diff --git "a/data/CHRG-116/CHRG-116hhrg35377.txt" "b/data/CHRG-116/CHRG-116hhrg35377.txt"
new file mode 100644--- /dev/null
+++ "b/data/CHRG-116/CHRG-116hhrg35377.txt"
@@ -0,0 +1,3679 @@
+
+ - TEXAS v. U.S.: THE REPUBLICAN LAWSUIT AND ITS IMPACTS ON AMERICANS WITH PREEXISTING CONDITIONS
+
+[House Hearing, 116 Congress]
+[From the U.S. Government Publishing Office]
+
+
+TEXAS v. U.S.: THE REPUBLICAN LAWSUIT AND ITS IMPACTS ON AMERICANS
+ WITH PREEXISTING CONDITIONS
+
+=======================================================================
+
+ HEARING
+
+ BEFORE THE
+
+ SUBCOMMITTEE ON HEALTH
+
+ OF THE
+
+ COMMITTEE ON ENERGY AND COMMERCE
+ HOUSE OF REPRESENTATIVES
+
+ ONE HUNDRED SIXTEENTH CONGRESS
+
+ FIRST SESSION
+ __________
+
+ FEBRUARY 6, 2019
+ __________
+
+ Serial No. 116-2
+
+ [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
+
+ Printed for the use of the Committee on Energy and Commerce
+
+ govinfo.gov/committee/house-energy
+ energycommerce.house.gov
+
+ ___________
+
+ U.S. GOVERNMENT PUBLISHING OFFICE
+
+35-377 PDF WASHINGTON : 2019
+
+
+
+ COMMITTEE ON ENERGY AND COMMERCE
+
+ FRANK PALLONE, Jr., New Jersey
+ Chairman
+BOBBY L. RUSH, Illinois GREG WALDEN, Oregon
+ANNA G. ESHOO, California Ranking Member
+ELIOT L. ENGEL, New York FRED UPTON, Michigan
+DIANA DeGETTE, Colorado JOHN SHIMKUS, Illinois
+MIKE DOYLE, Pennsylvania MICHAEL C. BURGESS, Texas
+JAN SCHAKOWSKY, Illinois STEVE SCALISE, Louisiana
+G. K. BUTTERFIELD, North Carolina ROBERT E. LATTA, Ohio
+DORIS O. MATSUI, California CATHY McMORRIS RODGERS, Washington
+KATHY CASTOR, Florida BRETT GUTHRIE, Kentucky
+JOHN P. SARBANES, Maryland PETE OLSON, Texas
+JERRY McNERNEY, California DAVID B. McKINLEY, West Virginia
+PETER WELCH, Vermont ADAM KINZINGER, Illinois
+BEN RAY LUJAN, New Mexico H. MORGAN GRIFFITH, Virginia
+PAUL TONKO, New York GUS M. BILIRAKIS, Florida
+YVETTE D. CLARKE, New York, Vice BILL JOHNSON, Ohio
+ Chair BILLY LONG, Missouri
+DAVID LOEBSACK, Iowa LARRY BUCSHON, Indiana
+KURT SCHRADER, Oregon BILL FLORES, Texas
+JOSEPH P. KENNEDY III, SUSAN W. BROOKS, Indiana
+ Massachusetts MARKWAYNE MULLIN, Oklahoma
+TONY CARDENAS, California RICHARD HUDSON, North Carolina
+RAUL RUIZ, California TIM WALBERG, Michigan
+SCOTT H. PETERS, California EARL L. ``BUDDY'' CARTER, Georgia
+DEBBIE DINGELL, Michigan JEFF DUNCAN, South Carolina
+MARC A. VEASEY, Texas GREG GIANFORTE, Montana
+ANN M. KUSTER, New Hampshire
+ROBIN L. KELLY, Illinois
+NANETTE DIAZ BARRAGAN, California
+A. DONALD McEACHIN, Virginia
+LISA BLUNT ROCHESTER, Delaware
+DARREN SOTO, Florida
+TOM O'HALLERAN, Arizona
+ ------
+
+ Professional Staff
+
+ JEFFREY C. CARROLL, Staff Director
+ TIFFANY GUARASCIO, Deputy Staff Director
+ MIKE BLOOMQUIST, Minority Staff Director
+ Subcommittee on Health
+
+ ANNA G. ESHOO, California
+ Chairwoman
+ELIOT L. ENGEL, New York MICHAEL C. BURGESS, Texas
+G. K. BUTTERFIELD, North Carolina, Ranking Member
+ Vice Chair FRED UPTON, Michigan
+DORIS O. MATSUI, California JOHN SHIMKUS, Illinois
+KATHY CASTOR, Florida BRETT GUTHRIE, Kentucky
+JOHN P. SARBANES, Maryland H. MORGAN GRIFFITH, Virginia
+BEN RAY LUJAN, New Mexico GUS M. BILIRAKIS, Florida
+KURT SCHRADER, Oregon BILLY LONG, Missouri
+JOSEPH P. KENNEDY III, LARRY BUCSHON, Indiana
+ Massachusetts SUSAN W. BROOKS, Indiana
+TONY CARDENAS, California MARKWAYNE MULLIN, Oklahoma
+PETER WELCH, Vermont RICHARD HUDSON, North Carolina
+RAUL RUIZ, California EARL L. ``BUDDY'' CARTER, Georgia
+DEBBIE DINGELL, Michigan GREG GIANFORTE, Montana
+ANN M. KUSTER, New Hampshire GREG WALDEN, Oregon (ex officio)
+ROBIN L. KELLY, Illinois
+NANETTE DIAZ BARRAGAN, California
+LISA BLUNT ROCHESTER, Delaware
+BOBBY L. RUSH, Illinois
+FRANK PALLONE, Jr., New Jersey (ex
+ officio)
+
+
+ C O N T E N T S
+
+ ----------
+ Page
+Hon. Anna G. Eshoo, a Representative in Congress from the State
+ of California, opening statement............................... 1
+ Prepared statement........................................... 3
+Hon. Michael C. Burgess, a Representative in Congress from the
+ State of Texas, opening statement.............................. 4
+ Prepared statement........................................... 6
+Hon. Frank Pallone, Jr., a Representative in Congress from the
+ State of New Jersey, opening statement......................... 8
+Hon. Greg Walden, a Representative in Congress from the State of
+ Oregon, opening statement...................................... 10
+ Prepared statement........................................... 12
+
+ Witnesses
+
+Christen Linke Young, Fellow, USC-Brookings Schaeffer Initiative
+ for Health Policy.............................................. 14
+ Prepared statement........................................... 17
+ Answers to submitted questions............................... 156
+Avik S. A. Roy, President, Foundation for Research on Equal
+ Opportunity.................................................... 22
+ Prepared statement........................................... 24
+Elena Hung, Cofounder, Little Lobbyists.......................... 32
+ Prepared statement........................................... 34
+ Answers to submitted questions............................... 161
+Thomas P. Miller, Resident Fellow in Health Policy Studies,
+ American Enterprise Institute.................................. 48
+ Prepared statement........................................... 50
+ Answers to submitted questions............................... 163
+Simon Lazarus, constitutional lawyer and writer.................. 70
+ Prepared statement........................................... 72
+
+ Submitted Material
+
+Letter of January 9, 2019, from Ms. Castor, et al., to Hon. Ron
+ DeSantis, Governor, State of Florida, submitted by Ms. Castor.. 116
+Letter of January 13, 2018, from Hon. Bill Nelson, a United
+ States Senator from the State of Florida, et al., to Hon. Rick
+ Scott, Governor, State of Florida, submitted by Ms. Castor..... 121
+Letter of January 26, 2017, from Mr. O'Halleran, et al., to Hon.
+ Paul D. Ryan, Speaker of the House, and Hon. Mitch McConnell,
+ Majority Leader, United States Senate, submitted by Mr.
+ O'Halleran..................................................... 124
+Letter of April 23, 2018, from American Cancer Society Cancer
+ Action Network, et al., to Hon. Alex Azar, Secretary,
+ Department of Health and Human Services, et al., submitted by
+ Ms. Eshoo...................................................... 128
+Letter of February 6, 2019, from Michael L. Munger, M.D., Board
+ Chair, American Academy of Family Physicians, to Ms. Eshoo and
+ Mr. Burgess, submitted by Ms. Eshoo............................ 139
+Statement of the American College of Physicians, February 6,
+ 2019, submitted by Ms. Eshoo................................... 141
+Editorial of December 16, 2018, ``Texas ObamaCare Blunder,'' The
+ Wall Street Journal, submitted by Ms. Eshoo.................... 146
+Article of December 15, 2018, ``What the Lawless Obamacare Ruling
+ Means,'' by Jonathan H. Adler and Abbe R. Gluck, The New York
+ Times, submitted by Ms. Eshoo.................................. 149
+Amici Brief of June 14, 2018, American Medical Association, et
+ al., Civil Action No.:4:18-cv-00167-O, submitted by Ms. Eshoo
+ \1\
+Amici Brief of June 15, 2018, Families USA, et al., No. 4:18-cv-
+ 00167-O, submitted by Ms. Eshoo \1\
+Amici Brief of June 14, 2018, American Cancer Society Cancer
+ Action Network, et al., Case No. 4:18-cv-00167-O, submitted by
+ Ms. Eshoo \1\
+Amici Brief of June 15, 2018, AARP Foundation, Civil Action
+ No.:4:18-cv-00167-O, submitted by Ms. Eshoo \1\
+Letter of February 5, 2019, from Mr. Walden and Mr. Burgess to
+ Mr. Pallone and Ms. Eshoo, submitted by Mr. Burgess............ 153
+
+----------
+
+\1\ The information has been retained in committee files and also is
+available at https://docs.house.gov/Committee/Calendar/
+ByEvent.aspx?EventID=108843.
+
+
+
+
+TEXAS v. U.S.: THE REPUBLICAN LAWSUIT AND ITS IMPACTS ON AMERICANS WITH
+ PREEXISTING CONDITIONS
+
+ ----------
+
+
+ WEDNESDAY, FEBRUARY 6, 2019
+
+ House of Representatives,
+ Subcommittee on Health,
+ Committee on Energy and Commerce,
+ Washington, DC.
+ The subcommittee met, pursuant to call, at 10:16 a.m., in
+room 2322, Rayburn House Office Building, Hon. Anna G. Eshoo
+(chairwoman of the subcommittee) presiding.
+ Members present: Representatives Eshoo, Butterfield,
+Matsui, Castor, Lujan, Cardenas, Schrader, Ruiz, Kuster, Kelly,
+Barragan, Blunt Rochester, Rush, Pallone (ex officio), Burgess
+(subcommittee ranking member), Upton, Guthrie, Griffith,
+Bilirakis, Bucshon, Brooks, Mullin, Hudson, Carter, Gianforte,
+and Walden (ex officio).
+ Also present: Representatives Veasey and O'Halleran.
+ Staff present: Jeffrey C. Carroll, Staff Director;
+Elizabeth Ertel, Office Manager; Waverly Gordon, Deputy Chief
+Counsel; Zach Kahan, Outreach and Member Service Coordinator;
+Saha Khatezai, Professional Staff Member; Una Lee, Senior
+Health Counsel; Kaitlyn Peel, Digital Director; Tim Robinson,
+Chief Counsel; Samantha Satchell, Professional Staff Member;
+Andrew Souvall, Director of Communications, Outreach, and
+Member Services; C. J. Young, Press Secretary; Adam Buckalew,
+Minority Director of Coalitions and Deputy Chief Counsel,
+Health; Margaret Tucker Fogarty, Minority Staff Assistant;
+Caleb Graff, Minority Professional Staff Member, Health; Peter
+Kielty, Minority General Counsel; Ryan Long, Minority Deputy
+Staff Director; J. P. Paluskiewicz, Minority Chief Counsel,
+Health; Kristen Shatynski, Minority Professional Staff Member,
+Health; Danielle Steele, Minority Counsel, Health.
+
+ OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN
+ CONGRESS FROM THE STATE OF CALIFORNIA
+
+ Ms. Eshoo. The Subcommittee on Health will now come to
+order. The Chair recognizes herself for 5 minutes for an
+opening statement, and the first thing that I would like to say
+is, ``Welcome.''
+ Welcome back the 116th Congress under the new majority, and
+I want to thank my Democratic colleagues for supporting me to
+do this work, to chair the subcommittee.
+ It is an enormous honor and it is--what is contained in the
+committee, of course, are some of the most important issues
+that the American people expressed at the polls in the midterm
+elections.
+ To our Republican colleagues, I know that there are areas
+where we can really work together. In some areas, we are going
+to have to stretch. But know that I look forward to working
+with all of you, and to those that are new members of the
+subcommittee, welcome to each one of you.
+ I know that you are going to bring great ideas and really
+be instructive to the rest of us, so welcome to you.
+ As I said, healthcare was the single most important issue
+to voters in the midterm elections, and it is a rarity that
+there would be one issue that would be the top issue in every
+single congressional district across the country. So this
+subcommittee is front and center.
+ We are beginning the Health Subcommittee's work by
+discussing the Texas v. United States lawsuit and its
+implications for the entire healthcare system, both public and
+private.
+ For over a hundred years, presidents, including Teddy
+Roosevelt, Harry Truman, Richard Nixon, and others attempted to
+reform our Nation's health insurance system and provide access
+to affordable health insurance for all Americans.
+ In 2010, through the efforts that began in this committee,
+the Affordable Care Act was signed into law and bold reforms to
+our public and private insurance programs were made.
+ Since the Affordable Care Act was signed into law, over 20
+million Americans have gained health insurance that is required
+to cover preexisting conditions. The law disallows charging
+sick consumers more, it allows children to stay on their
+parents' health insurance policy to the age of 26, and provides
+coverage for preventive health services with no cost sharing.
+ Last February, 20 attorneys general and Governors sued the
+Federal Government to challenge the constitutionality of that
+law. They claimed that, after the individual mandate was
+repealed by the Republicans' tax plan, the rest of the
+Affordable Care Act had to go, too.
+ The Trump administration's Department of Justice has
+refused to defend the Affordable Care Act in court and in
+December Judge Reed O'Connor of the Northern District of Texas
+declared the entire ACA invalid.
+ Twenty attorneys general, led by the attorney general from
+California, our former colleague, Xavier Becerra, have appealed
+Judge O'Connor's ruling.
+ For those enrolled in the Affordable Care Act, if the
+Republican lawsuit is successful, the 13 million Americans who
+gained health insurance through the Medicaid expansion will
+lose their health insurance.
+ The 9 million Americans who rely on tax credits to help
+them afford the insurance plan will no longer be able to afford
+their insurance and health insurance costs will skyrocket
+across the country when healthy people leave the marketplace
+for what I call junk insurance plans that won't cover them when
+they get sick--another implication leaving the sick and the
+most expensive patients in the individual market, driving up
+premiums for so many.
+ The insurance reforms of the ACA protect every American,
+including those who get their health insurance through their
+employer. Every insurance plan today is required to cover 10
+basic essential health benefits.
+ No longer are there lifetime limits. The 130 million
+patients with preexisting conditions cannot be denied coverage
+or charged more, and women can no longer be charged more
+because they are females.
+ [The prepared statement of Ms. Eshoo follows:]
+
+ Prepared statement of Hon. Anna G. Eshoo
+
+ Welcome to the first Health Subcommittee hearing of the
+116th Congress, under a Democratic majority, and welcome to the
+new members of the Health Subcommittee.
+ Healthcare was the single most important issue to voters in
+the 2018 election. It is a rarity for one issue to be so
+important in every Congressional District in the country.
+ We're beginning the Health Subcommittee's work by
+discussing the disastrous Texas v. United States lawsuit and
+its implications for the entire healthcare system, both public
+and private.
+ For over 100 years, presidents including Teddy Roosevelt,
+Harry Truman, and Richard Nixon attempted to reform our
+Nation's health insurance system and provide access to
+affordable health insurance for all Americans.
+ In 2010, through efforts that began in this committee, the
+Affordable Care Act was signed into law and bold reforms to our
+public and private insurance programs were implemented.
+ Since the Affordable Care Act was signed into law over 20
+million Americans have gained health insurance that is required
+to cover preexisting conditions; disallows charging sick
+consumers more; allows children to stay on their parent's
+health insurance until the age of 26 and provides coverage for
+preventive health services with no cost sharing.
+ Last February, 20 attorneys general and Governors sued the
+Federal Government to challenge the constitutionality of that
+law. They claimed that after the individual mandate was
+repealed by the Republican's tax plan, the rest of the
+Affordable Care Act had to go, too.
