Floor Statements

Madam President, I ask unanimous consent that a copy of my opening statement at the Senate Health Education, Labor, and Pensions Committee be printed in the Record.

Madam President, I ask unanimous consent that a copy of my opening statement at the Senate Health Education, Labor, and Pensions Committee be printed in the Record.

Mr. President, to be specific, 51 years ago, the United Citizens for Nixon-Agnew descended upon the city of Indianapolis, IN, a city to which a young man named Richard Lugar had been elected mayor. That was my first opportunity to meet former Senator Richard Lugar, who died a few days ago.

He became Richard Nixon's favorite mayor. He persuaded the suburban areas around Indianapolis and the city itself to do something almost no city in America has been able to do--Nashville did it; Miami did it; Louisville did it; and Indianapolis did it. It was to have a unified government--to get rid of 60 different municipal governments and form one. No one was very surprised when Richard Lugar was able to accomplish something, because he had been marked from the beginning as being a young man of extraordinary ability.

At Denison, where he went to college, he became a Rhodes Scholar. He studied at Oxford. He became a Navy intelligence officer. Later on in the sixties--and I have mentioned 1968 as the year in which we met him for the first time--as mayor, he was able to deal not only with the unification of Indianapolis but with the difficult racial times that occurred all over America during the late 1960s.

Nobody was surprised when he ran for the U.S. Senate in 1974. He was defeated in the Watergate sweep that wiped out a large number of promising young candidates, which I had a little personal experience with in Tennessee. Yet no one was surprised when he came back in 1976 and won.

As soon as he was elected, he organized the other Republican Senators who had been elected that year to vote for Howard Baker, Jr., for the Republican leader of the Senate in January 1977. Senator Baker won that race by one vote. You can imagine that Senator Baker had a very high opinion of Senator Richard Lugar, and they became close friends.

I first really worked with him in 1980 when I was the Governor of Tennessee. Senator Baker wanted to run for President, so he summoned to Nashville, to meet in my office, Senator Lugar and his young aide, Mitch Daniels--later, the Governor of Indiana and now the president of Purdue University--as well as Warren Rudman, the Senator from New Hampshire, and his young aide, Tom Rath. I admired Dick Lugar then, and I admired him throughout the rest of his career. It was a privilege to serve with him on the Foreign Relations Committee while he was the chairman of it when I was elected to the U.S. Senate.

I noticed that unlike all of us Senators, when Richard Lugar had something to say, he had something to say, so people actually listened to him. We

have a tradition in the Republican caucus in which we have Thursday lunches that are hosted by various members of our caucus. I have served something from the town in which Jack Daniel's is made--not the whiskey but the food. Senator Cindy Hyde-Smith served some Mississippi food last week before the recess. We will go around the room in the order in which we have come in, and everyone will stand up and say something. Well, we all say something, but what was different about Richard Lugar was, during those Thursday lunches, he actually had something to say. He was intelligent and thoughtful. He studied. He was never flamboyant. He was not into symbolic votes. He dominated Indiana politics for 36 years, and he had the respect of virtually anyone whom he ever met.

Not many Senators in our history have the opportunity to do what he did with former Senator Nunn and the Nunn-Lugar law, which was to basically dismantle thousands of nuclear weapons--take out the explosive parts of them and render them useless as instruments of war for the future. He continued to work for a safe world and played a major role in the New START treaty in 2010.

There will be many memorials and many speeches and many compliments paid to Senator Lugar. President Obama awarded him the Presidential Medal of Freedom--the highest civilian honor in our country. I will remember him for his quiet, unassuming, highly intelligent, thoughtful style of leadership. The world is better and safer because of Richard Lugar's life in public service. He was always a gentleman, always principled. He was a model for what all of us should hope for in our public officials. He was a good friend for many years.

I and Honey, my wife, and our family send our sympathy and our respect for the life of Richard Lugar to Char and his family.

I yield the floor.

Mr. President, I ask unanimous consent that a copy of my opening statement at the Senate Health Education, Labor, and Pensions Committee be printed in the Record.

Mr. President, I ask unanimous consent that a copy of my opening statement at the Senate Health, Education, Labor, and Pensions Committee be printed in the Record.

Mr. President, I ask unanimous consent that with respect to the Morales nomination, the motion to reconsider be considered made and laid upon the table and that the President be immediately notified of the Senate's action.

Mr. President, I ask unanimous consent that the mandatory quorum call be waived.

Mr. President I ask unanimous consent that a copy of my opening statement at the Subcommittee on Energy and Water Development's budget hearing for the Corps of Engineers and Bureau of Reclamation's fiscal year 2020 budget request be printed in the Record.

Mr. President I ask unanimous consent that a copy of my opening statement at the Senate Health, Education, Labor and Pensions Committee be printed in the Record.

Madam President, I thank the Senator from Alabama for including me today in the reading of Dr. King's letter from the Birmingham jail.

Senator Jones has standing to do this not just because he is from Alabama but because of his work as a U.S. attorney prosecuting Klansmen who blew up a church on 16th Street in Birmingham, killing children.

