican candidates; the Koch brothers, one of the wealthiest, most politically active families in America--we have enough money to provide them with up to a $39 billion tax break.

Under this legislation, we can provide a tax break of up to $27 billion to the Mars candy bar family and up to a $13.4 billion tax break to the Cox cable family.

In other words, at a time of massive needs in this country, we don't have enough money available to protect working families and the middle class, but we certainly have more money than we know what to do with in order to give incredible tax breaks to the richest people in this country.

The estate tax that we are going to be proposing does not give massive tax breaks to the wealthiest people in this country--quite the contrary. It says to those people that at a time of massive income and wealth inequality, instead of repealing the estate tax, we must substantially increase this tax on the multimillionaires and billionaires of this country and in doing that, not only come up with much needed revenue to address the needs of working families but also to reduce wealth inequality in America.

That is why this week I will be introducing legislation for an estate tax bill that would do exactly the opposite of what my Republican colleagues propose to do. Let me briefly explain what is in the legislation I am offering.

Under my bill, anytime someone inherits an estate in America of $3.5 million or less, that person will not pay one penny in estate taxes. They will get to keep that inheritance tax-free. That population includes 99.8 percent of the American people. The legislation I am proposing would not raise taxes by a penny on 99.8 percent of the American population.

If you are in the top two-tenths of 1 percent of the population--the population that inherits over $3.5 million--your taxes will, in fact, be going up, and they should be going up.

My legislation establishes a 45-percent tax on the value of an estate between $3.5 million and $10 million, a 50-percent tax on the value of an estate between $10 million and $50 million, a 55-percent tax on the value of an estate in excess of $50 million, and a 77-percent tax on the value of an estate above $1 billion. In other words, this bill begins to create a progressive tax system in America, which is based on ability to pay.

I know some may think otherwise, but the truth is, this is not a radical idea. From 1941 through 1976, the top estate tax rate was, in fact, 77 percent on estate values above $50 million. Back to 1976, the top estate tax rate was 77 percent.

This bill would also close tax loopholes that have allowed billionaire families, such as the Waltons, to pass fortunes from one generation to the next without paying their fair share of taxes.

Under this legislation, the families of all 588 billionaires in our country, who have a combined net worth of over $3 trillion, would pay up to $2.2 trillion in estate taxes.

Let me make a confession here. This idea, this approach, was not developed by Bernie Sanders. It is not a new idea. More than a century ago, a good Republican President named Teddy Roosevelt fought for the creation of a progressive estate tax to reduce the enormous concentration of wealth that existed during the Gilded Age.

What is really quite remarkable is that what Teddy Roosevelt talked about over 100 years ago during the Gilded Age of the 1920s, when little children were working in factories and fields and the wealthiest people were enjoying incredible wealth and luxury--the idea Teddy Roosevelt proposed then is as relevant today as it was back then. Let me quote what Teddy Roosevelt said more than 100 years ago:

The absence of effective state, and, especially, national

restraint upon unfair money-getting has tended to create a

small class of enormously wealthy and economically powerful

men, whose chief object is to hold and increase their power.

The prime need is to change the conditions which enable these

men to accumulate power. Therefore, I believe in a graduated

inheritance tax on big fortunes, properly safeguarded against

evasion and increasing rapidly in amount with the size of the

estate.

That was Teddy Roosevelt over 100 years ago. What Roosevelt said then is absolutely true for today.

From a moral and an economic perspective, our Nation will not thrive when so few people have so much wealth and power and so many people have so little wealth and power. This wealth and income inequality is not only unjust and unfair; the truth is, it is a real threat to our economy and our democracy.

We need a tax system in this country that tells the billionaire class that they are going to have to pay their fair share of taxes so that we do not have 30 million people without health insurance, so that we do not have young people graduating college $50,000, $100,000 in debt, so that we do not have an infrastructure that is crumbling, and so that we do not see our great country moving toward an oligarchic form of society where a handful of families enjoy incredible wealth and power at the expense of everybody else.

In my view, the fairest way to reduce wealth inequality, to invest in the middle class and working families of our country, and to preserve our democracy is to enact a progressive estate tax on the inherited wealth of multimillionaires and billionaires. That is exactly what I will be proposing.

Mr. President, I come to speak about the pending amendment we are going to vote on in about 25 minutes. It is an amendment that says it is a mistake to proceed with the withdrawal from Syria in the pace and scale that is currently proposed or that the White House has announced they are going to undertake.