+ The Trump administration's Department of Justice refused to
+defend the Affordable Care Act in court and in December, Judge
+Reed O'Connor of the Northern District of Texas declared the
+entire ACA invalid. 20 attorneys general, led by California's
+Xavier Beccera, have appealed Judge O'Connor's ruling.
+ For those enrolled in the Affordable Care Act, if the
+Republican lawsuit is successful, the 13 million Americans who
+gained health insurance through the Medicaid expansion will
+lose their health insurance; the 9 million Americans who rely
+on tax credits to help them afford their insurance plan will no
+longer be able to afford their insurance; and health insurance
+costs will sky rocket across the country when healthy people
+leave the marketplace for junk insurance plans that won't cover
+them when they get sick, leaving the sick and most expensive
+patients in the individual market, driving up premiums.
+ The insurance reforms of the ACA protect every American,
+even those who get their health insurance through their
+employer. Every insurance plan today is required to cover ten
+basic Essential Health Benefits; there are no longer lifetime
+limits; the 130 million patients with preexisting conditions
+cannot be denied coverage or charged more; and women can no
+longer be charged more because they are females.
+ Judge O'Connor's ruling in Texas v. United States declared
+the Affordable Care Act invalid in its entirety, threatening
+every one of the gains I just described. It is now up to the
+Democratic House to protect, defend and strengthen the ACA.
+ Even if legislation to require insurance companies to cover
+these patients' preexisting conditions is passed, insurers
+could charge anything they want to cover these services if the
+ACA is overturned.
+ On the very first day of this Congress, House Democrats
+voted to intervene in the Texas v. United States case as it
+moves through appeal. The House of Representatives will now
+represent the Government in this case to defend and uphold the
+ACA, because this administration refused to do so.
+ In the majority's work to defend and strengthen the ACA,
+this subcommittee will explore how the Trump administration's
+junk insurance plans are affecting the individual insurance
+market and harming people with preexisting conditions.
+ These plans aren't required to cover the same Essential
+Health Benefits as ACA-compliant plans and patients don't know
+that their health insurance won't pay for their treatments
+until they've gotten sick and it's too late.
+ Next week, our subcommittee will explore specific
+legislation to reverse the Trump administration's actions to
+expand junk plans. We're also going to discuss legislation that
+would restore outreach and enrollment funding that has been
+slashed by the Trump administration so that we can ensure
+healthcare is more affordable and assessible. And we will also
+discuss legislation that would reverse the Trump
+administration's guidance on 1332 waivers that would allow
+States to undermine the ACA's protections for preexisting
+conditions and could harm people's access to care.
+ We will work to reverse the harmful policies that have made
+healthcare more expensive for individuals who rely on the ACA
+and deliver on our promises to the American people to lower
+healthcare and prescription drug costs.
+ Welcome to our witnesses, and I look forward to your
+testimony.
+
+ Ms. Eshoo. I am going to stop here, and I am going to yield
+the rest of my time to Mr. Butterfield.
+ Mr. Butterfield. Thank you, Chairwoman Eshoo, for holding
+this very important hearing on the absolute importance of the
+Affordable Care Act and thank you for giving us an opportunity
+to expose the poorly written Texas case.
+ I want to talk a few seconds about sickle cell disease.
+More than one out of every 370 African Americans born with
+sickle cell disease and more than 100,000 Americans have this
+disease, including many in my State.
+ The disease creates intense pain, that patients usually
+must be hospitalized to receive their care. Without preexisting
+condition protections, tens of thousands of Americans with
+sickle cell could be charged more for insurance, they could be
+dropped from their plans and be prevented from enrolling in
+insurance plans altogether.
+ Republicans have tried and tried and tried to repeal the
+ACA more than 70 times. We, in this majority, have been sent
+here to protect the Affordable Care Act.
+ Thank you for the time. I yield back.
+ Ms. Eshoo. I thank the gentleman.
+ Next week--I just want to announce this--our subcommittee
+is going to explore specific legislation to reverse the
+administration's actions to expand the skinny plans--the junk
+insurance plans--and we are also going to discuss legislation
+that would restore outreach in enrollment funding that has been
+slashed by the administration, so we can ensure that healthcare
+is more affordable and accessible for all Americans.
+ We want to thank the witnesses that are here today. Welcome
+to you. We look forward to hearing your testimony. And now I
+would like to recognize Dr. Burgess, the ranking member of the
+Subcommittee on Health, for 5 minutes for his opening
+statement.
+
+OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
+ IN CONGRESS FROM THE STATE OF TEXAS
+
+ Mr. Burgess. Thank you, Chairwoman Eshoo.
+ Let me just take a moment to congratulate you. As you are
+quickly finding out, you now occupy the most important
+subcommittee chair in the entire United States House of
+Representatives, and I know this from firsthand experience.
+ We were the most active subcommittee in the United States
+House of Representatives in the last Congress. Hundreds of
+hours in hearings on health policy, and certainly look forward
+to that continuing through this term as well.
+ I want to thank our witnesses all for joining us this
+morning. We are here to discuss the issue of protecting access
+to healthcare for individuals with preexisting medical
+conditions in addition to the Texas v. Azar case.
+ So I think you heard the president say this last night in
+the State of the Union Address. There is broad bipartisan
+support for providing protections for patients with preexisting
+conditions.
+ I am glad we are holding our first hearing of the year. It
+is the end of the first week of February. So it is high time
+that we do this. It is unfortunate we are having a hearing that
+actually doesn't move toward the development of any policies
+that actually would improve healthcare for Americans.
+ To that effect, there are numerous options that you could
+bring before us that could moot the Texas v. Azar case. But the
+subcommittee apparently has chosen not to do so. For example,
+the bill to repeal the individual mandate is one that I have
+introduced previously.
+ You can join me on that effort, and if the individual
+mandate were repealed the case would probably not exist.
+ You could reestablish the tax in the individual mandate,
+which would certainly be your right to do so and, again, that
+would remove most of the argument for the court case as it
+exists today.
+ You know, I hear from constituents in north Texas concerned
+about not having access to affordable healthcare. In the
+district that I represent, because of the phenomenon known as
+silver loading, as the benchmark silver plans' premiums
+continue to increase, well, if you are getting a subsidy--what,
+me worry? No problem--I got a subsidy so I am doing OK.
+ But in the district that I represent, a schoolteacher and a
+policeman couple with two children are going to be covered in
+the individual market, and they are going to be outside the
+subsidy window.
+ So they buy a bronze plan because, like everybody, they buy
+on price, so that is the least expensive thing that is
+available to them, and then they are scared to death that they
+will have to use it because the deductible is so high.
+ If you get a kidney stone in the middle of the night and,
+guess what, that $4,500 emergency room bill is all yours. So I
+take meetings with families who are suffering from high
+healthcare and prescription drugs costs, and unfortunately we
+are not doing anything to address that today.
+ We could be using this time to discuss something upon--to
+develop policies to help those individuals and families. But,
+again, we are discussing something upon which we all agreed,
+but we are taking no substantive action to address.
+ Look, if you believe in Medicare for All, if you believe in
+a single-payer, Government-run, one-size-fits-all health
+system, let us have a hearing right here in this subcommittee.
+We are the authorizing committee. That is our job.
+ Instead, we have the House Budget Committee holding those
+hearings, and Democrats on that committee are introducing
+legislation. But these bills belong in the jurisdiction of the
+Energy and Commerce Committee, and yet we have not scheduled a
+hearing to discuss this agenda.
+ Do I agree with the policy or think it would be a good idea
+for the American people to have Medicare for All or one-size-
+fits-all health plans? No, I do not, and I would gladly engage
+in a meaningful dialogue about what such a policy would mean
+for the American people.
+ Single-payer healthcare would be another failed attempt at
+a one-size-fits-all approach. Americans are all different, and
+a universal healthcare plan that does not meet the varying
+needs of each and every individual at different stages of their
+life will probably not be successful.
+ Today, we should be focusing on the parts of the health
+insurance market that are working for Americans. Seventy-one
+percent of Americans are satisfied with employer-sponsored
+health insurance, which provides robust protections for
+individuals with preexisting conditions.
+ Quite simply, the success of employer-sponsored insurance
+markets--it is not worth wiping that out with the single-payer
+healthcare policy. Yet, the bill that was introduced last term,
+that is exactly what it did.
+ But today, there are a greater percentage of Americans in
+employer health coverage than at any time since the year 2000.
+ Since President Trump took office, the number of Americans
+in employer health coverage has increased by over 2\1/2\
+million. Given that the United States economy added more than
+300,000 jobs in January, the number of individuals and families
+covered by employer-sponsored plans is likely even greater
+still.
+ Instead of building upon the success of our existing health
+insurance framework, radical single-payer, Government-run
+Medicare would tear it down. It would eliminate the employer-
+sponsored health insurance, private health insurance, Indian
+health insurance, and make inroads against taking away the VA.
+ Again, I appreciate that we have organized and we are
+holding our first hearing. I believe we could be using our time
+much more productively. There is bipartisan support for
+protecting patients with preexisting conditions. I certainly
+look forward to hearing the testimony of our witnesses.
+ Thank you, I yield back.
+ [The prepared statement of Mr. Burgess follows:]
+
+ Prepared statement of Hon. Michael C. Burgess
+
+ Good morning, everyone, and thank you for joining us this
+morning for our first Health Subcommittee hearing of the 116th
+Congress. I would like to take a moment to congratulate our new
+Chair, Anna Eshoo. I look forward to partnering with you
+throughout this Congress.
+ Today, we are here to discuss the issue of protecting
+access to healthcare for individuals with pre-existing medical
+conditions in addition to the Texas v. U.S. court case. Let me
+be clear: This is an issue for which there is broad bipartisan
+support.
+ While I am glad that we are finally holding our first
+hearing of the year, I am disappointed that we are holding a
+passive hearing that doesn't move toward the development of any
+policies to improve healthcare for Americans. To that effect,
+there are numerous options that you could bring before us that
+could moot the Texas v. U.S. case, but you have chosen not to
+do so.
+ My constituents in North Texas are consistently concerned
+about not having access to affordable healthcare. In my
+district, that is the policeman and the schoolteacher with two
+children who have a bronze plan and cannot afford their high
+deductible. I take countless meetings with families suffering
+from high healthcare and prescription drug costs, but
+unfortunately that's not why you've convened us here today. We
+could be using this valuable time to develop policies to help
+those individuals and families, yet we are here discussing
+something upon which we all agree but are taking no substantive
+action to address.
+ If you believe in Medicare for All, a single-payer,
+Government-run, ``one-size-fits-all'' healthcare system, we
+should have a hearing on it right here in this subcommittee.
+The House Budget Committee and others are having hearings on
+this, and Democrats are introducing legislation. These bills
+belong in the jurisdiction of Energy and Commerce, and yet we
+have not scheduled a hearing to discuss this agenda. Do I agree
+with the policy or think it would be good for the American
+people? No, I do not; however, I would gladly engage in a
+meaningful dialogue about what such a policy would mean for the
+American people.
+ Single-payer healthcare would be another failed attempt at
+a one-size-fits-all approach to healthcare. Americans are all
+different and a universal healthcare plan will not meet the
+varying needs of each and every individual. Single-payer is not
+one-size-fits-all, it is really one-size-fits-no-one.
+ Today, we should be focusing on the parts of the health
+insurance market that are working for Americans. For example,
+71 percent of Americans are satisfied with their employer-
+sponsored health insurance, which provides robust protections
+for individuals with preexisting conditions. Quite simply, the
+success of the employer-sponsored insurance market is not worth
+wiping out with single-payer healthcare. In fact, today there
+is a greater percentage of Americans in employer health
+coverage than at any time since 2000.
+ Since President Trump took office, the number of Americans
+in employer health coverage has increased by more than 2.5
+million. Given that the United States economy added more than
+300,000 jobs in January, the number of individuals and families
+covered by employer-sponsored plans is likely even greater.
+ Instead of building upon the successes of our existing
+health insurance framework, radical, single-payer, Government-
+run Medicare for All policy would tear it down. It would
+eliminate employer-sponsored health insurance, private
+insurance, the Indian Health Service, and Medicaid and CHIP,
+and pave the road to the elimination of the VA. Existing
+Medicare beneficiaries would not be exempt from harm, as the
+policy would raid the Medicare Trust Fund, which is already
+slated to go bankrupt in 2026.
+ Again, while I appreciate that we have organized and are
+holding our first hearing, I believe that we could be using our
+time much more productively. There is bipartisan support for
+protecting individuals with preexisting conditions, and I look
+forward to future hearings where we can have substantive,
+bipartisan policy-based discussions. With that, I yield back.
+
+ Ms. Eshoo. I thank the ranking member, and let me just add
+a few points. You raised the issue of employer-sponsored
+healthcare. Our employer is the Federal Government, and we are
+covered by the Affordable Care Act.
+ Number two, we on our side support universal coverage, and
+so--but what the committee is going to be taking up is, and you
+pointed out some of the chinks in the armor of the Affordable
+Care Act--we want to strengthen it, and what you described
+relative to your constituents certainly applies to many of us
+on our side as well. So we plan to examine that, and we will.
+ Mr. Burgess. Will the gentlelady yield on the point on
+employer coverage for Members of Congress?
+ Ms. Eshoo. Mm-hmm.
+ Mr. Burgess. I actually rejected the special deal that
+Members of Congress got several years ago when we were required
+to take insurance under the Affordable Care Act and we all were
+required to join the DC exchange.
+ But we were given a large tax-free monthly subsidy to walk
+into that exchange. I thought that was illegal under the law. I
+did not take that. I bought a bronze plan--an unsubsidized
+bronze plan at healthcare.gov, the most miserable experience I
+have ever been through in my life.
+ And just like constituents in my district, I was scared to
+use my health insurance because the deductible was so high.
+ I yield back.
+ Ms. Eshoo. I thank the gentleman. It would be interesting
+to see how many Members have accepted the ACA, they and their
+families being covered by it.
+ And now I would like to recognize the chairman of the full
+committee, Mr. Pallone, who requested that this hearing be the
+first one to be taken up by the subcommittee--the Texas law
+case--and I call on the gentleman to make his statement.
+ Good morning to you.
+
+OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE
+ IN CONGRESS FROM THE STATE OF NEW JERSEY
+
+ Mr. Pallone. Thank you, Madam Chair, and thank you for all
+you have done over the years to help people get health
+insurance, to expand insurance, to address the price of
+prescription drugs and so many other things, and I am glad to
+see you in the chair of this subcommittee hearing.
+ Now, I was going to try to be nice today. But after I
+listened to Mr. Burgess, I can't be. You know, and I am sure
+this is--he is going to see this as personal, but I don't mean
+it that way.
+ But I just have to speak out, Mr. Burgess. Look, you were
+the chairman of this subcommittee the whole time that the
+Republicans tried unsuccessfully to repeal the Affordable Care
+Act.
+ I have had so many meetings where I saw you come in and
+take out your copy of the hearings on the Affordable Care Act
+and repeatedly tell us that the Affordable Care Act was bad
+law, terrible law, it needs to be repealed.
+ I saw no effort at all in the time that you were the
+chairman to try to work towards solutions in improving the
+Affordable Care Act. What I saw were constant efforts to join
+with President Trump to sabotage it.
+ And the reason that this hearing is important--because the
+ultimate sabotage would be to have the courts rule that the ACA
+is unconstitutional, which is totally bogus.
+ You found this, you know, right-wing judge somewhere in
+Texas--I love the State of Texas, but I don't know where you
+found him--and you did forum shopping to find him, and we know
+his opinion is going to be overturned.
+ But we still had to join a suit to say that his opinion was
+wrong and it wasn't based in any facts or any real analysis of
+the Constitution, and the reason we are having this hearing
+today is because we need to make the point that the Republicans
+are still trying to repeal the Affordable Care Act.
+ They are not looking to work with us to improve it. There
+were many opportunities when the senators--Senator Lamar
+Alexander and others--were trying to do things to improve the
+Affordable Care Act, to deal with the cost sharing that was
+thrown out by the president, to deal with reinsurance to make
+the market more competitive, and at no point was that brought
+up in this subcommittee under your leadership.
+ You know, you talk about the employer-sponsored system.
+Sure, we all agree 60 percent of the people get their insurance
+through their employer.
+ But those antidiscrimination provisions that you said are
+protected with employer-sponsored plans they came through
+actions of the Democrats and the Affordable Care Act that said
+that you could not discriminate--that you could not
+discriminate for preexisting conditions, that you had to have
+an essential benefit package. Those are a consequence of the
+ACA.