Senator Jones said that all of this was not too long ago. It was not too long ago for me. I remember a day--on August 28, 1963. I was a student at that time at New York University School of Law with an internship in the U.S. Department of Justice. It was a hot summer day, and the streets were filled with the March on Washington. It was about lunchtime, I believe, that I went outside into that crowd, and I heard a booming voice from a man who was standing on the steps of the Lincoln Memorial. I heard the words that he hoped his four little children one day would ``live in a nation where they will not be judged by the color of their skin.'' I am not sure, at that time and at that age, that I understood fully what I was seeing and hearing, but I was hearing Dr. King's ``I Have a Dream'' speech.

In 1962, a year earlier, I was a senior at Vanderbilt University in Nashville. It was not that long ago, but a lot has changed since then. Vanderbilt, a prestigious institution, just in that year was desegregating its undergraduate school. I was a part of that effort. But even then, Black Americans couldn't go to the same restaurants, stay at the same motels, or go to the same bathrooms--even then, and it was not that long ago.

Four months before I heard Dr. King speak in August of 1963, he wrote a letter from the Birmingham jail on the 16th of April, 1963. This was Dr. King's letter:

My Dear Fellow Clergymen:

While confined here in the Birmingham city jail, I came

across your recent statement calling my present activities

``unwise and untimely.''

Dr. King's letter went on to say:

I think I should indicate why I am here in Birmingham,

since you have been influenced by the view which argues

against ``outsiders coming in.'' I have the honor of serving

as president of the Southern Christian Leadership Conference,

an organization operating in every southern state, with

headquarters in Atlanta, Georgia. We have some eighty five

affiliated organizations across the South, and one of them is

the Alabama Christian Movement for Human Rights. Frequently

we share staff, educational and financial resources with our

affiliates. Several months ago the affiliate here in

Birmingham asked us to be on call to engage in a nonviolent

direct action program if such were deemed necessary. We

readily consented, and when the hour came we lived up to our

promise. So I, along with several members of my staff, am

here because I was invited here. I am here because I have

organizational ties here.

But more basically, I am in Birmingham because injustice is

here. Just as the prophets of the eighth century B.C. left

their villages and carried their ``thus saith the Lord'' far

beyond the boundaries of their home towns, and just as the

Apostle Paul left his village of Tarsus and carried the

gospel of Jesus Christ to the far corners of the Greco Roman

world, so am I compelled to carry the gospel of freedom

beyond my own home town. Like Paul, I must constantly respond

to the Macedonian call for aid.

Moreover, I am cognizant of the interrelatedness of all

communities and states. I cannot sit idly by in Atlanta and

not be concerned about what happens in Birmingham. Injustice

anywhere is a threat to justice everywhere. We are caught in

an inescapable network of mutuality, tied in a single garment

of destiny. Whatever affects one directly, affects all

indirectly. Never again can we afford to live with the

narrow, provincial ``outside agitator'' idea. Anyone who

lives inside the United States can never be considered an

outsider anywhere within its bounds.

You deplore the demonstrations taking place in Birmingham.

But your statement, I am sorry to say, fails to express a

similar concern for the conditions that brought about the

demonstrations. I am sure that none of you would want to rest

content with the superficial kind of social analysis that

deals merely with effects and does not grapple with

underlying causes. It is unfortunate that demonstrations are

taking place in Birmingham, but it is even more unfortunate

that the city's white power structure left the Negro

community with no alternative.

In any nonviolent campaign there are four basic steps:

collection of the facts to determine whether injustices

exist; negotiation; self purification; and direct action. We

have gone through all these steps in Birmingham. There can be

no gainsaying the fact that racial injustice engulfs this

community. Birmingham is probably the most thoroughly

segregated city in the United States. Its ugly record of

brutality is widely known. Negroes have experienced grossly

unjust treatment in the courts. There have been more unsolved

bombings of Negro homes and churches in Birmingham than in

any other city in the nation. These are the hard, brutal

facts of the case. On the basis of these conditions, Negro

leaders sought to negotiate with the city fathers. But the

latter consistently refused to engage in good faith

negotiation.

Dr. King's letter continues:

Then, last September, came the opportunity to talk with

leaders of Birmingham's economic community. In the course of

the negotiations, certain promises were made by the

merchants--for example, to remove the stores' humiliating

racial signs. On the basis of these promises, the Reverend

Fred Shuttlesworth and the leaders of the Alabama Christian

Movement for Human Rights agreed to a moratorium on all

demonstrations. As the weeks and months went by, we realized

that we were the victims of a broken promise. A few signs,

briefly removed, returned; the others remained. As the weeks

and months went by, we realized that we were the victims

of a broken promise. A few signs, briefly removed,

returned; the others remained. As in so many past

experiences, our hopes had been blasted, and the shadow of

deep disappointment settled upon us. We had no alternative

except to prepare for direct action, whereby we would

present our very bodies as a means of laying our case

before the conscience of the local and the national

community. Mindful of the difficulties involved, we

decided to undertake a process of self purification. We

began a series of workshops on nonviolence, and we

repeatedly asked ourselves: ``Are you able to accept blows

without retaliating?'' ``Are you able to endure the ordeal

of jail?''

Dr. King's letter continues:

We decided to schedule our direct action program for the

Easter season, realizing that except for Christmas, this is

the main shopping period of the year. Knowing that a strong

economic-withdrawal program would be the by product of direct

action, we felt that this would be the best time to bring

pressure to bear on the merchants for the needed change.

Then it occurred to us that Birmingham's mayoral election

was coming up in March, and we speedily decided to postpone

action until after election day. When we discovered that the

Commissioner of Public Safety, Eugene ``Bull'' Connor, had

piled up enough votes to be in the run off, we decided again

to postpone action until the day after the run off so that

the demonstrations could not be used to cloud the issues.