What I will say here today is what I said about it initially; that is, that I think it is a bad idea. I said it then, and I said it to the President in a subsequent meeting, and I think it is important to restate it here as we begin to vote, since I believe this issue is going to be covered in the press more as a political issue than as a foreign policy one.

It is unfortunate that a lot of these issues are wrapped up as political decisions. These are not votes on political decisions. These are votes on the conduct of American foreign policy, which oftentimes have no partisan lines but rather are ideological, in some cases, or just simply a different way to view an issue.

I share the White House's and the President's desire that as quickly as possible--the key words being ``as possible''--we end conflicts abroad. It is in the best interest of our Nation, our families, and the families of the service men and women who are stationed abroad and involved in conflict zones that this be the case. The problem is, if you do so in the wrong way, you end up dramatically increasing the likelihood of a future conflict that will involve even bigger wars, with an even higher investment of lives and resources to win.

Our foreign policy in the Middle East today--particularly in this region we are talking about with Syria and Iraq--is focused on two primary objectives, as clearly stated by the policymakers. The first is the regional threat of Iran, its growing influence and its spreading reach, and the other is counterterrorism. These are the two linchpins of why we are there in the first place.

The Iran threat is self-explanatory. They pose a threat to our allies in the region, particularly Israel but ultimately to the United States. The terror threat is one that reminds us how quickly we as a nation have a tendency to forget things.

Now, no one has forgotten September 11, 2001, but what we sometimes fail to remember is what made it possible in the first place. What made September 11, 2001, possible in the first place was that a terrorist organization--al-Qaida--led by Osama bin Laden, had established within Afghanistan a safe haven. Al-Qaida was not the Government of Afghanistan--that was the Taliban--but the Taliban allowed them to have a safe haven in Afghanistan, and from that safe haven, they were able to plot terrorist attacks against America and ultimately strike us here in the homeland. It was possible because they had a place that allowed them to do this.

It is, in fact, the key to any terrorist organization that would like to conduct external attacks and that would like to attack America. They have to have a place to operate from, and it cannot be a place where they are being followed, where they are being attacked, and where they are being wiped out by Americans or coalition forces. It has to be a safe haven.

My No. 1 concern about this decision that has been made is that it could lead to the reestablishment of safe havens inside of Syria from which ISIS and al-Qaida could reconstitute themselves, conduct external plotting, and ultimately attack the United States.

We already face this risk. In Northwest Syria today, there is very little sustained pressure on ISIS elements. In Idlib, there is virtually no pressure on al-Qaida. Now, imagine with even less coalition pressure being put upon them, how capable they can become and how quickly they can establish a place from which they can plot against us.

To understand why ISIS needs to plot against us and conduct spectacular attacks against Europe and the United States--this is a group that needs to prove it is still alive, and it is still strong. If they can't prove it, they

can't recruit people, and they can't raise money.

They are also in competition with other terrorist groups. In fact, ISIS is a spinoff of al-Qaida. These groups actually compete with one another for members and for resources. Both of them have a vested interest in attacking us abroad, not just in fulfillment of some ideological aims but as a means of survival because if these groups are able to conduct or inspire these kinds of attacks, it gives them credibility, they attract members and fighters, and it allows them to raise money for more attacks.

Some people will tell you: Well, let the others who are in the region take care of them--Turkey or Iran or the regime or the Russians. The problem is, none of these groups have shown any interest in fighting ISIS, not even a limited interest.

The Turks are largely interested in a buffer zone in the northern part of Syria--a buffer zone which the Kurds do not dominate because of their own internal politics. I am not claiming the Turks are fans of ISIS. I am saying ISIS is not their No. 1 priority.

Their No. 1 priority is defeating Kurdish forces and gaining control of a buffer zone in the northern part of Syria. That is what they are going to prioritize above anything and everywhere else. They are not a reliable partner, nor do they have the capability to be a reliable partner in sustaining pressure on ISIS.

Interestingly enough, if you look at what Turkey will need--even if they wanted to be a sustained partner against ISIS--it is logistical support from the United States of America. In essence, they can't even do what they are promising to do unless we are there with them to do it, but they don't want us to be there. That tells you they really just want us to leave so they can create this zone in the northern part of Syria.