+ So don't tell us that, you know, somehow that appeared
+miraculously in the private insurance market. That is not true
+at all.
+ Talk about Medicaid expansion, your State and so many other
+Republican States blocked Medicaid expansion. So there is so
+many people now that could have insurance that don't because
+they refuse to do it for ideological reasons.
+ You mentioned the Indian Health Service. I love the fact
+that the gentleman from Oklahoma had that Indian healthcare
+task force. Thank you. I appreciate that.
+ But I asked so many times in this subcommittee to have a
+hearing on the Indian Health Care Improvement Act which, again,
+was in the Affordable Care Act, otherwise it would never have
+passed, and that never happened.
+ We will do that. But talk about the Indian Health service--
+you did nothing to improve the Indian Health Service. And I am
+not suggesting that wasn't true for the gentleman of Oklahoma.
+He was very sympathetic.
+ But, in general, we did not have the hearing and we would
+not have had the Indian Health Service Improvement Act but for
+the ACA.
+ And finally, Medicare for All--who are you kidding? You are
+saying to us that you want to repeal the ACA and then you want
+to have a hearing on Medicare for All. You sent me a letter
+asking for a hearing on Medicare for All.
+ When does a Member of Congress, let alone the chairman or
+the ranking member, I guess, in this case, ask for a hearing on
+something that they oppose? I ask for hearings on things that I
+wanted to happen, like climate change and addressing climate
+change.
+ I don't ask for hearings on things that I oppose. I get a
+letter saying, ``Oh, we should have a hearing on Medicare for
+All but, by the way, we are totally opposed to it. It is a
+terrible idea. It will destroy the country.''
+ Oh, sure. We will have a hearing on something that you
+think is going to destroy the country. Now, don't get me wrong.
+We will address that issue. I am not suggesting we shouldn't.
+ But the cynicism of it all--the cynicism of coming here and
+suggesting that somehow you want--you have solutions? You have
+no solutions. I am more than willing to work with you. I am
+sure that Chairman Eshoo is willing to as well.
+ But don't tell us that you had solutions. You did not, and
+you continue not to have solutions. And I am sorry to begin the
+day this way, but I have no choice after what you said. I mean,
+it is just not--it is just not--it is disingenuous.
+ Thank you, Madam Chairwoman.
+ Ms. Eshoo. Thank you.
+ And now I will recognize the ranking member. Good morning.
+ Mr. Walden. Good morning.
+ Ms. Eshoo. The ranking member of the full committee, my
+friend Mr. Walden.
+ Mr. Walden. Thank you, Madam Chair. Congratulations on
+taking over the subcommittee.
+ Ms. Eshoo. Thank you very much. I appreciate it.
+ Mr. Walden. I always enjoyed working with you on
+telecommunications issues, and I know you will do a fine job
+leading this subcommittee.
+ Ms. Eshoo. Thank you.
+ Mr. Walden. I look forward to working with you. As we--I
+cannot help but respond a bit.
+
+ OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN
+ CONGRESS FROM THE STATE OF OREGON
+
+ Mr. Walden. I do wish we were meeting to pass bipartisan
+legislation and protect Americans with preexisting health
+conditions from losing their coverage, given the pending court
+case. And let me speak on behalf of Republicans because we
+fully support protecting Americans with preexisting conditions.
+ We have said this repeatedly, we have acted accordingly,
+and we mean it completely. We could and should inject certainty
+into the system by passing legislation to protect those with
+preexisting conditions, period.
+ On the opening day of the 116th Congress, House Republicans
+brought a powerful but simple measure to the floor that called
+on this body to legislate on what we all agree needs to be
+done, and that is to lock in protections for patients with
+preexisting conditions.
+ Unfortunately, that went down on a party-line vote. Our
+amendment was consistent with our long-held views with respect
+to the American Health Care Act, which our Democratic
+colleagues, frankly, in some cases, continue to misrepresent.
+ We provided protections for those with preexisting
+conditions under the AHCA. Insurance companies were prohibited
+from denying or not renewing coverage due to a preexisting
+condition, period.
+ Insurance companies were banned from rescinding coverage
+based on a preexisting condition, period. Insurance companies
+were banned from excluding benefits based on a preexisting
+condition, period.
+ Insurance companies were prevented from raising premiums on
+individuals with preexisting conditions who maintain continuous
+coverage, period.
+ The fact is, this is something we all agree on, and we
+should and could work together to expeditiously guarantee
+preexisting condition protections for all Americans and do so
+in a manner that can withstand judicial scrutiny. That is
+something I think we could find common ground on.
+ And while a status check on the ACA lawsuit is interesting
+and important, the ruling has been stayed. The attorneys
+general across the country have filed appeals. Speaker Pelosi
+has moved to intervene in the case I think three times and
+Americans' premiums and coverage for this year are not
+affected.
+ But what really does affect American consumers is out-of-
+control costs of healthcare. That is what they would like
+Congress to focus on and something I think we need to tackle as
+well.
+ The fact of the matter is that for too many Americans
+health insurance coverage exists solely on paper because
+healthcare costs and these new high deductibles are putting
+family budgets in peril.
+ When the Affordable Care Act passed, Democrats promised
+people that their insurance premiums would go down $2,500.
+Unfortunately, the exact opposite has occurred for many
+Americans, and not only have premiums gone up, not down, but
+think of what out-of-pocket costs have done. They have
+skyrocketed.
+ The latest solution from my friends on the other side of
+the aisle is some sort of Medicare for All proposal. And yes,
+we did ask for a hearing on it because I think it's something
+that Democrats ran on, believe in fully, and we should take
+time to understand it.
+ We know this plan would take away private health insurance
+from more than 150 million Americans. We are told it would end
+Medicare as we know it and would rack up more than $32 trillion
+in costs, not to mention delays in accessing health services.
+ So, Madam Chairwoman, other committees in this body have
+announced plans to have hearings on Medicare for All. Speaker
+Pelosi has said she is supportive of holding hearings on this
+plan, and Madam Chairwoman, I think I read you yourself said
+such hearings would be important to have.
+ A majority of House Democrats supported Medicare for All in
+the last Congress. In fact, two-thirds of the committee--
+Democrats' 20 Members, 11 whom are on this subcommittee--have
+cosponsored the plan.
+ I think it is important for the American people to fully
+understand what this huge new Government intervention to
+healthcare means for consumers if it were to become law.
+ Yesterday, Dr. Burgess and I did send you and Chairman
+Pallone a letter asking for a hearing on Medicare for All and
+we think, as the committee of primary jurisdiction, that just
+makes sense.
+ So as you're organizing your agenda for the future, we
+thought it was important to put that on it. The American people
+need to fully understand how Medicare for All is not Medicare
+at all but actually just Government-run, single-payer
+healthcare.
+ They need to know about the $32 trillion price tag for such
+a plan and how you pay for it. They need to know that it ends
+employer-sponsored healthcare, at least some versions of it do,
+forcing the 158 million Americans who get their health
+insurance through their job or through their union into a one-
+size-fits-all, Government-run plan.
+ So if you like waiting in line at the DMV, wait until the
+Government completely takes over healthcare. Seniors need to
+fully understand how this plan will affect the Medicare trust
+fund that they've paid into their entire lives and the impacts
+on access to their care.
+ Our Tribes need to understand how this plan could impact
+the Indian Health Service and our veterans deserve to know how
+this plan could pave the way to closing VA health services.
+ So the question is, when will we see the bill and when we
+will have a hearing on the legislation? Meanwhile, we need to
+work together to help States stabilize health markets damaged
+by the ACA.
+ Cut out-of-pocket costs, promote access to preventive
+services, encourage participation in private health insurance,
+and increase the number of options available through the
+market.
+ And I want to thank Mr. Pallone for raising the issue
+involving Senator Lamar Alexander. He and I and Susan Collins
+worked very well together to try and come up with a plan we
+could move through to deal with some of these issues.
+ Unfortunately, we could not get that done. So let us work
+together to lock in preexisting condition protections. Let's
+tackle the ever-rising healthcare costs and help our States
+offer consumers more affordable health insurance, and if you
+are going to move forward on a Medicare for All plan, we would
+like to make sure we have a hearing on it before the bill moves
+forward.
+ So with that, Madam Chair, thank you and congratulations
+again, and I yield back.
+ [The prepared statement of Mr. Walden follows:]
+
+ Prepared statement of Hon. Greg Walden
+
+ Good morning, Madam Chair. Congratulations on taking over
+the helm of this very important subcommittee. I only wish we
+were meeting today to pass bipartisan legislation to protect
+Americans with preexisting health conditions from losing
+coverage. Let me speak on behalf of Republicans: We fully
+support protecting Americans with preexisting conditions. We've
+said this repeatedly, we we've acted accordingly, and we mean
+it completely. We could-and should-inject certainty into the
+system by passing legislation to protect those with preexisting
+conditions.
+ On the opening day of the 116th Congress, House Republicans
+brought a powerful but simple measure to the floor that called
+on this body to legislate on what we all agree needs to be
+done--locking in protections for patients with preexisting
+conditions. Unfortunately, House Democrats voted it down.
+ Our amendment was consistent with our long-held views. With
+respect to the American Health Care Act, which our Democratic
+colleagues continue to mispresent, we provided protections for
+those with preexisting conditions. Under the AHCA:
+ Insurance companies were prohibited from denying
+or not renewing coverage due to a preexisting condition.
+Period.
+ Insurance companies were banned from rescinding
+coverage based on a preexisting condition. Period.
+ Insurance companies were banned from excluding
+benefits based on a preexisting condition. Period.
+ Insurance companies were prevented from raising
+premiums on individuals with preexisting conditions who
+maintain continuous coverage. Period.
+ The fact is, we agree on this issue. And we can work
+together expeditiously to guarantee preexisting condition
+protections for all Americans and do so in manner that can
+withstand judicial scrutiny.
+ And while a status check on the ACA lawsuit is interesting,
+the ruling has been stayed, Attorneys general across the
+country have filed appeals, Speaker Pelosi has moved to
+intervene in the case, and Americans' premiums and coverage for
+this year are not affected.
+ But what really does affect American consumers is the out-
+of-control costs of healthcare. That's what they would like
+Congress to focus on. When will we tackle the high cost of
+healthcare?
+ The fact of the matter is that for too many Americans
+health insurance coverage exists solely on paper because
+healthcare costs and high deductibles are putting family
+budgets in peril. When the Affordable Care Act passed,
+Democrats promised people their insurance premiums would go
+down $2500. Unfortunately, the exact opposite has occurred for
+many Americans. And not only have premiums gone up-not down-but
+also out-of-pocket costs have skyrocketed.
+ The latest ``solution'' from the Democratic Party is a
+Government takeover of healthcare, called Medicare for All. We
+know that this plan would take away private health insurance
+from more than 150 million Americans, end Medicare as we know
+it, and rack up more than $32-trillion in costs, not to mention
+delays in accessing health services.
+ Madam Chairwoman, other committees in this body have
+announced plans to have hearings on Medicare for All. Speaker
+Pelosi has said she is supportive of holding hearings on this
+radical plan. Madam Chairwoman, in fact, you yourself called
+for such hearings.
+ A majority of House Democrats supported Medicare for All in
+the last Congress--in fact, two-thirds of committee Democrats,
+20 Members, 11 of whom serve on the Health Subcommittee,
+cosponsored the plan.
+ I think it is important for the American people to fully
+understand what this huge, new, Government intervention into
+healthcare means for consumers. Yesterday, Dr. Burgess and I
+sent a letter to you and Chairman Pallone asking for a hearing
+on Medicare for All, as we are the committee with primary
+jurisdiction over healthcare issues.
+ The American people need to fully understand how Medicare
+for All is not Medicare at all, but actually just Government-
+run, single-payer healthcare. They need to know about the $32
+trillion price tag for such a plan, and the tax increases
+necessary to pay for it. They need to know that it ends
+employer-sponsored healthcare, forcing the 158 million
+Americans who get their healthcare through their job or union
+into a one-size-fits-all, Government-run plan. If you like
+waiting in line at the DMV, wait until the Government
+completely takes over healthcare.
+ Seniors need to fully understand how this plan does away
+with the Medicare Trust Fund that they have paid into their
+entire lives, and the impacts on their access to care. Our
+tribes need to understand how this plan impacts the Indian
+Health Service, and our veterans deserve to know how this plan
+paves the way to closing the VA.
+ So the question is, When will we see the bill, and when
+will we have a hearing on the legislation?
+ Meanwhile, we need to work together to help States
+stabilize health markets damaged by the ACA, cut out-of-pocket
+costs, promote access to preventive services, encourage
+participation in private health insurance, and increase the
+number of options available through the market.
+ So let's work together to lock in preexisting condition
+protections, tackle ever-rising healthcare costs, and help our
+States offer consumers more affordable health insurance. And if
+Democrats must move forward on a complete Government takeover
+of healthcare, please pledge to give the American people a
+chance to read the bill so that we'll all know what's in it
+before we have to vote on it.
+
+ Ms. Eshoo. I thank the ranking member of the full committee
+for his remarks. Several parts of it I don't agree with, but I
+thank him nonetheless.
+ Now we will go to the witnesses and their opening
+statements. We will start from the left to Ms. Christen Linke
+Young, a fellow, USC-Brookings Schaeffer Initiative for Health
+Policy.
+ Welcome to you, and you have 5 minutes, and I think you
+know what the lights mean. The green light will be on, then the
+yellow light comes on, which means 1 minute left, and then the
+red light.
+ So I would like all the witnesses to stick to that so that
+we can get to our questions of you, expert as you are. So
+welcome to each one of you and thank you, and you are
+recognized.
+
+ STATEMENTS OF CHRISTEN LINKE YOUNG, FELLOW, USC-BROOKINGS
+ SCHAEFFER INITIATIVE FOR HEALTH POLICY; AVIK S. A. ROY,
+ PRESIDENT, THE FOUNDATION FOR RESEARCH ON EQUAL OPPORTUNITY;
+ ELENA HUNG, COFOUNDER, LITTLE LOBBYISTS; THOMAS P. MILLER,
+ RESIDENT FELLOW IN HEALTH POLICY STUDIES, AMERICAN ENTERPRISE
+ INSTITUTE; SIMON LAZARUS, CONSTITUTIONAL LAWYER AND WRITER
+
+ STATEMENT OF CHRISTEN LINKE YOUNG
+
+ Ms. Young. Good morning, Chairwoman Eshoo, Ranking Member
+Burgess, members of the committee. Thank you for the
+opportunity to testify today.
+ I am Christen Linke Young, a fellow with the USC-Brookings
+Schaeffer Initiative on Health Policy. My testimony today
+reflects my personal views.
+ The Affordable Care Act has brought health coverage to
+millions of Americans. Since the law was passed, the uninsured
+rate has been cut nearly in half. The ACA's marketplaces are
+functioning well and offering millions of people comprehensive
+insurance.
+ Thirty-seven States have expanded Medicaid, and many of the
+remaining States are considering expansion proposals. Beyond
+its core coverage provisions, the ACA has become interwoven
+with the American healthcare system.
+ As just a few examples, the law put in place new consumer
+protections in employer-provided insurance, closed Medicare's
+prescription drug doughnut hole, changed Medicare reimbursement
+policies, reauthorized the Indian Health Service, authorized
+biosimilar drugs, and even required employers to provided space
+for nursing mothers.
+ One of the core goals of the ACA was to provide healthcare
+for Americans with preexisting conditions, and I would like to
+spend a few minutes discussing how the law achieves the
+objective.
+ By some estimates, as many as half of nonelderly Americans
+have a preexisting condition, and the protections the law
+offers to this group cannot be accomplished in a single
+provision or legislative proclamation.
+ Instead, it requires a variety of interlocking and
+complementary reforms threaded throughout the law. At the
+center are three critical reforms.
+ Consumers have a right to buy and renew a policy regardless
+of their health needs, have that policy cover needed care, and
+be charged the same price. Further, the ACA prohibits lifetime
+limits on care received and requires most insurers to cap
+copays and deductibles.
+ Crucially, the law ensures that insurance for the healthy
+and insurance for the sick are part of the single risk pool and
+it provides financial assistance tied to income to help make
+insurance affordable.
+ However, a recent lawsuit threatened this system of
+protections. In Texas v. United States, a group of States argue
+that changes made to the ACA's individual mandate in 2017
+rendered that provision unconstitutional.
+ Therefore, they puzzlingly argue that the entire ACA should
+be invalidated, stripping away protections for people with
+preexisting conditions and everything else in the law.