Dr. King continued:

Like many others, we waited to see Mr. Connor defeated, and

to this end we endured postponement after postponement.

Having

aided in this community need, we felt that our direct action

program could be delayed no longer.

Madam President, I yield the floor to the Senator from California, Ms. Harris.

Madam President, I ask unanimous consent that a copy of my opening statement at the Subcommittee on Energy and Water Development's budget hearing for the Department of Energy's fiscal year 2020 budget request be printed in the Record.

Madam President, nearly two years ago, just before the Senate voted to confirm Dr. Gottlieb to lead the Food and Drug Administration, FDA, I said that he was ``the right person to lead the FDA in [its] vital mission and move the agency forward so that America's patients can benefit from the remarkable discoveries . . . that our nation's researchers are working on.''

Since then, Dr. Gottlieb's leadership at FDA has proved that prediction correct.

Dr. Gottlieb has been one of the President's best appointments.

Two years ago, I also said that ``there's never been a more important time to capitalize on the significant funding Congress has given to medical research.''

Congress has given the National Institutes of Health, NIH, a $9 billion increase from 2015-2019, almost $40 billion dollars in 2019, and FDA plays a key role in bringing new treatments and cures to American patients.

In 2016, Congress passed what Leader McConnell called the most important legislation of the Congress, the 21st Century Cures Act, to help speed the development of new drugs and devices.

This exciting time in medicine also brings great promise to patients to lower the cost of medicine, as more promising treatments come to market, we see increased competition, which helps to drive down how much patients pay for medicines they need.

Dr. Gottlieb's successful tenure at the agency includes helping to bring more competition to the market. In 2018, FDA approved or tentatively approved over 1,000 generic drugs, approved 34 novel orphan drugs, which are drugs to treat rare diseases, and designated 18 regenerative medicines as regenerative medicine advanced therapies, so they can be reviewed faster.

Here are just a few other important things Dr. Gottlieb has accomplished:

When Dr. Gottlieb took over at FDA, Congress was working to reauthorize the four medical product user fee agreements that make up about a third of FDA's funding.

In addition to reauthorizing the four user fee agreements, Congress worked with Dr. Gottlieb and authorized an expedited approval process for generic

drugs where there is little or no market competition, called the Competitive Generic Therapies pathway, as part of the FDA Reauthorization Act of 2017.

Since August 2018, FDA has approved five new generic drugs under this pathway and has designated over 140 generic drug applications as qualifying for this pathway.

Dr. Gottlieb also announced a new plan, called the Biosimilar Action Plan, to bring generic versions of biologic drugs, called biosimilars, to help improve competition for biologics by increasing market entry of biosimilars and providing more treatment options for patients.

FDA has approved a total of 18 biosimilar products since 2010, when the biosimilar pathway was created, 13 of which were approved under Dr. Gottlieb's watch.

At his confirmation hearing, Dr. Gottlieb described the opioid crisis as ``having staggering human consequences. I think it's the biggest crisis facing the agency. . . . I think it's going to require an all- of-the-above approach . . .''

Last year, 72 senators worked on legislation to combat the opioid crisis.

Dr. Gottlieb provided us with crucial advice as we worked on this legislation and has begun to take advantage of the new law.

He has taken steps to help prevent illicit fentanyl, which is 100 times more powerful than heroin, from coming across the border.

He worked with Congress to clarify his authority to require opioids to be packaged in blister packs, such as a 3 or 7-day supply, to encourage doctors to prescribe responsibly; and clarified FDA's authority to require safe disposal options to accompany opioid packaging.

Dr. Collins, who leads the NIH, has predicted a nonaddictive opioid in the next decade, which really is the Holy Grail for fighting the opioid crisis and for helping the 50-100 million Americans living with pain.

I believe Dr. Gottlieb has laid groundwork to encourage the development of nonaddictive and nonopioid medicines and therapies to treat pain.

Dr. Gottlieb was integral to Congress's ability to reauthorize the animal drug user fees, which authorize the FDA to collect user fees to speed the review and approval of new drugs that farmers, families, and veterinarians rely on to keep their animals healthy and the food supply safe.

The 21st Century Cures Act created the Regenerative Medicine Advanced Therapy Designation, which is similar to the very successful breakthrough drug pathway that safely shortened the development and review time for certain drugs, to get them to patients who need them more quickly.

While we worked on that law, I heard the story of Nashville resident Doug Oliver.

In 2007, Doug began to have trouble seeing and, after a near accident, had his driver's license taken away and was declared legally blind.

The culprit was a rare form of macular degeneration.

His doctor at the Vanderbilt Eye Institute told him that while there were no cures, Doug could search online for a clinical trial.

Doug found a regenerative medicine clinical trial in Florida, where doctors took cells out of the bone marrow in his hip, spun them in a centrifuge, and then injected those into his eye.

Three days later, he began to see.

His eyesight eventually improved enough to get his driver's license back, and he became an effective advocate for more support for regenerative medicine, which we included in the 21st Century Cures Act.

So, with his improved vision, he began writing letters and visiting me to advocate for more support for regenerative medicine, which we did in the 21st Century Cures Act.

Two years ago, Doug gave me the cane he had used while he was blind. He said: ``I don't need it anymore.''