The regime only cares about ISIS if they are in population areas or if ISIS is threatening critical infrastructure. If ISIS is taking ahold of an oil facility somewhere, they will care. If ISIS is in the middle of a big city, they will care. All of these other vast spaces, they don't have the resources, and frankly they don't care, as long as they don't pose a threat to the regime, they don't pose a threat to population centers they want to control, and they don't pose a threat to critical infrastructure like oil. If they are not there, they are not going to spend their limited resources.

All things being equal, they probably want to defeat them, but they don't have the wherewithal to sustain pressure on them. They have limited resources, and they are going to invest those resources in controlling population centers and in controlling critical infrastructure.

So here is the answer: If the United States and the anti-ISIS coalition are not in Syria and operating until ISIS is completely wiped out, there will be no sustained pressure on ISIS or on al-Qaida, and they will both grow back stronger, and they will have the capability to plot against the homeland and American interests around the world. That is something we cannot allow to happen. We cannot have that happen.

Some may say: Well, we can target them. We just don't have to have 1,500 or 1,800 special operators on the ground. We don't need to do that. We can do it through the air and so forth. ISIS is becoming an insurgency. An insurgency is much different than a group with a flag that controls buildings and territory. You can find those people, and you can strike them. An insurgency is people who blend into the population.

By day, they are a baker or an accountant or a merchant, but in the evenings and at night, they are an ISIS fighter planting bombs and killing people. Insurgencies are very difficult to fight and almost impossible, if not impossible, to fight with simply airpower, which is why the situation in Syria has been so positive. Two thousand American servicemen and special operators, alongside thousands of Syrian Democratic Forces and Kurds--who are primarily doing the ground fighting with our logistical support and air support--have eroded ISIS's control of territory in the country, but they have not eliminated it, and there is enough of it left that it could reconstitute itself. In fact, it is in the process of doing so already. They are clearly capable of killing American servicemen, as they did a few days ago, and since that time, there have been a series of other IED attacks inside of Syria, some of which could have killed Americans.

This is a group who has openly talked about their desire to possess chemical weapons, which they could use at any moment, potentially, against Syrian Democratic Forces and Kurds in that area--and, by the way, putting directly in danger our remaining service men and women alongside them. This remains a dangerous group capable of conducting attacks not just in Syria but potentially--especially if they have a safe haven abroad--here in the United States.

That is not to even mention a group who doesn't get talked about enough anymore--al-Qaida. Al-Qaida still exists, and there is a part of Syria in which they are completely uncontested. No one is going after them. They completely dominate the area, and they do whatever they want from there. And I promise you they are not there starting a car wash; they are there working to expand their brand and reach, to resurrect the al-Qaida brand around the world. What is the fastest way to do that? By conducting an attack against the United States and our interests. We should be worried about that alone.

The first reason why I am against this policy and why I support this amendment is that this policy directly undermines one of the two pillars of our strategy and our policy in this region, and that is counterterrorism. The second is the spread of Iranian influence. Let there be no doubt that this withdrawal as currently structured is a win--perceptually at a minimum but I believe in reality--for Iran.

Let's begin in Southern Syria, the areas that border Israel and Jordan. Our withdrawal means Iran and their pro-Iranian forces that include Hezbollah militias will now have even more operating space from which to target Israel and will now be able to set up a more reliable ground route by which they can send weaponry into Lebanon to support Hezbollah so that one day they can attack Israel from the air with rockets, precision-guided munitions, and the like.

We see it already, for example, in Natanz, where the United States still maintains a presence very near a huge refugee camp. We can already see the pro-Iran, pro-regime forces beginning to encroach closer and closer upon the American position, to the point where we may have to leave simply because we no longer have a defensive posture we can sustain. But what the withdrawal has done is it has allowed Iran and the pro-regime forces to go to our allies, to go to the groups on the ground whom we have been working with to fight ISIS and say to them ``The Americans are unreliable. The Americans are leaving. You might as well partner up with us now. We are the only ones who can protect you'' or ``You can lay down your weapons and just go back to your families because Americans are leaving.'' I fear it is working. I fear that they may dictate the pace of our withdrawal, because that announcement alone has undermined our credibility in the eyes of the partners we have worked with in Southern Syria.

What I just outlined is also true in the north, where the Kurds are facing the risk of military attack from the Turks, and they are saying: America is leaving, and the only people left whom we can partner up with to protect us are Iran and the regime and/or the Russians.

In fact, we have left them no choice but to join up with Iran and the Russians and pro-regime forces because if the choice is between annihilation by a Turkish military attack and joining up with a regime to stop a Turkish intrusion, they are joining up with a regime in Iran, further increasing Iran's power in this country.