+ The Trump administration's Department of Justice has agreed
+with the claim of a constitutional deficiency, and they further
+agree that central pillars of the preexisting condition
+protection should be eliminated.
+ But, unlike the States, DOJ argues that the weakened
+remainder of the law should be left to stand. Other scholars
+can discuss the weakness of this legal argument. I would like
+to discuss its impacts on the healthcare system.
+ DOJ's position, that the law's core protections for people
+with preexisting conditions should be removed, would leave
+Americans with health needs without a reliable way to access
+coverage in the individual market.
+ Insurers would be able to deny coverage and charge more
+based on health status. In many ways, the market would look
+like it did before the ACA. Components of the law would
+formally remain in place, but it is unclear how some of those
+provisions would continue to work.
+ The States' position would wreak even greater havoc and
+fully return us to the markets that predated the ACA. In
+addition to removing central protections for those with
+preexisting conditions, the financial assistance for families
+purchasing coverage, and the ACA's funding for Medicaid
+expansion would disappear.
+ The Congressional Budget Office has estimated the repeal of
+the ACA would result in as many as 24 million additional
+uninsured Americans, and similar results could be expected
+here.
+ In addition, consumer protections for employer-based
+coverage would be eliminated, changes to Medicare would be
+undone, the Indian Health Service would not be reauthorized,
+the FDA couldn't approve biosimilar drugs. Indeed, these are
+just some of the many and far-reaching effects of eliminating a
+law that is deeply integrated into our healthcare system.
+ Before I close, I would like to briefly note that Texas v.
+United States is not the only recent development that threatens
+Americans with preexisting conditions. Recent policy actions by
+the Trump administration also attempt to change the law in ways
+that undermine the ACA.
+ As just a few examples, guidance under Section 1332 of the
+ACA purports to let States weaken protections for those with
+health needs. Nationwide, efforts to promote short-term
+coverage in association health plans seek to give healthy
+people options not available to the sick and drive up costs for
+those with healthcare needs.
+ Additionally, new waivers in the Medicaid programs allows
+States to place administrative burdens in front of those trying
+to access care.
+ To summarize, the Affordable Care Act has resulted in
+significant coverage gains and meaningful protections for
+people with preexisting conditions. Texas v. U.S. threatens
+those advances and could take us back to the pre-ACA individual
+market where a person's health status was a barrier to coverage
+and care.
+ The lawsuit would also damage other healthcare policies,
+and this litigation coincides with administrative attempts to
+undermine the ACA's protections for people with preexisting
+conditions.
+ Thank you.
+ [The prepared statement of Ms. Young follows:]
+ [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
+
+ Ms. Eshoo. Thank you very much.
+ Next, Mr. Avik Roy, president of the Foundation for
+Research and Equal Opportunity. Welcome.
+
+ STATEMENT OF AVIK S. A. ROY
+
+ Mr. Roy. Chairwoman Eshoo, Ranking Member Burgess, and
+members of the Health Subcommittee of the House Energy and
+Commerce Committee, thanks for inviting me to speak with you
+today.
+ I am Avik Roy and I am the president of the Foundation for
+Research on Equal Opportunity, a nonpartisan nonprofit think
+tank focussed on expanding economic opportunity to those who
+least have it.
+ When we launched in 2016, our first white paper showed how
+universal coverage done the right way can advance both the
+progressive and conservative values at the same time, expanding
+access while reducing Federal spending and burdensome
+regulations.
+ In my oral remarks, I am going to focus on a core problem
+that, respectfully, Congress has failed to solve: how to
+protect Americans with preexisting conditions while also
+ensuring that every American has access to affordable health
+insurance.
+ Thirty-two million U.S. residents go without coverage
+today. Fewer than half of those eligible for subsidies in the
+ACA exchanges have enrolled in ACA-based coverage.
+ This failure is the result of the flawed theory first
+articulated by MIT economist Jonathan Gruber underlying Title 1
+of the Affordable Care Act--that if Congress requires that
+insurers offer coverage to those with preexisting conditions
+and if Congress forces insurers to overcharge the healthy to
+undercharge the sick, Congress must also enact an individual
+mandate to prevent people from jumping in and out of the
+insurance market.
+ We should all know by now that Professor Gruber is not
+omniscient. After all, in 2009, Gruber said, what we know for
+sure about the ACA is that it will, quote, ``lower the cost of
+buying nongroup health insurance.''
+ In reality, premiums have more than doubled in the ACA's
+first 4 years, and the ACA subsidies only offset those
+increases for those with incomes near the poverty line.
+ There are two flaws with Gruber's theory, sometimes called
+the three-legged stool theory. First, the two ACA provisions
+that have had the largest impact on premiums have nothing to do
+with preexisting conditions.
+ Second, the ACA's individual mandate was so weak with so
+many loopholes that its impact on the market was negligible.
+Guaranteeing offers of coverage for those with preexisting
+conditions has no impact on premiums because the ACA limits the
+enrollment period for guaranteed issue plans to six weeks in
+the fall or winter.
+ The limited enrollment period, not the mandate, ensures
+that people can't game the system by dropping in and out. While
+community rating by health status does cause some adverse
+selection by overcharging healthy people who buy coverage,
+thereby discouraging healthy people from signing up, among
+enrollees of the same age this is not an actuarially
+significant problem.
+ The largest impact is from the ACA's 3-to-1 age bans which
+on their own double the cost of insurance for Americans in
+their 20s and 30s, forcing many to drop out of the market
+because younger people consume one-sixth of the healthcare that
+older people do.
+ In the court cases consolidated as NFIB v. Sebelius,
+President Obama's Solicitor General, Neal Katyal, repeatedly
+argued that if the individual mandate were ruled to be
+unconstitutional, much of the ACA should remain but that the
+ACA's guaranteed issue and health status community rating
+provisions, the ones that impact those with preexisting
+conditions, should also be struck from the law.
+ The Trump Justice Department has merely echoed this belief.
+Both administrations are more correct than the district judge
+in Texas v. Azar, who, in an egregious case of judicial
+activism, argued that the entirety of the ACA was inseparable
+from the mandate.
+ However, it is clear that both Justice Departments are also
+wrong. The zeroing out of the mandate penalty has not blown up
+the insurance market. Indeed, it has had no effect.
+ To be clear, it is not just ACA enthusiasts who have bought
+into Gruber's flawed theories. Many conservatives have as well.
+A number of conservative think tank scholars have argued that,
+because they oppose the individual mandate, we should also
+repeal the ACA's protections for those with preexisting
+conditions--that is, guaranteed issue and community rating by
+health status.
+ These scholars have argued that a better way to cover those
+with preexisting conditions is to place them in a separate
+insurance pool for high-risk individuals.
+ I want to state this very clearly: Those scholars are
+wrong. The most market-based approach for covering those with
+preexisting conditions is not to repeal the ACA's guaranteed
+issue and health status provisions but to preserve them and to
+integrate the principles of a high-risk pool into a single
+insurance market through reinsurance.
+ I have been pleased to see Republicans in Congress support
+legislation that would ensure the continuity of preexisting
+condition protections irrespective of the legal outcome in
+Texas v. U.S. I hope both parties can work together to achieve
+this.
+ Both parties can further improve the affordability of
+individual insurance by enacting a robust program of
+reinsurance and restoring 5-to-1 age bans.
+ On these and other matters, I look forward to working with
+all members of this committee both today and in the future to
+ensure that no American is forced into bankruptcy by high
+medical bills.
+ Thank you.
+ [The prepared statement of Mr. Roy follows:]
+ [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
+
+ Ms. Eshoo. Thank you very much, Mr. Roy.
+ You have testified here before, and we appreciate you being
+here again today. I would like to just suggest that, for the
+benefit of Members, that you get your testimony to us much
+earlier, all right?
+ Mr. Roy. I apologize.
+ Ms. Eshoo. Yes.
+ Mr. Roy. I was, of course, officially invited to testify
+before this committee on Monday. I had some personal and
+professional obligations that limited my ability to get the
+testimony in a timely fashion.
+ Ms. Eshoo. Yes.
+ Mr. Roy. I will be happy to brief any members of this
+committee or their staffs at another time.
+ Ms. Eshoo. Well, we thank you. I just--I have a bad habit,
+I read everything, and it wasn't there. So--but I heard today,
+and then we will all ask you our questions. Thank you.
+ The next witness is Ms. Hung, and she is the cofounder of
+Little Lobbyists. You are recognized for 5 minutes, and
+welcome.
+
+ STATEMENT OF ELENA HUNG
+
+ Ms. Hung. Thank you. Good morning.
+ Thank you, Chairwoman, Ranking Member, and members of the
+subcommittee for the opportunity to tell my story and share my
+concerns with you today.
+ My name is Elena Hung, and I am a mom. I am a proud mom of
+an amazing 4-year-old. My daughter, Xiomara, is a happy child.
+She is kind and smart and funny and a little bit naughty. She
+is the greatest joy of my life.
+ She is at home right now, getting ready to go to school.
+She attends an inclusive special education pre-K program, and I
+asked her if she wanted to come here today. She said she wanted
+to go to school instead.
+ It has been a long road to this moment. Xiomara was born
+with chronic complex medical conditions that affect her airway,
+lungs, heart, and kidneys. She spent the first 5 months of her
+life in the neonatal intensive care unit.
+ She uses a tracheostomy tube to breathe and a ventilator
+for additional respiratory support. She relies on a feeding
+tube for all of her nutrition. She participates in weekly
+therapies to help her learn how to walk and talk. But I am
+thrilled to tell you that Xiomara is thriving today.
+ This past year was her best year yet healthwise, and
+ironically it was also when her access to healthcare has been
+the most threatened. I sit before you today because families
+like mine--families with medically complex children--are
+terrified of what this lawsuit may mean for our kids.
+ You see, our lives are already filled with uncertainty--
+uncertainty about diagnoses, uncertainty about the effects of
+medications and the outcomes of surgeries. The one certainty we
+have is the Affordable Care Act and the healthcare coverage
+protection it provides.
+ We don't know what Xiomara's future holds, but with the
+ACA's protections in place we know this: We know Xiomara's 10
+preexisting conditions will be covered without penalty, even if
+we switch insurance plans or employers.
+ We know a ban on lifetime caps means that insurance
+companies cannot decide that her life isn't worth the cost and
+cut her off care just because she met some arbitrary dollar
+amount.
+ We know we won't have to worry about losing our home as a
+result of an unexpected hospitalization or emergency. We know
+Medicaid will provide the therapies and long-term services and
+supports that enable her independence.
+ I sit before you today on behalf of families like mine who
+fear that the only certainty we know could be taken away,
+pending the outcome of this lawsuit--this lawsuit that seeks to
+eliminate protections for people with preexisting conditions--
+and if that happens our children's lives will then depend on
+Congress where every so-called replacement plan proposed over
+the last 2 years has offered far less protection for our kids
+than the ACA does.
+ I sit here before you today on behalf of Isaac Crawley, who
+lost his insurance in 2010 after he met his lifetime limit just
+a few weeks after his first birthday but got it back after the
+ACA became law;
+ Myka Eilers, who was born with a preexisting congenital
+heart defect and was able to obtain health insurance again when
+her dad reopened his own business after being laid off;
+ Timmy Morrison, who spends part of his childhood in
+hospitals, both inpatient and outpatient, because his insurance
+plan covers what is essential to his care;
+ Claire Smith, who has a personal care attendant and is able
+to live at home with her family and be included in her
+community, thanks to Medicaid;
+ Simon Hatcher, who needs daily medications to prevent life-
+threatening seizures, medications which would cost over $6,000
+a month without insurance;
+ Colton Prifogle, who passed away on Sunday and was able to
+spend his final days pain-free with dignity, surrounded by
+love, because of the hospice care he received.
+ These are my friends, my friends that I love. These are
+Xiomara's friends. This is our life. I cofounded the Little
+Lobbyists, this group of families with medically complex
+children, some of whom are here today, because these are
+stories that desperately need to be told and heard alongside
+the data and numbers and policy analysis.
+ There are children like Xiomara in every State. That's
+millions of children with preexisting conditions and
+disabilities across the country. I sit before you today on the
+eve of another trip to the Children's Hospital.
+ Tomorrow I will hold my daughter's hand as I walk her to
+the OR for her procedure, and as I have done every time before,
+I know I will drown in worry, as a mother does.
+ But the thing that has always given me comfort is knowing
+that my Government believes my daughter's life has value and
+that the cost of medical care she needs to survive and thrive
+should not financially bankrupt us. It is my plea for that to
+always be true.
+ Thank you.
+ [The prepared statement of Ms. Hung follows:]
+ [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
+
+ Ms. Eshoo. Thank you, Elena. Beautiful testimony. Beautiful
+testimony. I wish Xiomara were here. Maybe we can provide a
+tape so that when she gets older she can hear her mother's
+testimony in the Congress of the United States. Thank you.
+ I now would like to recognize Mr. Thomas Miller, resident
+fellow at the American Enterprise Institute. Welcome, and thank
+you. You have 5 minutes.
+
+ STATEMENT OF THOMAS P. MILLER
+
+ Mr. Miller. Thank you, Chairwoman Eshoo. The mortifying
+silent C in my written testimony in your name must have been
+due to the speed with which I delivered the testimony on time.
+But I apologize for that.
+ Thank you also, Ranking Member Burgess and members of the
+subcommittee. Now let us all take a deep breath and get to it.
+ The Texas case remains in its relatively early stages. Its
+ultimate fate is as much as another 16 months away. The
+probability of a Supreme Court ruling that would overturn the
+entire ACA remains very, very low, just by last December's
+decision at the Federal district court level.
+ Any formal enforcement action to carry out that decision
+has been stayed while the case continues on appeal. We have
+been here before. Two longer-term trends in health policy
+persist: our overreliance on outsourcing personal healthcare
+decisions to third-party political intermediaries and then our
+chronic inability to reach compromises and resolve health
+policy issues through legislative mechanisms. They have fuelled
+a further explosion in extending health policy battles to our
+courts.
+ So welcome back to Groundhog Day, ACA litigation version.
+The plaintiff's overall case is not frivolous, but it does rely
+heavily on taking the actual text of the ACA literally and
+thereby limiting judicial scrutiny to what the Congress that
+enacted appeared on the limited record of that time to intend
+by what it did.
+ The plaintiffs are attempting to reverse engineer and
+leverage the unusually contorted Supreme Court opinion of Chief
+Justice Roberts in NFIB v. Sebelius.
+ Now, come critics insist that the 115th Congress that
+zeroed out the mandate tax also expressed a clear intent to
+retain all other ACA provisions. This ignores the limited scope
+of what that Congress had power to do through the vehicle of
+budget reconciliation in the tax-cutting Jobs Act. All that its
+Members actually voted into law was a change regarding
+individual mandate.
+ It did not and could not extend to the ACA's other
+nonbudgetary regulatory provisions, nor did it change the
+findings of fact still in statutory law first made by the 111th
+Congress that insisted the individual mandate was essential to
+the functioning of several other ACA provisions, notably,
+guaranteed issue and adjusted community rating.
+ The plaintiffs are not out of bounds in trying to hold
+Congress to its past word--it happens once in a while--and in
+building on the similar reasoning used by other Supreme Court
+majorities to strike down earlier ACA legal challenges.
+ Since that's the story for ACA defenders, they should have
+to stick to it, at least until a subsequent Congress actually
+votes to eliminate or revise those past findings of fact
+already in permanent law.
+ But, even if appellate courts also find some form of
+constitutional injury in what remains of the ACA's individual
+mandate as a tax-free regulatory command, the severability
+stage of such proceedings will become far more uphill for the
+plaintiffs.
+ Most of the time, the primary test is functionality in the
+sense of ascertaining how much of the remaining law with the
+Congress enacting it believe could be retained and still
+operate as it envisioned.
+ Given the murkiness of divining or rewriting legislative
+intent in harder cases like this one, it remains all but
+certain that an ultimate Supreme Court ruling would, at a
+minimum, follow up previous inclinations revealed in the 2012
+and 2015 ACA challenges and try to save as much of the law as
+possible.
+ Even appellate judges in the Fifth Circuit will note
+carefully the passage of time, the substantial embedded
+reliance costs, and the sheer administrative and political
+complexity of unwinding even a handful of ACA provisions on
+short notice.
+ So don't bet on more than a narrow finding that could sever
+whatever remains of an unconstitutional individual mandate
+without much remaining practical impact from the rest of the
+law.
+ On the health policy front, we might try to remember that,
+when congressional action produces as flawed legislative
+product justified in large part by mistaken premises and
+misrepresentations, it won't work well.