In Cures, we included a pathway to bring new regenerative medicine treatments, similar to the treatment Doug received, to patients more quickly.

Dr. Gottlieb has worked to implement that new pathway to help develop safe treatments to ensure more patients are able to take advantage of this cutting-edge, personalized medical technology.

Additionally, Dr. Gottlieb has helped the agency develop and advance guidances for gene therapies that will help new innovative companies developing these promising therapies, some of which may be for specific diseases and conditions that provide roadmaps for biotechnology companies who are leading the way in precision medicine.

During this exciting time in biomedical research, we are fortunate that Dr. Gottlieb was willing to serve.

The FDA and the biomedical community is in better shape today to advance medical innovation and develop the treatments and cures of the future because of his leadership.

Mr. President, I ask unanimous consent that a copy of my opening statement at the Subcommittee on Energy and Water Development's budget hearing for the National Nuclear Security Administration's fiscal year 2020 budget request be printed in the Record.

Thank you, Madam President.

Today I received a letter from the U.S. Ambassador to China, Terry Branstad. Governor Branstad's letter said the following:

I am delighted to inform you that China's Ministry of

Public Security announced China will make all forms of

fentanyl a controlled substance effective May 1, 2019. If

implemented effectively, this will fulfill the commitment

President Xi made to the President at the G-20 last December

in Buenos Aires. That commitment and this key development are

direct results of your visit to Beijing during which you

highlighted China's role in the global opioid crisis.

Separately, I have asked my staff to share diplomatic

reporting with you that addresses China's action in greater

detail.

That is from Ambassador Terry Branstad, our Ambassador to China.

This is important news. It will save thousands of American lives. President Trump deserves great credit for persuading President Xi at their meeting in Argentina in December to do this, the one thing that our drug enforcement agents have said will reduce the flow of fentanyl into the United States more than any other single thing.

President Xi, the President of China, deserves the thanks of the American people for making this decision because our Drug Enforcement Agency is convinced that this decision by China and its senior officials will save thousands of American lives.

The reason for this, we were told by our Drug Enforcement Agency personnel in China, is that, one way or the other, almost every bit of fentanyl that makes its way into the United States starts in China. These chemicals are made and mixed there. Then they come through the mail. They come through Mexico, through China, many different ways, but the chemicals start in China.

Every time China has made some form of fentanyl illegal, the availability of that form of fentanyl in the United States has begun to go straight down.

What President Trump and President Xi agreed to do on May 1 is to make all forms of fentanyl illegal. This means that if some clever scientist in China says: Well, this form of fentanyl is illegal, so I will make a different form that isn't, that clever scientist will now be out of business.

One thing the Chinese know very well how to do is to police their country. I would not want to be the Chinese person, after May 1, who is in violation of Chinese law that says all forms of fentanyl are controlled substances and illegal in China.

In October, I led a delegation of senior Members of the House of Representatives and the Senate to meet with the Chinese senior delegation. One would have thought that all we talked about was trade because trade was important to all of our States, but at Governor Branstad's insistence, in every meeting we had with senior Chinese officials, we said: Fentanyl is our biggest problem, and you can solve our biggest problem more than anybody else in the world. Instead of being our problem, why don't you be our solution? Why don't you let the United States point to China and say that you helped us solve a problem that is killing thousands of Americans on a regular basis?

China agreed to do that in December with President Trump. It has now been announced that on May 1, all forms of fentanyl will be controlled and therefore illegal.

We should watch and make sure it is effectively done, but what we should say today is: President Trump, we thank you for putting fentanyl on top of a busy agenda in December, and, President Xi, we are grateful to you for a decision we believe will save thousands of American lives. I might add, it is very helpful to have such an effective Ambassador as Terry Branstad in China because he knew how to focus the attention of many visiting delegations.

Our delegation wasn't the only one who carried this message; Senator Portman and others have been there. But this is an example of China responding to an urgent American problem, and we ought to give both Presidents much more than a pat on the back for this important step.

Healthcare

Madam President, I often suggest to Tennesseans that we should look at Washington as if it were a split-screen television. For example, last October, on one screen, you would have seen Senators throwing food at each other all month long over the Kavanaugh debate, but in another part of the Capitol, you had 72 Senators working together--Democrats, Republicans, three different committees from the Senate, five from the House--working together to enact what the President called the single most important law to deal with a public health epidemic ever passed, and that was the opioids bill.

While we are arguing--which we know how to do--on such issues as the border or the special counsel's report, on the other screen, you will see a lot of work getting done if you take time to look. That means there are bipartisan efforts. That means Republicans and Democrats are working together. It takes 60 votes to get most things done here. We are 53 to 47. So, as I learned to count in the public schools of Tennessee, I know I need to work with some Democrats to get up to 60. Usually, we find that when we do that, we get up to 70 or 80 or 85 because we can take even the most difficult issues and find our way through them.

Today, I want to talk about one of those efforts--a bipartisan effort to try to reduce healthcare costs. Healthcare and health insurance are often conflated. We often mix them up, both in Congress and in media stories. The President sometimes does that too. I want to be very clear that what I am talking about is a bipartisan working effort, that healthcare itself, not just health insurance, is too expensive.