It is not just contained within Syria; this announcement has actually accelerated the process of putting pressure on us to also get out of Iraq. All of the pro-Iran political parties inside the Iraqi Parliament are pushing very hard, very aggressively to pass a law that kicks America out of Iraq, and they are moving quickly on this. We see their tentacles in Afghanistan, where they are beginning to create internal political pressure through their

parliamentary body to force America to pick a date: Tell us when you are leaving, a date certain.

People may say: What is wrong with this? Get out of Syria. Get out of Iraq. Get out of Afghanistan. Why are we fighting other people's wars?

We are not. These are not other people's wars; these are ours. These people who are going to operate in these safe havens and Iran--we are their target. They want to strike at us. And if we are not in Afghanistan and we are not in Iraq and we are not in Syria, then from where exactly are we going to conduct operations against terrorism? From where exactly are we going to be postured to defend ourselves if Iran decides to strike our other military facilities in the region? The answer is, we won't have anyplace to do that from. We won't. Not to mention what it says to the region.

Understand this: The Iranians and our enemies in the region have been telling everyone for a long time--and the Russians echo this--``The Americans are unreliable. They always abandon their friends. You can't count on them'' or ``America is a declining power.'' That is the other argument they use openly: ``America is a great power in decline, and every year that goes by, you will see that they can't back up their words, and that is why you can't count on them. America is weakened.'' I don't believe that is true. In fact, we know that is not true. But halfway around the world, they do, and when we take actions that prove it, it makes it true in the minds of a lot of people and a lot of countries, and it actually is dangerous because it could invite someone to take a reckless and irresponsible action on the basis of miscalculation. Someone may actually believe ``America is now weak; let's attack them,'' and then we will be in a war.

The best way to prevent a war is to make sure those who want to fight you know they have no chance of winning. If you give them any belief that they have a chance to win because you have withdrawn and, as a result, reinforced the narrative being used against you, I believe you will have increased the chance of war.

This is being used against us right now. Iran is openly parroting this. They are holding this up as an example of an Iranian win. They are saying: This proves our strategy has been working. The Americans are leaving Syria. They are going to have to leave Iraq. They are going to leave Afghanistan with their tail between their legs. We are winning, and they are losing.

It reinforces a narrative, by the way, that is also used against us by the Chinese and other parts of the world.

This is a very dangerous situation. That is why this is a bad idea. This is about a lot more than just pulling out and not wasting any more money in these other places. There is no one in the world who wishes that more than I do. I wish the money, I wish the lives, I wish all of this investment had not had to be spent. I openly wonder, how much more could we be doing if we didn't have this threat? But here is the problem: Whether or not we want it to exist, the Iranian threat and the threat of terrorism exist.

We cannot deal with the world the way we want it to be; we have to deal with the world the way it is. We didn't create the terror threat, but it is there. We can ignore ISIS, we can ignore al-Qaida, and we can ignore Iran, but they will not ignore us. We can decide not to go after them, but they will come after us.

I think it is a grave mistake because if we allow al-Qaida or ISIS or both to have a resurgence, they will attack the United States of America, they will attack our allies and our interests around the world, and they will try and they will plot to attack us here at home. The Iranian influence operation and their growth and influence in Iraq and Syria and now in Lebanon and increasingly in Yemen--and God forbid, in the future, in Bahrain--pose an existential threat to all of our allies in this region--none more so than the State of Israel. That is why I support this amendment. That is why I hope all of my colleagues will support this amendment.

It is important that the legislative branch and the Senate, which has a constitutional role to play in the setting of American foreign policy--they come to us to confirm people, and they come to us to fund these things--that we play our rightful role in the setting of American foreign policy. It is important that the Senate be on the right side of this issue so that we can hope to influence future actions and policies before they are taken and we can help change them once they have been taken in places headed in the wrong direction.

Mr. President, I yield the floor

Mr. President, on Tuesday of this week, the Senate Finance Committee had a very important hearing on the skyrocketing costs of prescription drugs, something the Presiding Officer knows a lot about.

In 2017, a study found that more than half of Americans regularly take some form of prescription medication. Modern medicine has made living with chronic health conditions that would have once been debilitating or fatal--like diabetes, high blood pressure, or asthma-- modern medicine has made living with those conditions manageable. That is a blessing for which we are all grateful.