+ The ACA's architects and proponents oversold the
+effectiveness and attractiveness of the individual mandate,
+claiming it could hold the law's insurance coverage provisions
+together while keeping official budgetary costs and coverage
+estimates within the bounds of CBO's scoring.
+ But what worked to launch the ACA and keep it viable in
+theory and politics did not work well in practice, and, to be
+blunt, one of the primary ways that the Obama administration
+sold its proposals for health policy overhaul was to exaggerate
+the size, scope, and nature of the potential population facing
+coverage problems due to preexisting health conditions.
+ Of course public policy should address remaining problems.
+It could and should be improved in other less proscriptive and
+more transparent ways than the ACA attempted.
+ My written testimony suggests a number of option available
+to lawmakers if some of the ACA's current overbroad regulatory
+provisions were stricken down in court in the near future.
+ However, we are not back in 2012 or 2010 or even 2017
+anymore, at least outside of our court system. Changes in
+popular expectations and health industry practices since 2010
+are substantial breaks on even well-structured proposals for
+serious reform. But that is where the real work needs to be
+restarted.
+ It is often said with apocryphal attribution that God takes
+care of children, drunks, or fools, and the United States of
+America. Well, let's not press our luck. To produce better
+lawsuits, fewer lawsuits, let us try to write and enact better
+laws.
+ Thank you.
+ [The prepared statement of Mr. Miller follows:]
+ [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
+
+ Ms. Eshoo. Thank you.
+ And now our last witness, Mr. Thomas Miller, resident
+fellow--I am sorry--Mr. Simon Lazarus, constitutional----
+ Mr. Miller. I think he's younger than I am.
+ Ms. Eshoo [continuing]. Constitutional lawyer and writer.
+Welcome. It is lovely to see you, and thank you for being here
+to be a witness and be instructive to us.
+ You have 5 minutes.
+
+ STATEMENT OF SIMON LAZARUS
+
+ Mr. Lazarus. Thank you, Chair Eshoo, and Ranking Member
+Burgess and members of the subcommittee. My name is Simon
+Lazarus. I am a lawyer and writer on constitutional and legal
+issues relating to, among other things, the ACA.
+ I have had the privilege of testifying before this
+subcommittee and other congressional committees numerous times.
+I am currently retired, and the views that I express here are
+my own and cannot be attributed to any of the organizations for
+which I previously worked or other organizations.
+ I have to say that I am not sure how important my task is,
+because I think all of the witnesses have pretty much agreed
+with the bottom line, and that includes the witnesses invited
+by the minority, and that is that this decision to invalidate
+the entire ACA is, in significant respects, and I think many of
+us agree that in all respects, completely baseless legally and
+has close to zero chances of being upheld on appeal.
+ And in light of all of that, Tom, I have to--I am puzzled
+by your assertion that the lawsuit is not frivolous, because
+that sounds to me like the definition of frivolousness in a
+lawsuit.
+ In any event, I think it should be underscored that it is
+not a coincidence that even the minority witnesses think very
+little of this lawsuit, because, as soon as the decision came
+down, it was attacked in extremely strong terms across the
+political spectrum.
+ As the Wall Street Journal editorialized, ``While no one
+opposes Obamacare more than we do, Judge O'Connor's decision is
+likely to be overturned on appeal.'' Legal experts, including
+prominent anti-ACA conservatives, have blistered Judge
+O'Connor's result.
+ For example, Phillip Klein, the executive editor of the
+Washington Examiner, called the decision ``an assault on the
+rule of law.'' Professor Jonathan Adler, who is an architect of
+the second fundamental legal challenge to the ACA--that's King
+v. Burwell--which I think the idea for which was hatched at a
+meeting that you probably hosted----
+ Mr. Miller. I have been here before.
+ Mr. Lazarus. OK. And that effort to kill the ACA was
+rejected by the Supreme Court in 2015. In any event, Professor
+Adler called the decision, quote, ``an exercise of raw judicial
+power unmoored from the relevant doctrines concerning when
+judges may strike down a whole law because of a single alleged
+legal infirmity buried within it.''
+ And on the courts, if one is going to be a prognosticator,
+just look at the basic facts. Chief Justice John Roberts'
+pertinent opinions nearly ensure at least a 5-4 Supreme Court
+majority to reverse Judge O'Connor, and moreover it should be
+noted that Justice Brett Kavanaugh, looking at his prior
+decisions as a DC circuit judge, also looks very likely to join
+a larger majority to reverse Judge O'Connor.
+ So my job here is just to try to explain what the legal
+reasons are for this negative judgment on O'Connor's decision,
+so I am going to try to briefly do that.
+ To begin with, the court could well dismiss the case for
+lack of standing to sue on the part of any of the plaintiffs
+who brought the case. The State government plaintiffs barely
+pretend to have a colorable standing argument.
+ The two individual plaintiffs complain that, though it is
+enforceable, the mandate nonetheless imposes a legal obligation
+to buy insurance and they would feel uncomfortable violating
+that obligation.
+ The problem with this is that Chief Justice Roberts in his
+2012 NFIB v. Sebelius decision, which upheld the mandate,
+expressly ruled that and based his decision, really, on the
+determination that, if individuals did not buy insurance--thus,
+quote, ``choosing to pay the penalty rather than obtain
+insurance''--they will have fully complied with the law.
+ Now, post-TCJA--the Tax Cut and Jobs Act--a nonpurchaser
+will still not be in violation of the law simply because
+Congress reduced to zero the financial incentive to choose the
+purchase option.
+ So no one is compelled to buy insurance in order to avoid a
+penalty since none exists nor to follow the law, because he
+will be following or she will be following the law.
+ So there is no injury period, no standing to sue. That is a
+very likely result, even in the Fifth Circuit, I would say.
+ Ms. Eshoo. Mr. Lazarus, can you just summarize----
+ Mr. Lazarus. OK. I am sorry.
+ Well, in addition, I would just say on the merits the ACA's
+mandate provision remains a valid exercise of the tax power and
+that is pretty much for the same reasoning that there is no
+standing, and that is because Congress' determination after the
+original ACA passed to drop the penalty to zero did not strip
+Congress of its constitutional power under the tax authority.
+ And nor can its subsequent determination sensibly mean that
+it was no longer using that power. And finally, I would just
+want to add really to what other people have said and some of
+the members of the subcommittee have eloquently said, that to
+take the further leap that, if the mandate provision is
+unconstitutional after the reduction of the penalty to zero--
+which it really should not be found, but if it is--there is
+absolutely no basis whatsoever for striking down the rest of
+the ACA.
+ [The prepared statement of Mr. Lazarus follows:]
+ [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
+
+ Ms. Eshoo. Thank you very much.
+ All right. I am going to--we have how concluded the
+statements of our witnesses. We thank you again for them. Each
+Member will have 5 minutes to ask questions of the witnesses,
+and I will start by recognizing myself for 5 minutes.
+ I appreciate the discussion about the legalities, and of
+course we are discussing Texas v. United States today. But the
+issue of preexisting conditions keeps coming up, and I would
+like Ms. Young and anyone else to chime in.
+ This issue of what our Republican colleagues say that they
+are for, and I listen to C-SPAN a lot and especially during the
+days running up to the election, and they covered Senate races
+and House races, and I heard Republicans over and over and over
+again in those debates with their opponents saying, ``I am for
+preexisting conditions.''
+ Now, can anyone address how you extract that out of what we
+have now, the Affordable Care Act, and have standalone
+insurance policies? Where is the guarantee about what the price
+would be for that policy?
+ Would you like to----
+ Ms. Young. The Affordable Care Act--absolutely. The
+Affordable Care Act requires that all insurance plans charge
+consumers the same price regardless of----
+ Ms. Eshoo. That I understand. That's what we put in. But
+the minority is saying that they are for preexisting
+conditions, except they have voted against the ACA countless
+times.
+ So if you were to extract just that one issue and write a
+bill on it, where is the guarantee on what the price would be
+for that standalone policy?
+ Ms. Young. In my view, it is very difficult to put together
+a system of protections for people with preexisting conditions
+that doesn't include a panoply of reforms similar to many of
+the reforms that were included in the Affordable Care Act.
+ So you need to ensure people can buy a policy. You need to
+ensure that that policy doesn't exclude coverage for their
+particular healthcare needs.
+ You need to ensure that they are able to purchase at a fair
+price and you need to surround that with reforms that really
+create a functioning insurance market by providing financial
+assistance, stable risk adjustment, and other associated
+provisions like that.
+ Ms. Eshoo. I want to get to something that is out there,
+and that is what I refer to in my opening statement. I refer to
+them as junk plans. It is my understanding that many of these
+plans exclude coverage for prescription drugs, for mental
+health and substance use disorders.
+ Who would like to address this? Is this correct?
+ Ms. Young. I can address that.
+ Ms. Eshoo. Uh-huh. Go ahead.
+ Ms. Young. I believe you are referring to short-term
+limited duration coverage.
+ Ms. Eshoo. Right. Mm-hmm.
+ Ms. Young. Those plans are not required to cover any
+particular benefit, and many of them can and likely will
+exclude coverage for benefits like prescription drugs,
+maternity care, substance use and mental health services,
+things like that.
+ Ms. Eshoo. Now, are these plans medically underwritten?
+ Ms. Young. Many of them are, yes.
+ Ms. Eshoo. And how does that differ from the process by
+which Americans get health insurance on the individual market
+today?
+ Ms. Young. Medical underwriting refers to a process where
+insurance companies require individuals to fill out a detailed
+health history questionnaire and then use the results of that
+to determine if the individual can purchase a policy and if so
+on what terms.
+ That was a common practice in the individual market before
+the Affordable Care Act. It is permitted for short-term limited
+duration plans today.
+ In contrast, in the ACA-compliant individual market,
+insurers are not prohibited to medically underwrite. Consumers
+sign up for a policy based only on information about their age
+and their income if they are seeking tax credits with no health
+history screening.
+ Ms. Eshoo. I see. Mr. Lazarus----
+ Mr. Miller. Chairwoman Eshoo, could you ask the rest of the
+panel, and we are getting a one-sided view of this. The ACA's
+protections are----
+ Ms. Eshoo. I didn't call on you. I would like to call on
+Mr. Lazarus. Are you giving us comfort that the lawsuit is not
+going to go anywhere? Is that what you believe?
+ Mr. Lazarus. I think all of the witnesses have basically
+said that, at least with respect to the notion that, if the
+mandate provision is now found to be unconstitutional, which I
+don't think it will be or should be, the quantum leap that the
+Republican attorneys general and Judge O'Connor took to then
+say the whole law has to go, I don't think any member of the
+panel thinks that there is much chance of that occurring.
+ So I don't know whether that answers your--that doesn't
+mean, however, that the fact that there is this dagger pointed
+at the heart of our healthcare system is out there causing
+uncertainty, that it was--basically, opponents of the ACA have
+outsourced to a judge, which Chairman Pallone correctly said
+was a target of forum shopping who has a widespread reputation
+of, one article said, tossing out Democratic policies that
+Republican opponents don't like.
+ Ms. Eshoo. I think my time has more than expired. Thank
+you.
+ I now would like to recognize the ranking member of the
+subcommittee, Dr. Burgess.
+ Mr. Burgess. I thank you for the recognition.
+ Mr. Miller, let me just give you an opportunity. You were
+trying to respond with something about the ACA protections.
+ Mr. Miller. Sure. It is a complex issue, but we need to
+remember that in the best of the world, the ACA left a lot of
+other folks unprotected. If you didn't comply with the
+individual mandate, you didn't get coverage. You got fined. You
+got insult on top of injury, and there is no coverage to it.
+ So there are breakdowns in any imagined perfect system.
+There are other approaches which can also fill that hole. You
+are going to have to put some money in. You are going to have
+to resolve----
+ I don't think the Republicans did a good job of it in 2017
+in explaining and defining what that meant. They began
+backfilling as they went along with reinsurance. There are ways
+to extend HIPAA over to the individual market.
+ Those are all thoughtful alternative approaches, and if you
+don't have an individual mandate, you should come up with
+something else. And we are not going to have an individual
+mandate. That appears to be the case.
+ So you are leaving a hole there and there are other ways to
+provide stronger incentives, and it requires some robust
+protections where if you went into something like a high-risk
+pool or an invisible risk pool you could requalify for that
+full-scale portability after 18 months.
+ So there are ways to connect the dots. It is heavier
+lifting, and it is more work than just waving your arms and
+saying, ``We mandated it, it must work,'' even though it
+doesn't.
+ Mr. Burgess. And I thank you for that clarification, and
+just--continuous coverage was part of the bill that we worked
+on 2 years ago.
+ Mr. Miller. A number of options. Yes.
+ Mr. Burgess. Which, of course, is what exists in Medicare.
+I mean, if you do not purchase Medicare within 3 months of your
+65th birthday, guess what? You get an assessment for the rest
+of your life in Part B of Medicare.
+ So, Mr. Miller, I actually agree with you and, I guess,
+other witnesses. My expectation is that this case will not be
+successful on appeal, and I base that on the fact that I have
+been wrong about every assumption I have made about the
+Affordable Care Act ever since its inception in 2009.
+ So perhaps I can be wrong about that assumption, but I do
+assume that it will not survive on appeal.
+ Let me just ask you, because I have had difficulty finding
+this information--you may have some sense--how much money has
+been collected under the individual mandate? The fines that
+have been paid--do we have an idea what that dollar figure is?
+ Mr. Miller. Yes. I did that a couple years ago in the Ways
+and Means. I knew it was going to come up today. I can supply
+it for you.
+ Mr. Burgess. Great.
+ Mr. Miller. This is--with a bit of a lag it ends up being
+calculated. Not a lot, and it's somewhat randomly distributed.
+It tends to be the lower-income people who didn't know how to
+get out of the individual mandate who ended up paying it,
+surprisingly enough. But it did not amount to a large amount,
+and it didn't have a lot of coverage effects.
+ Mr. Burgess. So, basically, the effect of the Tax and Jobs
+Act of 2017 was current law because no one behaved as if it was
+a real thing anyway.
+ Mr. Miller. Well, it had some other ripple consequences.
+But in that, practical consequences were not as significant as
+is often said.
+ Mr. Burgess. Well, let me ask you this. I mentioned in my
+opening statement that perhaps ways to end this lawsuit would
+be to either repeal the individual mandate outright or
+reestablish the tax within the individual mandate. Do you agree
+that either of those activities would----
+ Mr. Miller. That requires actually legislating, which is a
+hard thing to do these days on Capitol Hill.
+ Mr. Burgess. I think--yes, sir. But it would achieve the
+goal of breaking the lawsuit.
+ Mr. Miller. Sure. And there is lots of other things. I
+mean, States could pay us their own individual mandate. As I
+said, you could also just rescind your findings of fact in the
+old Congress and say, ``We were wrong, we are sorry.''
+ Mr. Burgess. I don't think that is going to happen.
+ Let me just ask you. I mentioned the phenomenon of silver
+loading in my opening statement. Would you walk us through, for
+people who are not familiar with that as a technical term----
+ Mr. Miller. Sure.
+ Mr. Burgess [continuing]. The phenomenon of silver loading?
+ Mr. Miller. It is a bit of a ripple of the other litigation
+over the cost-sharing reduction subsidies, and that has got a
+tangled web in itself.
+ But, cleverly, a number of States, insurance regulators,
+and insurers figured out a way to game the system, which is how
+do you get bigger tax credits for insurance by increasing your
+premiums.
+ There was also worry about what those market were doing,
+which fueled some of that increase, and a lot of spikes in the
+individual market over the previous 2 years as a result of
+that, and the silver loading embellished that.
+ Now, that was great for folks who were already covered
+where, because of the comprehensiveness of their subsidy income
+related, they weren't out any extra dollars as those premiums
+went up.
+ But the folks in the rest of the individual market--and
+Avik can talk to this as well--that is where we had our
+coverage losses, and that is where you got the damage being
+done. Those are the victims--the byproducts of doing good on
+one hand and it spills over into other people.
+ Mr. Burgess. That's the teacher and policeman that I
+referenced in my district who have two children. They are
+outside the subsidy window.
+ Mr. Roy, could you just briefly comment on the effect of a
+Medicare for All policy on what union members receive as their
+health insurance?
+ Mr. Roy. Well, I mean, of course, there are many different
+definitions of Medicare for All, but if we define it as the
+elimination of private insurance then, obviously, union members
+who have either Taft-Hartley-based plans or employer-sponsored
+insurance, that would be replaced by a public option or
+something like that. I assume that is what you mean.