Health insurance has gotten a lot of attention lately. The President tweeted earlier this week that ``deductibles, in many cases [are] way over $7,000, mak[ing] it almost worthless or unusable.'' I agree. High deductibles tied to high premiums make healthcare inaccessible for too many Americans. I know the President is looking at ways to give Americans more affordable health insurance and to protect patients with preexisting conditions, and I look forward to hearing his plan. But the truth is, the cost of health insurance will not come down or even grow more slowly unless we lower the cost of healthcare. You can't have low- cost health insurance when you have high-cost healthcare.

My top healthcare priority this Congress is to enact legislation that will give all Americans an opportunity for better health outcomes and better health experiences at a lower cost. Democrats and Republicans are working together on that to get a result.

That is why Senator Murray, the lead Democrat on the Senate's Health Committee, and I are working with Senator Grassley and Senator Wyden, the senior leaders on the Senate Finance Committee, which shares jurisdiction over healthcare. We are working together on developing specific, bipartisan steps to help deal with the startling fact--which has come by way of experts who come before our Health Committee--that up to half of what Americans spend on healthcare is unnecessary. That is according to Dr. Brent James of the National Academies in testimony before our committee.

Last December, in order to help focus on reducing healthcare costs, after the Senate Health Committee held five hearings on reducing the cost of healthcare, I wrote a letter to the American Enterprise Institute, the Brookings Institution, governors, State insurance commissioners, doctors, patient groups, academic experts, and the public asking them to submit specific recommendations to Congress to lower healthcare costs. As of the March 1 deadline for response, we have received over 400 recommendations, some as many as 50 pages long.

I want to talk about some of those today. Before I do, it is important to know that the cost of healthcare, in effect, has become a tax on the budgets of families, employers, the Federal Government, and State governments. Warren Buffett has called the ballooning cost of healthcare ``a hungry tapeworm on the American economy.''

Almost every day, I hear from Tennesseans who are concerned that healthcare is too expensive. For example, Sherry from Hermitage, TN, wrote me about her daughter's family and said:

They are new parents now and spend almost as much on

healthcare premiums as they do on their mortgage payment.

That doesn't include the out-of-pocket expenses, such as

copays and deductibles.

Many people worry about a surprise billing, which is when a patient receives care at an in-network hospital, but an out-of-network specialist--like an anesthesiologist, for instance--also treats the patient.

Todd is a father from Knoxville, TN, who recently took his son to an emergency room after a bicycle accident. The son was treated. Todd paid a $150 copay because the emergency room was in-network for his health insurance, and they headed home. Todd was pretty surprised when he received a bill later for $1,800 because even though the emergency room was in-network, the doctor who treated his son was not.

I hear a lot about the high cost of prescription drugs. Shirley recently wrote me from Franklin saying:

As a 71-year-old senior with arthritis, I rely on Enbrel to

keep my systems in check. My copay has just been increased

from $95 to $170 every 90 days. At this rate, I will have to

begin limiting my usage in order to balance the monthly

budget.

I hear from doctors about administrative burden. Dr. Lee Gross, a Florida direct primary care doctor, testified at one of our hearings that insurance and government regulations were making primary care too expensive. Dr. Gross founded one of the first direct primary care practices. This is where a patient might pay $60 a month for an adult, $25 for the first child, $10 for each child after, and receive all their primary care--strep tests, vaccines, minor surgical procedures, and more. He calls it ``NetFlix for healthcare. After you pay your membership, you don't have to pay for each episode of care.''

Dr. Atul Gawande, who is leading the Amazon-Berkshire Hathaway- JPMorgan healthcare venture, told me recently in a conversation that direct primary care doctors are a powerful group for driving improved outcomes in healthcare because the doctors take responsibility for the outcomes, the risks, and the cost to the patient.

I also hear that the place where medical procedures are performed can make healthcare more expensive. For example, Michael from Johnson City shared that he recently had an endoscopy of his esophagus--a fairly common, routine procedure. He had the procedure at an outpatient facility, which typically is less expensive than a hospital; however, the procedure was billed as being done at a hospital. Michael is on Medicare, and he wrote to me saying: ``Not only am I charged a higher ``hospital'' rate, but taxpayers are charged a higher rate, as well.''

I imagine that every Senator has heard similar stories from people in their States and wants to do something about reducing the cost of healthcare.

In addition to the more than 400 comments we received, the American Enterprise Institute and Brookings sent us a detailed list of 18 specific policy recommendations. The Senate Health Committee can work on some of these. Some of these fall into the jurisdiction of other committees, and some are steps the administration itself can take without congressional action.

My staff and I are still reviewing all of these recommendations, but I want to mention some of them today.

One reason healthcare is so expensive is that the cost is in a black box. Patients just don't know how much a particular test and procedure will cost. That makes it nearly impossible to adequately plan for future healthcare expenses, and because of that, the healthcare system does not operate with the discipline and the cost-saving benefits of a real market.

Congress has already taken some steps to increase transparency. For example, last Congress, we passed and the President signed legislation by Senator Collins of Maine to ban the so-called gag clauses in pharmacy contracts that prevented pharmacists from telling a patient that a drug was cheaper if they paid with cash instead of their insurance.

Now we have received recommendations on how to build on that first step. For example, patients shouldn't be prohibited from knowing the cost of a surgery or a doctor's visit in advance of scheduling the procedure or appointment. Insurers and employers should

not be prohibited from providing patients with information recommending lower cost options or higher quality providers.