I know, at the same time, many of my constituents and many Americans struggle to buy prescription drugs to treat common health problems, not because they aren't widely available but because they simply are unaffordable. For many higher cost, brand-named drugs, generic alternatives are available at a lower price. For example, I happened to take a drug called Lipitor, which previously was covered by a patent. As a result of that patent, the cost of the drug was higher because the producer of the drug had a monopoly. We grant that monopoly for a period of time--I believe it is 12 years--in order for them to recoup their research and investment dollars. Unfortunately, many of these efforts to come up with lifesaving drugs are unsuccessful. So in order to encourage innovation and lifesaving discoveries, we have to find a way to allow drug companies to recover their sunk costs and make a profit.

Generic drugs have really been a lifesaver for many people. That same Lipitor that I take now is off of patent and is available for a few dollars for a 30-day supply. That is just one example. One study found that 93 percent of generic prescriptions are filled at $20 or less, with the average cost being just more than a little over $6, but for many drugs, there are no low-cost alternatives, and people are increasingly struggling to cover the rising costs of their medication.

One witness from Indiana, Kathy Sego, I think, speaks for a lot of parents who have children suffering from diabetes needing insulin, and I think her story was emblematic of that problem across the country.

In her case, she is a wife, a mother of two, and a choir teacher. Her son Hunter is one of the more than 30 million Americans who suffer from diabetes, and he relies on insulin to manage his blood sugar.

Kathy told us that when her son Hunter started college, he started to go to the pharmacy to pick up his insulin prescription himself. That is when he discovered that it cost $1,700 a month, even with health insurance. The copay--the part they were responsible for and had been paying for Hunter, unbeknownst to him--is $1,700 a month. Kathy assured him that, unfortunately, that cost was correct; $1,700 only covers a 1- month supply.

Over the next few weeks, their family began to notice a change in their son Hunter. He was losing weight, falling behind in school, and was depressed--a far cry from what she said was his normally positive and energetic self. Unbeknownst to his parents, Hunter had only purchased one vial of insulin when he needed four, and he began rationing his supply of the drug. To try to counterbalance that, he began skipping meals--which is dangerous for a diabetic to do, let alone an incredibly active college football player like him. Fortunately, in time, his family realized what had happened, and they intervened, avoiding what could have been fatal consequences, but her family still battles with the expense of this insulin.

Kathy says she worries about what happens when Hunter graduates from college, noting that his life choices are contingent upon his ability to pay for the medicine he needs to keep him alive. She wondered at our hearing: Can he afford an apartment, utility bills, and repay his student loans? Hunter, she said, needs insulin to live, but should that need for insulin keep him from living?

About 1.5 million Americans have type 1 diabetes like Hunter, where their body produces no insulin to deal with the blood sugar, but as I mentioned earlier, 30 million Americans, according to the Centers for Disease Control, have diabetes, and about 3 million of those 30 million are in my State of Texas. Three million Texans have diabetes for which insulin is a required treatment.

While we know it is common to see higher drug prices for new drugs that have recently completed the costly research-and-development phase, that is not the case for insulin, which has been around for nearly a century and is a type of biologic drug which is generally more expensive to produce.

I hope Kathy and Hunter's story--which could be told millions of times by other families across the country--impels us to investigate the causes for these unreasonable costs for some of these prescription drugs. I hope we find a solution--and I am confident we will if we try hard enough--that will allow families like Kathy's to live without the burden of wondering how to pay for their healthcare costs, particularly when it comes to prescription drugs.

At Tuesday's hearing, I also questioned our witnesses about a phenomenon known as rebates and the way pharmacy benefit managers deal with pharmaceutical companies.

I noted that, ordinarily, it was a crime to kick back money to a provider. For some reason that nobody could justify, there was an exclusion for these rebates by pharmacy benefit managers to pharmaceutical companies.

In the case of prescription drug pricing, rebates and discounts provided by manufacturers could mean the difference between a drug being covered by your insurance plan or not, and, certainly, whatever the net price is after the rebate is not transparent to anybody, much less to the consumer, or returned directly to the consumer. Not only does this drive up the list price and out-of-pocket cost of lifesaving drugs, but it makes it impossible for Congress or anybody to determine where each dollar goes.

I find this lack of transparency alarming. It shouldn't take an advanced degree to figure out where your money is going when you buy prescription drugs or how to shop for the most effective drug at the right price. When it comes to prescription drugs, we need to promote transparency first and foremost, and we need to streamline and eliminate regulations and laws that allow the middlemen to unnecessarily drive up prices. We know we have the opportunity to do that in the coming months.