+ Mr. Burgess. Yes, sir. Thank you. Thank you for being here.
+ I yield back.
+ Ms. Eshoo. Thank you, Ranking Member.
+ And who are we going to? To recognize the gentlewoman from
+the great State of California and its capital, Sacramento, Ms.
+Matsui.
+ Ms. Matsui. Thank you, Madam Chair.
+ Thank you all for joining us today. The topic of this
+hearing is incredibly important to me and my constituents and
+all Americans whose lives have been changed by the Affordable
+Care Act.
+ A special thank you to Ms. Hung for sharing your daughter's
+story and for your incredible advocacy work on behalf of
+children and families everywhere.
+ When we started writing the ACA 9 years ago, I consulted
+with a full range of healthcare leaders in my district in
+Sacramento. They called together the hospitals, the health
+plans, the community health centers, the patients, and all
+those who contribute to our healthcare systems and all those
+who use it also.
+ Everything was carefully constructed. We tried to think
+about everything but, obviously, you can't think of everything.
+But we consulted as widely as possible because we also knew
+that each policy would affect the next and the system as a
+whole.
+ You simply cannot consider radical changes to the law in a
+vacuum, yet that is exactly what this ruling of the lawsuit
+does. By using the repeal of the individual mandate in the GOP
+tax bill as justification of this suit, the court has declared
+the entire Affordable Care Act invalid.
+ Millions of Californians and Americans stand to lose
+critical health protections, including protections for people
+especially with preexisting conditions. Vital protections for
+Medicare beneficiaries including expanded preventive services
+and closing the prescription drug doughnut hole will be thrown
+into chaos.
+ I was pleased to join my colleagues to vote for the House
+of Representatives to intervene in this lawsuit and defend the
+ACA in our continued fight to protect people with preexisting
+conditions and for the healthcare of all Americans, and I think
+you know that that is something that all Americans care about
+when you think about preexisting conditions. Everybody has some
+sort of preexisting conditions.
+ For me, the potential consequences of the lawsuit are too
+great to not fully consider, especially for the impact on
+people confronting mental illness and substance abuse.
+ The passage of the ACA was a monumental step forward in our
+fight to confront the mental health and substance abuse crisis
+in this country and led to the largest coverage gains for
+mental health in a generation through the expansion of
+Medicaid.
+ Ms. Linke Young, can you briefly discuss why the consumer
+protections of the ACA are so important to individuals
+struggling with mental illness or substance abuse?
+ Ms. Young. Absolutely. Preexisting law--law that existed
+prior to 2009--established a baseline protection for people
+with mental illness that said that, if their insurance plan
+covered mental illness--mental health needs--then it had to do
+so on the same terms that it covered their physical treatment.
+ But it didn't require any insurance product to include
+coverage of mental health benefits. And so it was typical for
+coverage in the individual market to exclude mental health
+benefits completely.
+ With the Affordable Care Act, plans were required to
+include coverage for mental health and substance use disorder
+services and to do so at parity on the same terms as they
+include coverage for physical health benefits, and that brought
+mental health benefits to about 10 million Americans who
+wouldn't have otherwise had it.
+ In addition, the Medicaid expansion in the 37 States and DC
+and that have taken that option has enabled many, many people
+with serious mental health needs, including substance use
+disorder, to access treatment that they would not otherwise
+have been able to access.
+ Ms. Matsui. So this would be very serious, and I am
+thinking about the 37 States that did expand Medicaid, if this
+decision was upheld.
+ I just really feel, frankly, that it is difficult enough
+when you have mental illness or someone in your family does,
+the stigma that is attached to it, whereas with the Medicaid
+expansion I believe that most people will seek the treatment
+that they really need.
+ And what do you foresee with the loss of this expansion if
+it were to happen?
+ Ms. Young. If Federal funding for Medicaid expansion was no
+longer available, then the States that have expansion in place
+would need to choose whether to find State funding to fill that
+gap or to scale back their expansion or cut benefits or reduce
+provider rates or some combination of those policies.
+ The Congressional Budget Office and most experts expect
+that many States would retract the expansion and move those
+residents that were covered through expansion off the Medicaid
+rolls, and most of them are likely to become uninsured and
+would not continue to have access to mental health and
+substance use disorder coverage.
+ Ms. Matsui. So, in essence, we will be going backwards then
+once again. OK.
+ Thank you very much, and I yield back the balance of my
+time.
+ Ms. Eshoo. Thank you, Ms. Matsui.
+ I would now like to recognize the gentleman from Kentucky,
+Mr. Guthrie.
+ Mr. Guthrie. Thank you very much, and again,
+congratulations on your----
+ Ms. Eshoo. Thank you.
+ Mr. Guthrie [continuing]. On being the chair. I enjoyed
+being vice chair a couple of times and learned a lot about the
+healthcare system and moving forward.
+ And I know today the title is how does the Texas case
+affect preexisting conditions, and I think we are hearing from
+everybody that it would probably be near unanimous if we did a
+legislative fix to preexisting conditions regardless of where
+the case goes, and so I was listening to Dr. Burgess talk
+earlier about having a hearing for Medicare for All, and I
+think the chair of the full committee said that, well, ``Why
+would you want to have a hearing for a piece of legislation you
+say you're not for?''
+ I think it is important for us to talk about and the issues
+that would come because there are, I think, at least four or
+five presidential candidates that already said they were for
+it.
+ So it is not just some obscure bill that somebody files
+every year. It has now gotten into the public space that we
+need to discuss.
+ And Ms. Hung, I appreciate your testimony. I have nothing
+compared to your issues with your child, but I had a son that
+had some issues when he was a boy. He is 23 now, and so about a
+month of just, ``What is going to happen?''--so I understand
+the preexisting conditions--and then another year and a half,
+maybe 2 years, in and out of children's hospitals. But we got
+the best words a parent can hear when a physician walks in:
+``We know what the problem is now, and we can fix it.''
+ Matter of fact, just last fall he thought he was having
+some problems--so he lives in Chicago, west of Chicago. I went
+to see a--to a doctor with him and the doctor said, ``Hey, it
+is something else, it is something routine we can treat.'' He
+goes, ``By the way, you had a really great surgeon when he was
+8.'' So we were just reinforced with it. So everything kind of
+works.
+ And so what has kind of impressed me, and I guess I am
+going to just talk a little bit instead of ask questions, but
+what has always impressed me about the care--Vanderbilt
+Children's Hospital is where we were--that he has received and
+just the innovation our healthcare system is producing.
+ It is absolutely amazing innovation coming out in our
+healthcare system. The artificial pancreas is real now. People
+can have it now. You can cure hepatitis C with a pill. It is
+just amazing what is happening with some people, not a lot. It
+is not universal, but stage four melanoma is being cured with
+precision medicine.
+ I mean, those things are happening in our healthcare
+system. They are expensive, and my biggest concern if we go to
+a Government-run, that we just lose that healthcare. We
+innovate, and the world--and President Trump talked about it a
+little last night--is living off our investment in innovation.
+But if we don't invest and innovate, who is going to do it and
+who is going to have the care that we have?
+ As a matter of fact, we are investing and innovating so
+quickly, this committee spent an awful lot of time over the
+last couple of years to put 21st Century Cures in place so the
+Government regulatory structure can keep up with the vast
+investment.
+ I know we spent a lot of time in the last couple years
+doing oversight. I hope we will continue to do oversight of
+implementation of 21st Century Cures.
+ So my only point is, and I will yield back in just a couple
+seconds, is that it is important when we look at such massive
+changes to our healthcare system, the way people get health
+insurance.
+ You know, most people still get it through their employer.
+Is that going to go away? People get it through--we talked
+about the Indian Health Services. Is that going to go away? Is
+it a road to get rid of the VA?
+ Just, there is so much change that is proposed in what
+people boil down to one--a bumper sticker, Medicare for All--
+that it has implications for everybody. It has implications for
+the whole country, and universal coverage is a positive thing.
+ But if you get to the--I tell you, if you get to the
+Medicare reimbursements throughout the entire healthcare
+system, I am convinced we won't have the innovation that
+completely--my son is completely healed--that had some
+innovative surgeries--for his privacy I won't say--but 15 years
+ago that now are probably completely different on what you see.
+ My cousin is a NICU doctor, and the stuff that--the babies
+that he now sees that are surviving, and we have a colleague
+here that had a daughter born without kidneys who, I guess--
+Abby must be about 5 or 6 now.
+ And so it is just--that is a concern, and I think that when
+we are going to have a piece of legislation that has kind of
+been boiled down to a bumper sticker but it is going to have
+impact on everybody living in this country and everybody
+throughout the world--because I wish the world would help
+subsidize some of the innovations that we are producing--that
+it is worthy for us to have serious discussions and not just
+dismiss it as we are not being serious.
+ So and I can tell you I am, I know Dr. Burgess is and I
+think the rest of the committee would be, and I appreciate you
+guys all being here and sharing your stories.
+ But we can fix preexisting conditions. I think we are all
+on board with that, and Madam Chair, I yield back.
+ Ms. Eshoo. I thank you, Mr. Burgess. Always a gentleman.
+ Let us see. Who is next? The chairman of the full
+committee, Mr. Pallone.
+ Mr. Pallone. Thank you.
+ I wanted to ask Ms. Young a couple questions--really, one
+question. On the day of the Texas district court's ruling,
+President Trump immediately praised Judge O'Connor's decision
+to strike down protections for preexisting conditions.
+ The next day he referred to the ruling as, quote, ``great
+news for America,'' and just last week in an interview with The
+New York Times, President Trump boasted that the Texas lawsuit
+will terminate the ACA and referred to the ruling as a victory.
+ In his testimony, Mr. Roy claims that President Trump
+supports protecting people with preexisting conditions. I think
+that could not be further from the truth. The truth is,
+President Trump has sought to undermine and unravel protections
+for more than 130 million Americans living with preexisting
+conditions and, understandably, that is not a record that
+Republicans want to promote.
+ But I also want to remind folks that, since this is not a
+fact that my colleagues on the other side seem to want to
+acknowledge, and that is that the Republican lawsuit brought by
+Republican attorneys general, who asked the district court to
+strike down the entire ACA.
+ So the fact that my colleagues and our minority witnesses
+today are trying to disassociate themselves from Judge
+O'Connor's ruling, which did exactly what the Republican AGs
+asked for, I think is quite extraordinary.
+ Mr. Roy asserts in his written testimony that Congress
+should pass a simple bill reiterating guaranteed issue and
+community rating in the event that the district court's
+decision is upheld by the Supreme Court.
+ So, and then we have this GOP bill or motion during the
+rules package where they said that, you know, they would do
+legislation that would only include guaranteed issue and
+community rating, and that would ensure sufficient protections
+for preexisting conditions, whatever the courts decide.
+ So, basically, Ms. Young, I have one question. Can you
+explain why what Mr. Roy is asserting--that reinstating only
+these two provisions on guaranteeing issue and community
+rating--is insufficient to protect individuals with a
+preexisting condition and the same, of course, is with the
+House GOP bill that would do that.
+ Why is this not going to work to actually guarantee
+protection for individuals with preexisting conditions?
+ Ms. Young. The district court's opinion, as you note,
+struck down the entirety of the ACA. So not just its
+protections for people with preexisting conditions, but the
+financial assistance available to buy marketplace coverage,
+funding for Medicaid expansion, a host of provisions in
+Medicare, protections through the employer insurance and
+associated reforms.
+ So a standalone action that reinstated two preexisting
+conditions protections without wrapping that in the financial
+assistance and the risk adjustment and the Medicaid expansion
+and the other components of the ACA that are, in my view,
+important to make the system function, would not restore the
+system that we have today where people with preexisting
+conditions have access to a functioning market where they can
+buy coverage that meets their health needs.
+ In fact, there have been some efforts by the Congressional
+Budget Office to score various proposals that keep some types
+of preexisting condition protections in place but eliminate the
+financial assistance, and the Congressional Budget Office,
+under some scenarios, actually finds that those lead to even
+greater coverage losses than simply repealing the Affordable
+Care Act.
+ So implementing those two provisions on their own without
+financial assistance and other protections would be
+insufficient.
+ Mr. Pallone. I mean, I think this is so important because,
+you know, again, Mr. Roy--and he is just reiterating what some
+of my Republican colleagues say. They just neglect all these
+other things that are so important for people with preexisting
+conditions.
+ You didn't mention junk plans. I mean, my intuition tells
+me, and I am not--you know, I talk to people about it in my
+district--you know, that if you start selling these junk plans
+that don't provide certain coverage, one of the things is it is
+important for people with preexisting conditions to have a
+robust plan that provides coverage for a lot of things that
+didn't exist before the ACA.
+ I mean, that is, again, important--the fact that you have a
+robust essential benefits is also important for people with
+preexisting conditions, too, right?
+ Ms. Young. Those are both critical protections. In
+particular, the ACA seeks to ensure that insurance for the
+healthy and insurance for the sick are part of a single
+combined risk pool.
+ Efforts to promote short-term plans or other policies that
+don't comply with the ACA protections siphon healthy people out
+of the central market and drive up costs for those with
+preexisting conditions and anyone else seeking----
+ Mr. Pallone. Yes. So you are pointing out the very fact
+that you have a larger insurance pool, which has resulted from
+the ACA, in itself is important for people with preexisting
+conditions and if you take out the healthier or the wealthier
+because you don't have a mandate anymore, that hurts them too,
+correct?
+ Ms. Young. Efforts to move healthier people out of the
+individual market will increase premiums for those that remain
+in complaint coverage, yes.
+ Mr. Pallone. All right. Thank you so much.
+ Ms. Eshoo. Thank you, Mr. Pallone.
+ And now I want to recognize the ranking member of the full
+committee, Mr. Walden.
+ Mr. Walden. Thank you, Madam Chair, and I want to thank all
+of our witnesses. We have another hearing--an important one--
+going on downstairs. That is why some of us are bouncing back
+and forth between climate change and healthcare.
+ And I want to again say thank you for being here and
+reiterate that as Republicans we believe strongly in providing
+preexisting condition protection for all consumers, and if you
+go back to 1996, when HIPAA was passed under Republicans, we
+provided for continuous coverage protection for people with
+pre-ex.
+ I mean, this is something we believe in before ACA and
+something I believe in personally and deeply and something that
+we are ready to legislate on, and I think at least giving that
+guarantee and certainty to people would make a huge level of
+comfort for them.
+ And I just--you know, I didn't mean to shake things up this
+morning, but asking for a hearing on Medicare for All was
+something I thought was appropriate, given that other
+committees are already announcing their hearings, and that
+going back to when ACA was shoved through here and then Speaker
+Pelosi saying we had to pass it so you could find out what is
+in it--we don't want to repeat that. We need to know what is in
+it. We need thoughtful consideration. I think this committee is
+the place to have that. So I still think that is important.
+ I want to thank both Tom and Avik for being here--Mr. Roy--
+for being here on short notice. You said, Mr. Roy, that
+Congress should pass a simple standalone measure guaranteeing
+that insurers offer coverage in the individual health insurance
+market to anyone regardless of prior health status.
+ Mr. Roy. Yes, I did.
+ Mr. Walden. And do you want to respond? You didn't get a
+chance to kind of respond here. So do you want to respond to
+what was asked of the other witnesses around you?
+ Mr. Roy. Well, thank you, Mr. Walden. I appreciate the
+opportunity to actually explain my written testimony----
+ Mr. Walden. Go ahead.
+ Mr. Roy [continuing]. In this setting. The key here is that
+three-fourths of the variation of the premiums in health
+insurance in a fully underwritten market are associated with
+age, not health status or gender or anything else--preexisting
+conditions.
+ Mr. Walden. OK.
+ Mr. Roy. So the point is, if everybody of the same age--all
+27-year-olds, all 50-year-olds, all 45-year-olds--if all 45-
+year-olds are charged the same premium, the variation in
+premiums between the healthy paying a little more and the sick
+paying a little less is not that big of a difference. It
+doesn't cause a lot of adverse selection.
+ What drives adverse selection in the ACA is the fact that
+younger people are forced to pay, effectively, double or triple
+what they were paying before----
+ Mr. Walden. Right.
+ Mr. Roy [continuing]. To allegedly subsidize the premiums
+for older people. So revising age bands would be a huge step in
+moving in the right direction. Reinsurance, which is
+effectively a high-risk pool within a single-risk pool, would
+help basically also reduce the premiums that healthy people pay
+so that people with preexisting conditions could get better
+coverage.
+ So you can have a standalone bill that would ensure that
+people with preexisting conditions have access to affordable
+coverage.