Another recommendation--this one from AEI and Brookings--is that employers contribute claims data--which is information on how much a test or service costs and how much insurance paid for it--to what is known as an all payer claims database. Eighteen States currently have these databases so employers and insurers can see trends in healthcare spending. This would help break open the black box around the claims data for the 181 million Americans who get their healthcare on the job.

One of our new Health Committee Members, Senator Braun of Indiana, owns a manufacturing and distribution company. He employed over 1,000 people before he became a Senator. He was aggressive about helping his employees reduce healthcare costs.

Healthcare Bluebook, a Tennessee company that testified at one of our five hearings on how to reduce healthcare costs, recommended that we look at the clauses in contracts employers sign with insurers that block the employer from accessing de-identified claims data that they could use ``for purpose of price and quality transparency.''

The Trump administration is also focused on transparency. For example, Secretary Azar has proposed a regulation to start requiring that advertisements for prescription drugs include the list price, and he has asked for feedback on the idea of requiring that the prices patients pay for medical services also be disclosed.

Another strategy for achieving better outcomes and better experiences at lower costs is to focus on the 300,000 primary care doctors in our country. Dr. Sapna Kripalani of Vanderbilt testified at one of our healthcare cost hearings that primary care providers are the ``quarterbacks'' of healthcare. By coordinating patients' care, managing their chronic diseases, and providing other preventive care, primary care doctors are able to help patients stay healthy and out of the emergency room.

Adam Boehler, who leads the Center for Medicare and Medicaid Innovation, told me that while primary care accounts for only 3 to 7 percent of healthcare spending, it can affect as much as half of all healthcare spending.

One recommendation we received came from Dr. Gilliam, a primary care doctor in West Tennessee who runs a direct primary care practice--the same type of practice I mentioned earlier that Dr. Gross runs. Dr. Gilliam said: ``[Direct primary care] is the only model that is able to offer affordable healthcare with complete price transparency.''

One suggestion we have heard is to change Internal Revenue Service rules that block Americans from using their health savings accounts to pay for the monthly direct primary care fee.

Then there is drug pricing. Many recommendations are focused on reducing what we spend on prescription drugs, which is about 17 percent of all healthcare spending.

One way is reforming prescription drug rebates, the discounts that pharmacy benefit managers negotiate with pharmaceutical companies. The Trump administration has proposed a new rule for the $29 billion rebates on prescription drugs that the government pays for through Medicare Part D. One recommendation is to expand that to the estimated $40 billion of rebates negotiated in the private market.

Another way to lower drug prices is to increase competition through generic drugs, which can be up to 85 percent less expensive than brand drugs when there are multiple approved generics. I have heard concerns about brand drug companies not providing generic companies the samples needed to make generic drugs and other ways that brands delay drug competition.

It was recommended that we increase competition for the generic versions of biologic drugs, which are called biosimilars. One way to do that may be with a bill Senator Collins introduced to ensure that biosimilar manufacturers have access to the information they need to develop and bring to market more biosimilars.

Then there is surprise billing.

AEI and Brookings also recommended we focus on helping to eliminate surprise medical billing, which is what happened when Todd, of Knoxville, took his son to the emergency room. AEI and Brookings said the issue is not that insurance companies have limited doctors and hospitals in their networks but that emergency departments and ancillary physicians, as well as hospitalists and ambulance companies, have a lucrative out-of-network billing arrangement that is unavailable to other providers, which encourages doctors to go out of network and send patients high bills. Senator Cassidy and Senator Hassan are leading the way to help eliminate surprise billing.

We received comments about the importance of the seamless exchange of information between electronic health records, which includes stopping information blocking.

A goal of the 21st Century Cures Act, which is a bipartisan bill that Senator McConnell said was the most important bill that Congress, was to make it easier for patients to access their health records and for doctors and hospitals to get the information they need to treat patients. Last month, the Department of Health and Human Services released two proposed rules required by the Cures Act to lead to better coordinated care and to less unnecessary health care. We held a hearing on those last week. We heard a story of the better experiences and outcomes that can happen when health records are interoperable. Finally, there is the consolidation of healthcare.

We received comments on the decreasing choices and competition in the healthcare system, which is when hospitals merge with doctors' offices or other hospitals, when insurers merge with other insurers, or when hospitals and insurers merge so that these hospitals or insurers have even more control over the market.

Some argue that the consolidation in healthcare can benefit patients and lower costs. Others say that it gives patients fewer options and that healthcare prices increase.

AEI and Brookings suggested that one way to address the potential negative consequences of consolidation would be to improve oversight of the 340B drug discount program, which has been found to incentivize hospitals to purchase physician practices or to employ physicians directly in order to bring in additional revenue from the 340B discounts. This echoes what we heard at our committee's three hearings.

I am also asking for other Senators to continue to come forward to Senator Murray, to Senator Wyden, to Senator Grassley, and to me with their specific proposals as to how we can reduce healthcare costs. What I hope to do is to compile the proposals that fall under the jurisdiction of our Senate HELP Committee into a package of legislation that the committee will vote on early in the summer. We could then combine that with whatever the Senate Finance Committee passes and ask the leader to put it on the Senate floor and work with the House to send legislation to the President's desk.

This morning, in a hearing before the Appropriations Committee, Secretary Azar reiterated his support and the President's support for this bipartisan process to reduce health care costs.