We shouldn't require people suffering from chronic diseases to subsidize the healthcare costs of healthy people. There is something strangely wrong about this picture. I am glad we had the opportunity to listen to witnesses on this topic, and I thank them for taking the time to share their insights.

I look forward to continuing to work with all of our colleagues on the Finance Committee and generally to identify ways to make prescription drugs more affordable and accessible to the American people.

As the Presiding Officer knows, given his background in healthcare, I am confident he can be an important part of that solution, as well.

Tribute to Susan Pamerleau

Mr. President, switching gears just a bit, I want to share a quick good-news story of two outstanding Texans who blazed the trail for women in public service.

While I was in San Antonio, my hometown, a couple of weeks ago, I had the chance to congratulate our new U.S. marshal for the Western District of Texas, Susan Pamerleau. Over the years, she has held many impressive titles--general in the Air Force and sheriff--and now she is a U.S. Marshal. In addition to each of those, I have always been proud to know her under a different title--as a friend.

At Susan's ceremonial swearing-in, Chief Judge Orlando Garcia opened by noting the historical significance of her being the first female marshal ever in the Western District of Texas, which was established in 1857.

Susan's long and impressive career began at Lackland Air Force Base in Texas, where my dad happened to have been stationed at one time, where she received her commission through officer training school. Over the course of her 32-year career in the Air Force, she rose through the ranks and retired, ultimately, as an Air Force major general in the year 2000.

When she returned to Texas, Susan joined USAA as a vice president and later became senior vice president. It wasn't until 10 years later that her career in law enforcement began when she was elected sheriff of Bexar County, TX, which is the 11th largest sheriff's office in the Nation.

Susan was the first woman to hold that role as well, but she said:

It was not about being the first woman. It was really about

redefining the role of what the Bexar County sheriff does.

Over the years, I have had the opportunity to work with her on a number of issues impacting my constituents and our constituents, including mental health and law enforcement reforms. I think she has made an enormous contribution to both of those areas.

Needless to say, I was thrilled when the President nominated Susan to be the new U.S. marshal for the Western District of Texas and when she was confirmed last fall. Her integrity, leadership, and management skills are critical to the Western District of Texas, which comprises 68 counties and more than 6 million people.

I wish, once again, to congratulate my dear friend Susan Pamerleau on becoming the U.S. marshal, and I look forward to continuing to work with her as we serve together the people of Texas

Remembering Mary Lou Robinson

Mr. President, finally, when you talk about women opening doors in Texas, you can't leave out Mary Lou Robinson, who sadly passed away last weekend at the age of 92.

Her long and distinguished legal career began at the University of Texas School of Law, where she met her husband, A.J. After law school, they returned to Amarillo, TX, where they opened up the firm appropriately named Robinson & Robinson.

In 1955, she left the private practice of law when Potter County commissioners appointed her judge of the Potter County Court at Law, making her the first in a series of firsts for this remarkable woman.

Judge Robinson found her passion, and she was hooked. In the coming decades, she became an advocate for women's rights, and she helped to promote the passage of the Texas Equal Rights Amendment, a constitutional amendment voted on by the people in 1972.

Over the course of her remarkable 63-year judicial career, Judge Robinson served as the 108th District Court judge, followed by associate and then chief justice of the 7th Court of Appeals, located in Amarillo.

In 1979, she was appointed by President Jimmy Carter to be a judge of the U.S. District Court for Northern District of Texas, where she served for nearly 40 years.

Her career is impressive, not only for its length but for its quality. One attorney practicing before Judge Robinson noted: ``Lawyers may disagree on a lot of things, but almost all agree that she treats everyone equally and fairly.'' That is high praise for a district judge.

Judge Robinson will be remembered as an inspiring and devoted judge, an early advocate for women's rights, and a beloved member of her community.

Last summer, Senator Cruz and I introduced a bill to rename the Federal building and courthouse in Amarillo the J. Marvin Jones Federal Building and the Mary Lou Robinson United States Courthouse.

This lasting testament to her judicial career will live on for generations, and I am proud that Senator Cruz and I were able to cement this legacy for this legal pioneer.

While our family sends our prayers to the family of Mary Lou Robinson, we can all be proud of her distinguished career of service, not only to her beloved community in Amarillo but to the State of Texas and to the Nation as a whole.

I yield the floor.