+ Mr. Walden. I would hope so. I think it is really
+important. I mean, we were for preexisting protections. I was
+for getting rid of the insurance caps before ACA. I thought
+they were discriminatory against those who through no fault of
+their own had consequential health issues that could have blown
+through their lifetime caps.
+ And so I think there are things we could still find common
+ground on, and I wonder if you want to address the Medicare for
+All proposal as well.
+ Now, we haven't seen it spelled out. I know the Budget
+Committee is, I guess, having it scored and hearings on it. But
+I am concerned about the impacts it may have on delay in terms
+of getting healthcare. I am concerned about what it might do to
+the Medicare trust fund.
+ Do you have--do you want to opine on that while you are
+here?
+ Mr. Roy. Well, I have written a lot at Forbes and elsewhere
+about how Medicare for All from a fiscal standpoint is
+unworkable because of the gigantic transfers it would assign to
+the Federal Government.
+ It would increase Federal spending by somewhere between 28
+and 33 trillion dollars over a 10-year period, which would be
+an increase in overall Federal spending of 71 percent.
+ Now, that is not if--that excludes the impact of cutting
+what you pay hospitals and doctors and drug companies by 50
+percent, which is what you would have to do to effectively make
+the numbers work.
+ I do want to urge you, Mr. Walden, and your colleagues that
+while Medicare for All is unworkable, and I think most people
+know that, the status quo is unacceptable, too.
+ Mr. Walden. Right.
+ Mr. Roy. And I think it is extremely important for this
+committee in particular to tackle the high cost of hospital
+care, the high cost of drug prices.
+ Mr. Walden. Yes. That was--if I had stayed on as chair that
+was going to be our big priority this cycle. Surprise billing--
+I mean, you go in, you have a procedure, you have played by all
+the rules, and it turns out the anesthesiologist that put you
+under wasn't in your program and you get billed. That is wrong.
+That is just--I think we can find common ground on that one.
+ We took on the issue of getting generic drugs into market,
+and under the change in the law we passed last year, Dr.
+Gottlieb now has set a record for getting new generics in the
+market and driving both choice and innovation but also price
+down, and this administration--I have been in the meetings with
+the president and CEOs of the pharmaceutical companies. He is
+serious about getting costs down on drugs and getting to the
+middle part of this, too.
+ We need to look from one end to the other and, Madam Chair,
+I think we can find common ground here to do that and get
+transparency, accountability so consumers can have choice and
+so we can drive down costs.
+ I have used up my time, and I thank our witnesses again.
+ Madam Chair, I yield back.
+ Ms. Eshoo. I thank the ranking member.
+ We plan to examine all of that, and I think--I hope that we
+can find common ground on it because these are issues that
+impact all of our constituents, and they need to be addressed.
+ And on the surprise billing, I know that the Senate is
+trying to deal with it, and we should here as well. I think
+that your clock is not working at the witness table.
+ Mr. Roy. That is correct.
+ Ms. Eshoo. But it is working up here, OK. So maybe you can
+refer to that one.
+ Now I would like to call on the gentlewoman from Florida,
+Ms. Castor.
+ Ms. Castor. Thank you, Madam Chair. Witnesses, thank you
+very much for being here, and colleagues, thank you for all of
+your attention here.
+ I just think it is so wrong for the Trump administration
+and Republicans in Congress to continue to try to rip
+affordable health coverage away from American families,
+especially our neighbors with preexisting conditions.
+ This lawsuit is just a continuation of their efforts to do
+that. When they couldn't pass the bill here in the Congress--in
+the last Congress, despite Republican majorities--and I am
+sorry to say that my home State of Florida under Rick Scott's
+administration joined that Federal lawsuit.
+ Thirteen Democratic members of the Florida delegation have
+written to our new Governor and attorney general, asking--
+urging them to remove the State of Florida from the Federal
+lawsuit that would kill the Affordable Care Act and rip health
+coverage away from American families, including individuals
+with preexisting health conditions.
+ This follows the letter we sent to Rick Scott as well, and
+I would like to ask unanimous consent that these letters be
+admitted into the record of this hearing.
+ [The information appears at the conclusion of the hearing.]
+ Ms. Castor. American families are simply tired of the
+assault on affordable healthcare and, Chairwoman Eshoo, you
+raised the point about the skimpy junk insurance plans, because
+one way that the Trump administration and Republicans are
+trying to undermine affordable care are these junk health plans
+that do not provide fundamental coverage.
+ When you pay your hard-earned copayment and premiums, you
+should actually get a meaningful health insurance policy, not
+some skimpy plan that is just going to subject you to huge
+costs.
+ These subpar and deceptive junk plans exclude coverage for
+preexisting conditions. They discriminate based on age and
+health status and your gender.
+ Consumers are tricked into buying these junk plans,
+mistakenly believing that they are the comprehensive ACA plan,
+but then they are faced with huge out-of-pocket costs. For
+example, in a recent Bloomberg article, Dawn Jones from Atlanta
+was enrolled in a short-term junk plan when she was diagnosed
+with breast cancer. Her insurer refused to pay for her cancer
+treatment, leaving her with a $400,000 bill.
+ Another patient in Pennsylvania faced $250,000 in unpaid
+medical bills because her junk short-term policy did not
+provide for prescription drug coverage and other basic
+services.
+ The Trump administration now is actively promoting these
+junk plans, and I want American families and consumers across
+the country to be on alert. Don't buy in to these false
+promises.
+ Ms. Young, you have talked a little bit about this, but
+will you go deeper into this? Help us educate families across
+the country. I understand that these plans often impose
+lifetime and annual limits. Is that correct?
+ Ms. Young. It is, yes.
+ Ms. Castor. And that is something the Affordable Care Act
+outlawed?
+ Ms. Young. Correct.
+ Ms. Castor. Can you describe what these plans typically
+look like and what kind of coverage they purport to provide?
+ Ms. Young. Short-term limited duration insurance is not
+regulated at the Federal level. None of the Federal consumer
+protections apply. Some State law protections may apply or----
+ Ms. Castor. Consumer protections--name them.
+ Ms. Young. The requirement that plans cover essential
+health benefits, the prohibition on annual and lifetime limits,
+the requirement that the insurance company impose a cap on the
+total copays and deductibles an individual can face over the
+year, requirements to cover preventive services, to not exclude
+coverage for preexisting conditions and other----
+ Ms. Castor. Wait a minute. Wait a minute. I have heard some
+of my Republican colleagues say they are all in favor of that.
+But can you be in favor of preexisting condition protection on
+the one hand and then say, ``Oh, yes, we believe these junk
+insurance plans are the answer,'' like the Trump administration
+and Republicans in Congress are promoting?
+ Ms. Young. Short-term limited duration plans do not have to
+comply with the requirements about preexisting conditions. That
+is correct.
+ Ms. Castor. Can you describe why an individual who is
+healthy when they sign up for one of these junk plans could
+still be subject to hundreds of thousands of dollars in medical
+bills?
+ Ms. Young. There is no requirement that short-term plans
+cover any particular healthcare cost. So an individual who
+doesn't read the fine print behind their policy might discover,
+for example, that the plan only covers hospital stays of a few
+days and individuals are on the hook for all additional
+hospital expenses.
+ They may find that the plan has a very low annual limit, so
+that once they have spent 10 or 20 thousand dollars, they are
+responsible for bearing the full cost or any variation like
+that where they simply discover when they need to access the
+healthcare system that the plan doesn't include the coverage
+that they had hoped to purchase.
+ Ms. Castor. Thank you very much, and we will be working to
+ensure that consumers are protected and, when they pay their
+premiums and copays, they actually get a meaningful health
+insurance policy.
+ Thank you, and I yield back.
+ Ms. Eshoo. I thank the gentlewoman.
+ I now would like to call on Mr. Griffith from Virginia. You
+are recognized for 5 minutes.
+ Mr. Griffith. Thank you very much, Madam Chair. I
+appreciate it.
+ Here is the dilemma that we have. In my district, which is
+financially stressed in many parts of it--I represent 29
+jurisdictions in rural southwest--always put the pause in
+there--Virginia.
+ So when ACA came in so many of my people immediately came
+to me, long before the Trump administration came in, and in
+their minds the ACA was junk insurance, because when they were
+promised that their premiums would go down, they now had
+premiums that were financially crippling.
+ When they were promised that they would have better access,
+they now found that they had high deductibles and they now
+found that their copays had gone through the roof.
+ So there is no question--I never argued--that the
+preexisting condition was a problem that should have been dealt
+with long before the ACA, and I understand the concerns and the
+frustration that people had who had preexisting conditions, and
+we need to take care of that and we will take care of that.
+ I don't see anybody who would argue at this point that we
+shouldn't deal with people with preexisting conditions and make
+sure they have access to affordable healthcare, which is why I
+supported our attempts to get an amendment put in on day one of
+this Congress that would say, get the committees of
+jurisdiction.
+ In fact, it referenced the Energy and Commerce Committee--
+this committee--and the Ways and Means Committee to report out
+a bill that took care of all of the concerns we have heard
+today and said it guarantees no American citizen can be denied
+health insurance coverage as the result of a previous illness
+or health status and guarantees no American citizen can be
+charged higher premiums or cost sharing as the result of a
+previous illness or health status, thus ensuring affordable
+health coverage for those with preexisting conditions.
+ That is where we are. That is what we stand for. So, you
+know, I find it interesting that this debate has become--you
+know, and I am hearing about junk insurance and how Republicans
+are evil, that they want junk insurance.
+ I hear it on a regular basis that my people think that what
+they have got now is junk. It is all they can afford, and it is
+costing them a fortune.
+ So, Mr. Roy, what do you have to say about that?
+ Mr. Roy. I have found the conversation we have been having
+about so-called junk insurance interesting because nobody seems
+to be asking the question as to why people are voluntarily
+buying so-called junk insurance.
+ They are buying it because the premiums are half or a third
+or a quarter of what the premiums are for the Affordable Care
+Act for them.
+ Mr. Griffith. And if you can't afford something else, you
+are going to buy something that you can afford. Isn't that
+correct?
+ Mr. Roy. A hundred percent. So a plan that has all the
+bells and whistles but it is unaffordable to you is
+effectively, worthless, whereas a plan that may not have all
+the bells and whistles but at least provides you some coverage
+is.
+ And the great tragedy of the Affordable Care Act is that we
+did not have to have that dichotomy. We could have had plans
+that had robust coverage for people with preexisting conditions
+and protections for people regardless of health status and yet
+were still affordable.
+ I have outlined it both in my written testimony, in my oral
+testimony, and many, many other documents that I have presented
+to this committee in the past, how we could achieve that.
+ Mr. Griffith. Now, you would agree with me for those people
+who may have bought the junk insurance without knowing what
+they were getting into that we probably ought to pass something
+that says that the things that aren't going to be covered--if
+you're only getting $20,000 worth of care and then you have to
+take the full bill after that, as Ms. Castor talked about--we
+should have that in bold language on the front of the policy.
+ You would agree that we should put some consumer protection
+in that and make sure there is transparency so people are well-
+advised of what they are getting or not getting. Isn't that
+true?
+ Mr. Roy. I have no problem with robust disclosure about
+what is in a short-term limited duration plan versus an ACA-
+compliant plan. To a degree, we already have that in the sense
+if you are buying off the ACA plan, I think most consumers know
+that those plans have fewer protections, but more disclosure,
+and more clarity in disclosure would be a good thing.
+ Mr. Griffith. Absolutely. I agree with that.
+ You know, what is interesting is everybody seems to have
+gone after Judge O'Connor. I don't know him. I haven't studied
+his opinions.
+ But I do find this interesting. I thought it was the right
+thing to do. He put a stay on his ruling so it didn't create a
+national catastrophe or suddenly people are having to scramble
+to figure out what to do.
+ Mr. Miller, isn't that a little unusual in this day--I
+mean, people have accused him of being biased or having a
+political bent and using his power. But I seem to recall all
+kinds of opinions by judges that I thought were coming from a
+slightly different philosophical bent but who went out there on
+a limb, stretched--pushed the envelope of the law.
+ But instead of saying, ``Now, let us wait until the appeal
+is over and make sure this is right before we affect the
+average citizen,'' they just let it go into effect. But Judge
+O'Connor said, ``No, in case this is overturned, I want to make
+sure nobody is adversely impacted'' and put a stay on his own
+ruling.
+ Isn't that unusual, and wasn't that the right thing to do?
+ Mr. Miller. No, it is not--it is hopscotch. We have had
+some Federal judges who have had nationwide injunctions
+reaching way beyond what you would think would be the normal
+process.
+ Mr. Griffith. Yes. I have noticed that.
+ Mr. Miller. I think all the parties understood what
+practically was going on here. I would just point out on the
+legalities of this, just to clean up the record, one of the
+things about----
+ Ms. Eshoo. Just summarize quickly, because your time is up.
+ Mr. Miller. My time is up. OK.
+ Mr. Griffith. You could summarize, she said.
+ Ms. Eshoo. Quickly.
+ Mr. Miller. I will just say, real fast, we left out the
+argument about tax guardrails, which was in Chief Justice
+Roberts' opinion, and Si is exaggerating what is there and
+isn't there.
+ The problem is that, when you take it apart, there is
+nothing left behind.
+ Ms. Eshoo. OK. I think your time is expired.
+ Mr. Miller. It was his testimony, was that this tax didn't
+exist anymore.
+ Ms. Eshoo. All right. We are now going to go to and
+recognize Dr. Ruiz from California.
+ Mr. Ruiz. Thank you. It is so wonderful to be on this
+committee finally. So thank you to all----
+ [Laughter.]
+ Ms. Eshoo. He hasn't stopped celebrating.
+ Mr. Ruiz. Thank you to all the witnesses for joining us
+today. We have over 130 million Americans that have preexisting
+conditions. The ACA defended full protections for people with
+preexisting conditions, and those are three components.
+ One is that insurance companies cannot deny insurance to
+people with preexisting conditions; two, they cannot deny
+coverage of specific treatments related to the preexisting
+condition illness; and three, they cannot discriminate by
+increasing the prices towards people who have a preexisting
+condition.
+ Let me give you some examples of some of the benefits and
+hardships that people would face if this lawsuit is completed.
+ My district is home to Desert AIDS Project, an FQHC that
+was founded in 1984 to address the AIDS crisis. It is the
+Coachella Valley's primary nonprofit resource for individuals
+living with HIV/AIDS. They have grown to become one of the
+leading nonprofits and effective HIV/AIDS treatment in the
+Nation.
+ And the folks at Desert AIDS Project know how to end the
+HIV/AIDS epidemic. Basically, you need prevention and you need
+treatment. They told me that the ACA has been critical in
+providing treatment to the HIV--in order to get the HIV viral
+load at an uninfectious low level.
+ So the problems before the ACA was that insurance companies
+didn't used to have to pay for HIV tests, for example, or
+individuals with HIV couldn't get Medicaid coverage until they
+were really sick on full-blown AIDS, many already on their
+death beds.
+ Now, because of the ACA, insurance companies must cover
+essential health benefits like HIV tests and antiviral
+medications, which by the way the folks on the other side have
+attempted to repeal.
+ Because of the ACA and the Medicaid expansion many HIV-
+infected middle class families now have health insurance for
+the very first time. Unfortunately, I can't say that for HIV
+patients throughout our country including in States like Texas
+that didn't expand the Medicaid coverage.
+ And, by the way, this is another example of ACA that those
+on the other side attempted to repeal. Before the passage of
+the ACA, 90 percent of Desert AIDS Project clients did not have
+health insurance, and now, with the ACA, 99.9 percent of
+clients have health insurance coverage in Desert AIDS Project.
+ Let me repeat that statistic. Insurance coverage for these
+patients went from only 10 percent to 99.9 percent because of
+the ACA. And yet, the president, while claiming to be committed
+to eliminating the HIV/AIDS epidemic in 10 years, is actively
+taking measures to take away these protections of this very
+population by rolling back the Medicaid expansion and weakening
+and undermining preexisting conditions protections.
+ This would be devastating to Desert AIDS Project clients
+and patients, and yet this is just one example of the
+devastation that repeal of the ACA would cause on individuals
+with preexisting conditions.
+ Ms. Young, could you discuss the potential impact of the
+lawsuit on individuals with preexisting conditions if the
+district court's decision is upheld?
+ Ms. Young. If the district court decision were to be upheld
+as written, it would disrupt the coverage for people with
+preexisting condition in all segments of the insurance market.