My staff and I will continue to review recommendations and work with other Members to incorporate ways so that Americans like Sherry, Todd, Shirley, and Michael will have better outcomes and better experiences at lower costs.

I yield the floor.

Madam President, the distinguished Senator from Washington and I often agree on issues, and for the most part we agree on this. We agree that equal pay for equal work is the right thing to do. What I would add is that equal pay for equal work is already the law.

Paycheck discrimination on the basis of gender is wrong. It is already illegal in the United States. Congress prohibited discrimination based on gender in the Equal Pay Act of 1963 and Title VII of the Civil Rights Act of 1964.

The Equal Pay Act is very clear: ``No employer . . . shall discriminate . . . between employees on the basis of sex by paying wages to employees . . . less than . . . he pays . . . employees of the opposite sex . . . for equal work . . . which requires equal skill, effort, and responsibility, and which are performed under similar working conditions. . . . ''

Equal pay for equal work. That already is the law; therefore, it is unnecessary to have yet another law saying basically the same thing. I object.

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

Mr. President, my Democratic friends from the other side of the aisle often come to me and ask me to cosponsor bills so they will be bipartisan, making it more likely we will get a result. Sometimes they come to me on a difficult issue, and they ask me, in their words, ``to rise above politics'' and support the institution and the Constitution, and often I do that. I think my reputation for that here is pretty secure.

So I have an offer, an invitation I made earlier to my Democratic friends to invite them to join me in rising above politics--it will be a harder vote for them than it will be for me--and help us change the Senate rules in the correct way to restore the Presidential nomination process to the stature that it deserves and work together to try to achieve what we did in 2011, 2012, and 2013.

On March 14, the Democratic leader came to the floor, and he said the following words:

There are times when loyalty to America, to our

Constitution, to our principles, and to what has made this

country great should lead Members to rise above and rise to

the occasion.

He was talking about the vote on the national emergency declaration President Trump made.

The Democratic leader continued:

I hope and I pray that this moment is one of those times

when Members choose country over party and when Members rise

above politics for the sake of fidelity to our constitutional

principles and this great United States of America.

That was the Democratic leader, the Senator from New York.

The next day, 12 of us did just that. We voted for the resolution to overturn the declaration of emergency, or, as I have explained to many of my constituents who have said something to me about it, I voted for the Constitution.

A month or so earlier, we were encouraged by the Democratic leader and our friends on the other side to vote to open the government. It was the same sort of speech, the same opportunity to rise above politics. Six of us did--six of us on this side of the aisle.

In 2011, 2012, and 2013, when Barack Obama was President and Harry Reid was the leader of the Democratic majority in the Senate, it occurred to me and others that the Presidential nominating process was in shambles. It was embarrassing to ask distinguished Americans to be nominated for a position and then say ``You are innocent until you are nominated'' or drag

things out for a long period of time. It was a bad process.

The President of the United States has 1,200 nominations to make to Federal appointees--1,200 today, but then, it was more like 1,400. One of the most important and perhaps the best known function of the Senate is advice and consent. Our advice and consent to the Presidential nominations is a crucial part of the checks and balances in our constitutional system that was established to keep one part of our government from having too much power. In other words, if the President wants somebody and we don't, that is it. If he does and we confirm, then that person knows us, knows this body, and knows about article I, and when he or she wants money for their Department, they have to come to the Congress elected by the people. That is the Presidential nominating process. That is why it is so important to the Senate and to the people of this country.

So in 2011, 2012, and 2013, Senators Reid, McConnell, Schumer, Barrasso, Levin, McCain, Kyl, Cardin, Collins, Lieberman, and I all, along with some others, worked to change the Senate rules to make it easier for President Obama and his successors to gain confirmation of Presidential nominees. As a Republican Senator during a Democratic administration, I spent dozens of hours on that project to make it easier for that Democratic President, with a Senate majority that was Democratic, to form a government.

We changed the rules the right way. In other words, we followed the rules, and the Senate passed standing orders, with large, bipartisan margins, to do a number of things. We ended secret holds. We removed 163 major positions from the necessity of advice and consent. We removed 3,163 minor positions from advice and consent. We created 272 positions that are Presidential nominations and made them privileged so they could come to the floor and then go on to be voted on if no one objected or required them to go to committee. We made it easier to bring legislation to the floor. We made it easier to go to conference. We simplified the forms you have to fill out if you are a nominee. We did all that in a bipartisan way.

One more thing: By a vote of 78 votes, we decided we would reduce the postcloture debate time for sub-Cabinet members to 8 hours and for district judges to 2 hours. As a practical matter, that means if the majority leader brings up a sub-Cabinet member on Monday, we have to wait an intervening day--that is Tuesday--and then we vote on cutting off debate on Wednesday. And how many more hours do we need to debate it? Then it was 30. Today it is 30. We said: Then let's make it 8 for sub-Cabinet members and 2 for district judges. That expired at the end of President Obama's time because we made it for just one Congress, but that is what we did.

I might add, Republicans did not insist that these new rules should be delayed until after the next Presidential election, when there might be a Republican President. You might say we rose above politics.

I might also add that today some people say: Well, they don't want to vote for anything that might seem to support President Trump because he is not popular in the Democratic primary. I can tell you that in 2013, President Obama was not all that popular in the Republican primary in Tennessee or in any other of the primaries, but we thought it was more important to defend this institution and preserve its traditional and constitutional role of advice and consent.