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

Mr. President, I come to the floor today to express my opposition to the amendment before the Senate right now with respect to the disposition of American forces in Syria.

First, for my colleagues, let me stipulate that President Trump's Syria policy has been an absolute mess. It has been a train wreck. It has been a dumpster fire on a daily basis. That is something Republicans and Democrats can agree on, and I assume that is the reason we are having this debate right now.

There is bipartisan consternation over a policy in Syria that seems to change daily. It often changes based upon who the last person was to walk into the Oval Office or catch the President's ear.

The current policy seems to be that the President is intent on pulling out the 2,000 or so troops that are there at the request of the leader of Turkey. He would love to see the United States pull out so that he could move his troops in and overrun the Kurdish forces, which have been our partners for several years in trying to root out ISIS and extremist groups from Syria.

Let me also stipulate that I was one who did not support sending American troops into Syria in the first place. I have never believed that there is a military solution, led by the United States, to the host of problems that ravage that country. But once you have made that commitment, if you are going to undo it, you have to do it in some orderly fashion. To simply decide on a moment's notice, without any discussion with our allies or partners, that we are moving troops out is the wrong way to undo a commitment that I would argue was wrong in the first place.

You have to have a plan in place for the security of those you are leaving behind--both the Kurdish forces that you have pushed to bring the fight to ISIS, as well as all of the civilians who could be caught in the crossfire between an advancing Turkish force and a defensively oriented Kurdish force.

This is not why I am on the floor today--to try to, once again, rehash all of the ways that Trump's policy in Syria has gone wrong. I want to talk about why this amendment is not the right way for us to proceed as a means of correcting Trump's backward policies and how it could, frankly, get us more deeply mired into a series of conflicts in the Middle East, which are not supported--nor will they be supported-- by the American people.

First, we should be debating an authorization of military force for American forces in Syria, not an amendment that restricts an illegal use of military force.

The President does not have congressional authorization to use U.S. troops to fight ISIS in Syria or anywhere else. He claims he does because he has taken the 2001 AUMF and suggested that because some elements of al-Qaida eventually became elements of ISIS, that authorization continues. There is no one who voted then for that authorization some 17 years ago who thought that it would now be used as a means to fight a very different terrorist organization.

We should be having a debate about renewing America's authorization of military force so that it is updated for the enemies we are actually fighting, instead of conceding that the President has what is now, potentially, unlimited ability to fight anyone, anywhere around the world, who has any kind of affiliation to a terrorist group named 17 years ago. We are not doing that. Instead, through this amendment, in some way, shape, or form, we are ratifying the President's extra- constitutional use of military force overseas, green-lighting the continued end-around on congressional authorization that this President and many other Presidents would like to continue.

Let me also concede that this perversion of the 2001 AUMF was not invented by President Trump. It was invented by President Obama. I opposed it then, as I oppose it now.

Second, the language of this bill suggests that our mission inside Syria is not just to fight ISIS. The language of this bill suggests that our troops are in Syria to fight Iran as well. Over and over again, this amendment is peppered with references to the rationale for our existence in Syria being not just to fight ISIS but also to counter Iranian influence.

In fact, the amendment lists a series of conditions that we believe need to be filled before troops are to be withdrawn. Among those conditions is a strategy to ``stop Iran from dominating the region.'' That is an interesting debate for us to have: What should be the role of the United States to stop Iran from dominating the region?

I agree with my Republican colleagues that it is not in the security interests of the United States, nor our allies, for Iran to continue to gain a bigger foothold in the region, but there is absolutely no congressional authorization for U.S. forces to be in Syria to counter Iran or to fight Iran or to try to be a bulwark against Iranian aggression. No matter what kind of hoops you jump through to try to contort the 2001 AUMF to counter ISIS, you cannot get it to cover Iran.

This resolution--I don't know that it suggests, but it essentially admits--it asserts--that our troops are inside Syria today not just to fight ISIS but to stop Iran from gaining a bigger foothold there and, in fact, makes a condition of our troops' withdrawal be a strategy to continue to press back against the Iranians. There is no AUMF for that.

Let me tell you my real worry. Putting a bipartisan stamp of approval today on an amendment that suggests our troops are inside Syria, in part, to counter Iran will ultimately empower those in the administration who are rooting for actual war with Iran. If Democrats and Republicans say here, today, that our mission inside Syria is ultimately to fight Iran, then doesn't that potentially put some imprimatur of congressional support for a bigger conflagration with Iran that some in the administration may be trying to achieve?

Third, this amendment leaves the impression that there is an American-led military solution to all of the vexing problems inside Syria. There is none. There is none. If we really want to have a debate about the future of American policy in Syria, then we need to come to the conclusion that, ultimately, if we want to be a real player in the long-term disposition of Syria for the betterment of the Syrian people, then American diplomats, American refugee programs, and American economic development aid are going to be much more dispositive than 2,000 American troops.

Let me give you an example. In Northern Syria, where the Kurds exist and where American troops are for the time being, we have a problem. As I outlined before, the problem is a relatively simple one. We have pushed the Kurds to become more and more influential in the military and governance matters of that region. That was important for us because the Kurds were the most likely fighting force to be able to oust ISIS, but we knew ahead of time that this was going to create a problem with the Kurds, who see the YPG--the Kurdish military--as a terrorist group. We don't agree with them, but we knew ahead of time that the Turks would not stand for the long-term empowerment of the YPG in those portions of Syria.

We have now reached the point at which the rubber hits the road--at which Erdogan has said: We are not going to stand for that. We are going to bring our troops in, creating a potential flashpoint there.

There is a solution here, and Erdogan outlined it in an op-ed he wrote for a major American newspaper. He said: Well, listen, we understand the Kurds are going to have to be influential, but it has to be Kurds we support, not Kurds we believe to be affiliated with terrorist groups. That is a really tricky needle to thread, and I am not sure that it ever can be threaded. But the way you do that is, frankly, not with tanks or with American marines but with diplomats and with experienced

foreign policy hands--people who know how to work out a complicated political arrangement in which the Kurds continue to be able to run that region but the Turks decide to hold back and not press forward militarily. That is a diplomatic and political quandary that cannot be solved by the American military.

This amendment seems to suggest that we can solve all of our problems--or many of our problems--if we just keep 2,000 troops there.

Fourth, the back end of this amendment lays out a series of criteria that have to be fulfilled before the troops can be removed. I mentioned one of them--that there has to be a strategy to combat Iranian influence. The final of these criteria is that ISIS has to have been substantially defeated in the region and a certification has to be made to that effect.

Well, let me ask my colleagues this--it is a legitimate question, not a rhetorical one. I don't know the answer, and maybe someone can provide it to me. When was the last time this Congress tied the Executive hands in that way? When was the last time this Congress actually laid out the conditions by which the Executive cannot withdraw troops from a region? That seems to be a very curious exercise of our foreign policy oversight responsibility.

I am someone who has suggested for a long time that we have largely abdicated that responsibility. I would love for us to be debating foreign policy and exercising our oversight more often, but the idea that we would, as a legislative body, tell the President that he cannot withdraw troops from a place unless x, y, and z criteria are met seems to be dangerous and restrictive because there are all sorts of conditions that you can imagine that aren't listed in this amendment by which a President may feel it is in our best interest to bring troops home.

The Constitution doesn't vest in this Congress the power to undeclare war. It vests in us the power to declare war. To me, I worry that by restricting the aperture by which the President can make an argument to bring troops home, we ultimately will end up having them be in harm's way for longer than is necessary.

Maybe this isn't unprecedented. Maybe there are other times where we have done this, but it does seem to be fairly unprecedented for the legislature to tie the Executive's hands and tell him or her that he has to keep troops in a place for a certain period of time.

I wanted to come down to the floor and express my reservations about this amendment. Again, I wish we were having a debate on an AUMF. I wish this weren't the way in which we were exercising our constitutional prerogative on foreign policy. I am deeply worried-- deeply worried--about language in this amendment that empowers those in the administration who are jonesing for a fight with Iran. I do not believe that however capable and brave our troops are in Syria, they ultimately are the answer. If we want to have a debate on Syria policy, let's talk about all the other ways that we need to engage in Syria in order to bring stability to that place. I do worry about how we tie this President's hands or any President's hands when they want to bring our troops home and get them out of harm's way.

Trump has completely botched policy in Syria, but that shouldn't go-- even Trump's most ferocious opponents--from endorsing endless wars. That shouldn't require Democrats to be against everything that he is for. He is pulling our troops out in a way that I oppose, but I worry about the long-term implications of this Congress asking for a fight in Syria that is unauthorized and then tying the President's hands when it comes to getting troops out of harm's way in places in far-off lands.

I oppose the amendment and encourage my colleagues to do the same.

I yield the floor.