So, on February 25 of this year, I came to the floor and, in effect, invited my colleagues on the other side of the aisle to rise above politics--the same thing they often say to me. I invited them to work with me, Senator Lankford, and Senator Blunt to speed up the confirmation of Presidential nominees, to rise above partisanship and to rise above politics for the benefit of the institution. It was a pretty easy ask, I might say, because I am basically inviting them to do what 78 of us agreed to do in 2013, which is to reduce the amount of postcloture debate time for sub-Cabinet members and district judges.

I don't think rising above politics ought to be a one-way street. At a time when many complained that the Executive has too much power, the Senate is deliberately weakening itself when we undermine our advice and consent role. What is the result of that?

Well, it diminishes our constitutional role to advise and consent because what happens in the executive branch is it just is loaded up with acting appointees who have never had to go through our confirmation process.

President Trump is probably pretty happy with that. He could just put an acting person in a particular position. That person doesn't have to go through the process and doesn't have to answer a lot of questions. He or she is just there and immediately there. Such as John Ryder, the TVA board member from my State, who doesn't have to answer a lot of questions or such as two district judges from my State--excellent individuals--who waited 10 months to be confirmed or such as the U.S. marshal for the Middle District of Tennessee, who had already been the U.S. marshal before, who had to wait more than 1 year. There was none of that. Just put in an acting person and run the government without regard to the Senate.

As the Democratic leader said to me 2 weeks ago and 6 weeks ago, I would ask him and others to rise above politics for the benefit of this institution and change the rules the right way to speed up the confirmation process.

The Senate Rules Committee gave us the right way. They adopted a resolution in the regular order. Basically, it is the same resolution, with a few differences, that we passed with 78 votes in 2013.

In my February 25 speech, I said to my friends on the other side: If you don't like it in exactly the form it is, please suggest something reasonable back. That is the way we do things. Let's amend it. Let's do it exactly the way we did it before in 2013.

I have been encouraged by some discussion by some Members on the other side of the aisle but nothing certain. The proposal offered by Senator Blunt and Senator Lankford would not reduce the number of hours we debate Supreme Court Justices, wouldn't reduce the number of hours we debate Cabinet members or certain Board nominations, but it would divide the 30 hours of postcloture debate equally between Republicans and Democrats. Basically, it would put the Senate back in the place where the Senate has always been throughout the history of the Senate.

Nominations have been decided by 51 votes--not 60 or 67 but by 51-- and they have been decided reasonably promptly. Sometimes they were defeated, but they were decided. The Blunt-Lankford resolution would do just that. Nominations would be decided by 51 votes, and they could be decided reasonably promptly so we would not be diminishing the advice and consent role of the Senate.

Everyone in this body knows what the problem is. One hundred and twenty-eight times the majority leader has had to file a motion to cut off debate--we call that cloture--in order to advance a nomination. Let's say it is for a Tennessee Valley Authority part-time board member. So he will file the motion on Monday. We don't do anything on Tuesday. Nothing would change with that. We vote on cloture on Wednesday--that is 51 votes--and then we have 30 hours of debate. Now it is Thursday. So we could take a whole week dealing with a part-time TVA board member. That has been done 128 times. That was almost never done for previous Presidents.

We are faced with a truly miserable choice. We know this has to change. Our friends on the other side know it has to change. They know if they have a Democratic President in 18 or 20 months, there will be at least one Republican Senator who will do to them what they are doing to President Trump. The Democratic President will not be able to form a government, and so we will further diminish the Senate in its role. So we have a truly miserable choice: either we continue to diminish the constitutional advice and consent role of the Senate--we could do that--or we use what we call the Harry Reid precedent to change the rules of the Senate by a majority vote.

The problem with the Harry Reid precedent is, it doesn't really change the rules. It just says the rules don't mean what they say. It is as if the referee said: Well, the rule book says first down is 10 yards, but I am going to rule that it is 9. It is a Senate precedent, and the majority may do it, but we should avoid that if we possibly can.

I don't like the Harry Reid precedent. I believe it presents a truly miserable option, but even more miserable is continuing this debasement of the advice and consent role of the Senate--one I worked to do more about in 2011, 2012, and 2013 with the distinguished Democratic leader, the Republican leader, and so many Senators.

As my friend the Democratic leader, who I see has now come to the floor, said to me and other Republicans 2 weeks ago: ``I understand the politics are difficult--much harder for you than for me--but our nation, our Constitution, the beauty of this government, demands that we rise to the occasion.'' Well, on the declaration of the national emergency on that occasion, 12 of us did; and on reopening the government a few weeks earlier, 6 of us did; and in 2011, 2012, and 2013, 78 of us voted to reduce the postcloture time for sub-Cabinet nominees.

I know it can be a difficult vote in the Democratic caucus, but I earnestly hope that between now and the time we vote this week, that we will not be presented with this truly miserable choice of continuing to debase the advice and consent tradition of the Senate or using the Harry Reid precedent to change the Senate rules by majority vote.

If some of us can rise above partisanship on article I to vote against the declaration of emergency, to vote to reopen the government, and to remove the delay in Presidential nominees when there is a Democratic President and a Democratic leader of the Senate, it is my hope that some of my Democratic friends will agree to do that this week and help us avoid what I have described as a truly miserable choice.

I thank the Presiding Officer.

I yield the floor.

Recognition of the Minority Leader