+ So we talked a lot about the individual market. The core
+protections in the individual market today would be eliminated
+along with the financial assistance that enables them to afford
+coverage and make those markets stable.
+ In employer coverage, people with preexisting conditions
+would also face the loss of certain protections. They would
+once again be exposed to lifetime or annual limits and they
+could face unlimited copays.
+ Mr. Ruiz. Let me get to another point because, you know, we
+are hearing a lot of political trickery here in the
+conversations. A number of the folks on the other side have
+introduced bills that will pick and choose which one of these
+three components that make up full protections for preexisting
+conditions that they want to have in certain bills.
+ For example, one bill says, we want guaranteed issue and
+community rating which will help keep the costs low for
+everybody but don't include the prohibition on preexisting
+coverage exclusions.
+ Another bill includes guaranteed issue and the ban on
+preexisting coverage exclusion but does not include the
+community rating, saying, well, let us charge people with
+preexisting more than other folks.
+ So they claim these bills are adequate to protect consumers
+with preexisting conditions. Can you explain why these bills
+are inadequate to protect individuals with preexisting
+conditions?
+ Ms. Young. Very briefly, requiring insurance companies to
+sell a policy but allow preexisting condition exclusions
+requires them to sell something but it doesn't have to have
+anything in it. It is a little bit like selling a car without
+an engine.
+ And allowing unlimited preexisting condition rate-ups tells
+the consumer that they can buy a car but they could be charged
+Tesla prices even if they are buying a Toyota Camry. That is
+not what the Affordable Care Act does. It puts in place a
+comprehensive series of protections.
+ Mr. Ruiz. Thank you.
+ Ms. Eshoo. Your time has expired. I thank the gentleman.
+ I now would like to recognize Dr. Bucshon from Indiana.
+ Mr. Bucshon. Thank you, and congratulations on your
+chairmanship. Look forward to working with you.
+ I am a physician. I was a heart surgeon before I was in
+Congress, and we all support protections for preexisting
+conditions. Look, I had a couple of patients over the years who
+I did heart surgery on who had--one had had Hodgkin's disease
+in his 20s, and his entire life after that he could not afford
+health coverage, and that is just plain wrong. We all know
+that.
+ I had an employee of mine whose wife met her lifetime cap
+because of a serious heart condition and had to ultimately go
+onto Medicaid. That is not right.
+ So I think Republicans for many years have supported
+protecting people with preexisting conditions. I think we are
+in a policy discussion about the most appropriate way to do
+that.
+ And so I really think what we should be focusing on is to
+make sure that people actually have coverage that they can
+afford--quality affordable health coverage, and under the ACA,
+as was previously described, the deductibles can be very high.
+You couldn't keep your doctor and your hospital, as everyone
+said that supported the ACA, and so we are not meeting that
+goal.
+ And now we have heard from the Democrats about Medicare for
+All and their bill in the last Congress, H.R. 676, would have
+made it illegal for private physician practices to participate
+in a Government healthcare program. And by the way, Medicare
+for All doesn't even solve the main problem we have in
+healthcare, which is the huge cost.
+ I keep telling people if you continue to debate how to pay
+for a product that is too expensive, you are not going to catch
+up. It doesn't matter who is paying for it. It doesn't matter
+if the Government is paying for it or a partial hybrid system
+like we have now.
+ So I am hoping we can have some hearings on how we get the
+cost down, and the insurance problem kind of almost can solve
+itself if we can do that.
+ We should be talking about the fact that people with
+preexisting conditions really don't have protections, and it
+doesn't work if you don't have actual access to a physician.
+ So Mr. Miller and Mr. Roy--I will start with Mr. Roy--can
+you talk about what could happen in the U.S. if private
+physician practices were not allowed to participate in a
+single-payer program, hypothetically, and would that create
+access issues for patients?
+ Mr. Roy. Well, we already have access issues for patients
+in the Medicaid program. A lot of physicians don't accept
+Medicaid----
+ Mr. Bucshon. That is correct.
+ Mr. Roy [continuing]. Even though they theoretically
+participate in the Medicaid program. That is also an increasing
+problem in Medicare because there are disparities in the
+reimbursement rates between private insurers, Medicare, and
+especially Medicaid.
+ And this is one of the other flaws in the ACA, is it relied
+on a program with very poor provider access to expand coverage.
+I think the exchanges at least have the virtue of using private
+insurers to expand coverage rather than the Medicaid program
+with its much lower reimbursement rates.
+ Mr. Bucshon. So I would argue that, you know, then if you
+go to a Medicare for All, you have access issues on steroids,
+potentially, and especially if you don't allow private practice
+physicians--what I am saying, nonhospital or Government-
+employed physicians, which is what we would all be--to
+participate in the program, which is actually not what other
+countries do.
+ In England, for example, you can have your private practice
+and also participate in the National Health Service.
+ Mr.----
+ Mr. Miller. You are more likely to have Medicaid for All
+than Medicare for All until you solve the--and say ``Stop, we
+can't deal with that.'' The problem is we would love to give
+away all kinds of stuff. We just don't want to pay for it.
+ Now, we can shovel it off into ways in which you get less
+than what was promised and say, ``We have done our job.'' We
+did that to an extent with the ACA. You find the lowest-cost
+way to make people think they are getting something that is
+less than what they actually received.
+ That is why the individual market as a whole has shrunk in
+recent years. It is because those people who are not well-
+subsidized in the exchanges are finding out they can't afford
+coverage anymore.
+ Mr. Bucshon. So, I mean, and I will stick with you, Mr.
+Miller. Do you think if the iteration of Medicare for All bans
+private practice physicians not to be able to participate that
+we would put ourselves at risk of creating a two-tiered system
+where the haves can have private coverage and there can be
+private hospitals as there is in other countries?
+ Mr. Miller. Well, already we have got plenty of tiers in
+our system to begin with. It would exacerbate those problems
+and I don't think we would live with it politically, which is
+why it would probably short circuit.
+ But it is at least a danger when people believe in the
+theory of what seems easy but the reality is very different.
+ Mr. Bucshon. Yes. I mean, I would have an ethical problem
+as a physician treating patients differently based on whether
+or not they are wealthy or whether or not they are subjected to
+a Medicare for All system, right.
+ So, ethically, I can tell you physicians would have a
+substantial problem with that. Other countries kind of do that
+because that is just the way it is there and I think in many
+respects their citizens don't have a problem with it because
+that is just what they have always lived with.
+ But I would agree with you that in the United States there
+would be some issues.
+ Mr. Roy, do you have any comments on that?
+ Mr. Roy. I do. I would just like to add that at the
+Foundation for Research on Equal Opportunity we put together a
+detailed proposal for private insurance for all, where everyone
+buys their own health insurance with robust protections for
+preexisting conditions and health status and robust financial
+assistance for people who otherwise can't afford coverage in a
+way that is affordable, that would actually reduce Federal
+spending by $10 trillion over three decades but would ensure 12
+million more people have access to health insurance than do
+today under current law.
+ So there are ways to address the problem of affordability
+and access of health insurance while also reducing the
+underlying cost of coverage and care and making the fiscal
+system more sustainable.
+ Mr. Bucshon. Yes. I mean, I think we should be also putting
+focus on the cost of the product itself, right, and the reasons
+why it costs so much are multi-factorial. It is a free market
+system.
+ The other thing is, I told my local hospital administrators
+that if we get Medicare for All, get ready to have a Federal
+office in your private hospital that tells you how to run your
+business.
+ I yield back.
+ Ms. Eshoo. I thank the doctor.
+ And last, but not least, Mr. Rush from Illinois is
+recognized for 5 minutes for questioning.
+ Mr. Rush. Thank you, Madam Chair.
+ Madam Chair, I also want to congratulate you for your
+becoming chair of the subcommittee and----
+ Ms. Eshoo. I thank you very much.
+ Mr. Rush [continuing]. I have been a Member of Congress for
+quite--for, as you have, for over 26 years, and this is my
+first time being a member of this subcommittee, and I am
+looking forward to working with you and other members of the
+subcommittee.
+ I want to--as I recall, when this Affordable Care Act was
+passed, there were millions of Americans who were without
+health insurance totally. They were uninsured. They had no help
+at all, no assistance from anyone to deal with their illnesses
+and their diseases.
+ And since the Act was passed, approximately 20 million
+Americans have gained health coverage, including over a million
+in my State, and I don't want to overlook that fact. I don't
+want to get that fact lost in the minutia of what we--of any
+one particular aspect of our discussion.
+ In 2016, almost 14,000 of my constituents received
+healthcare subsidies to make their healthcare more affordable.
+One aspect of the ACA that I like is insurance companies must
+now spend at least 80 percent of their premium on actual
+healthcare as opposed to other kinds of pay for CEOs and also
+for an increase of their profits.
+ And the insurance rate has increased between--the uninsured
+rate, rather, has increased between the years 2013 and 2017--
+since 2017 in my State.
+ Ms. Young, how many Americans would expect to lose coverage
+if this court decision in Texas were upheld?
+ Ms. Young. The Congressional Budget Office has estimated
+that repeal of the Affordable Care Act against their 2016
+baseline would result in 24 million additional uninsured
+Americans, and upholding the district court's decision we could
+expect sort of broadly similar results with adjustments for the
+new baseline.
+ Mr. Rush. Mm-hmm.
+ I want to ask Ms. Hung, you've been sitting here patiently,
+remarkably, listening to a lot of discussion between experts.
+But how do you feel about your daughter? How do you feel? What
+is your reaction to all of this as it relates to the looming
+problem that you have if this case is upheld?
+ Ms. Hung. Thank you. No one is going to sit here and say
+that they are not going to protect preexisting conditions,
+right. No one is going to say that. But that is what we have
+seen. That is what families like mine have seen--repeal
+efforts, proposals that don't cover preexisting conditions or
+claim to give a freedom of choice to choose what kind of
+insurance we want.
+ Well, the choice that I want is insurance that covers, that
+guarantees that these protections are in place. I don't want to
+sit in the NICU at my daughter's bedside wondering if she is
+going to make it and also then have to decide what kind of
+insurance I am going to buy and imagine what needs that she
+will have in order to cover that.
+ So I sit here and say, well, what worked for me is that I
+got to spend 169 days at my daughter's bedside without worrying
+about whether we would go bankrupt or lose our home, and that
+is the guarantee that we need.
+ Mr. Rush. Madam Chair, I yield back.
+ Ms. Hung. Thank you.
+ Ms. Eshoo. I thank the gentleman.
+ I now would like to call on another new member of the
+subcommittee, and we welcome her. Ms. Blunt Rochester from the
+small but great State of Delaware.
+ [Laughter.]
+ Ms. Blunt Rochester. Thank you, Madam Chairwoman.
+ First of all, thank you so much for your leadership. It is
+an honor for me to be on this subcommittee. And excuse me, I
+had competing committees for my first day of subcommittees and
+so I have been running back and forth.
+ But this is a very important topic, and I want to
+acknowledge Ms. Hung. The last time I saw you we were at a
+press event with then-Leader Pelosi highlighting the Little
+Lobbyists and the work that you do and have been doing, and
+just your support of protecting preexisting conditions for
+children across the country.
+ And it is really admirable that you advocate not only for
+your child but for all children across the country and have
+been fighting for decades. And I was hoping that you could talk
+a little bit about the formation of the Little Lobbyists and
+who they are, what it is all about, how it formed.
+ Ms. Hung. Thank you, Congresswoman, and thank you for your
+support. I did not set out to start the Little Lobbyists. It
+kind of just happened. We were following the news, where
+families like mine, families with children with complex medical
+needs and disabilities, were very concerned, were very worried.
+And we decided to speak up and tell our stories.
+ And I tell my story because I know that many have been
+fortunate to not experience the challenges and hardships that
+we have seen. I also know that many have not experienced the
+joy and gratitude that I had in being Xiomara's mother.
+ So I feel a responsibility to uplift these stories that we
+weren't seeing being represented. Now, I have spent more than
+my fair share of time in the hospital. I have witnessed my baby
+on the brink of life and death one too many times.
+ I know what is possible with access to healthcare--quality
+healthcare--and I think I can say that I have a profound
+understanding, more than many Americans, how fragile life is,
+and it is with that understanding that I have chosen to spend
+my time raising that awareness.
+ I acknowledge my privilege. I acknowledge my proximity to
+Washington, DC, to come here. There are so many stories like
+mine across the country of families who are just fighting for
+their children, who want to spend that time on their kids and
+not worrying about filing for bankruptcy or losing their home
+or wondering if they can afford lifesaving medication.
+ Ms. Blunt Rochester. Yes, that was going to be my next
+question. How does this uncertainty affect your family? How is
+it affecting individuals that you work with and are talking to
+and other Little Lobbyists?
+ Ms. Hung. It is everything. It is everything. So the
+uncertainty is not knowing. I mean, we don't know what the
+future holds. None of us do. But to add this on top of what we
+are going through, on top of the NICU moms that I know that are
+worrying, who are trying to keep their jobs and trying to be
+there for their children, to add this level of uncertainty on
+top of it is just devastating.
+ Ms. Blunt Rochester. I wanted to have your voice heard. I
+know from hearing that we have a lot of great experts and a
+great panel here, and I would like to bring it back to what
+this is all about. Maybe--I don't know if I am the last one
+speaking or--but I wanted to bring it back to why we are doing
+this and why we are here.
+ I have served the State of Delaware in different
+capacities, as our deputy secretary of health and social
+services, I have been in State personnel, so I have seen
+healthcare from that perspective and also from an advocacy
+perspective as CEO of the Urban League.
+ But hearing your story makes this real for us and is really
+one of the reasons why I wanted to be on this committee. So I
+thank you for your testimony. I thank the committee for your
+expert testimony, and I yield back the balance of my time.
+ Ms. Eshoo. Thank you very much.
+ I don't see anyone else from the Republican side.
+ Mr. Burgess. There's some people coming back, but proceed.
+ Ms. Eshoo. OK. All right. We will move on.
+ I now would like to recognize the gentleman from
+California, Mr. Cardenas.
+ Mr. Cardenas. Thank you, and thank you, Chairwoman Eshoo
+and Ranking Member Burgess, and all the staff for all the work
+that went into holding this hearing of this committee, and I
+appreciate all the effort that has gone into all of the
+attention that we are putting forth to healthcare both at the
+staff level and at the Member level, and certainly for the
+advocates in the community as well.
+ Thank you so much for your diverse perspectives on what is
+important to the health and well-being of all Americans.
+ I think, while the legal arguments and implications of this
+case are important, I want to take a few minutes to focus on
+the very personal threats posed by these attacks to the
+Affordable Care Act.
+ This ruling, if upheld, would take away healthcare for tens
+of millions of Americans, including our most vulnerable,
+especially children and seniors. They are especially at risk,
+and people with preexisting conditions, we would see them just
+be dropped from the ability to get healthcare.
+ For some of us, this is literally a life-and-death
+situation and, as lawmakers, I hope that we don't lose sight of
+the fact of how critical this is, and as the lawmakers for this
+country, I hope that we can move expeditiously with making sure
+that we can figure out a way to not allow the courts to
+determine the future and the fate of millions of Americans when
+it comes to their healthcare and healthcare access.
+ Also, I want to thank everybody who is here today, and also
+the court's ruling would ideologically and politically, you
+know, follow through with the motivation that I believe close
+to 70 times or so in this Congress there was an effort to end
+it, not mend it, when it comes to the Affordable Care Act, and
+I think it is inappropriate for us to look at in such a black-
+and-white manner.
+ There are cause and effects should the Affordable Care Act
+go away. I happen to be personally one of those individuals
+that, through a portion of my childhood, did not have true
+access to healthcare, and it's the kind of thing that no parent
+should go through and the kind of situation that no American
+should ever have to contemplate, waiting until that dire moment
+where you have to go to the emergency room instead of just
+looking forward to the opportunity to, you know, sticking out
+your tongue and asking the doctor questions and they ask you
+questions and they find out what is or is not wrong, and that
+is the kind of America that used to be.
+ And since the Affordable Care Act, imperfect as it is, that
+is not the America of today. The America of today means that,
+if a young child has asthma, that family can in fact find a way
+to get an equal policy of healthcare just like their neighbor
+who doesn't have a family member with a preexisting condition.
+ So with that, I would like to, with the short balance of my
+time, ask Ms. Hung, could you please expand on the uncertainty
+that you have already described that your family would face
+should this court decision end the Affordable Care Act as we
+know it?
+ And then also could you please share with us, are you
+speaking only for you and your family or is this something that
+perhaps hundreds of thousands if not more American families
+would suffer that fate that you are describing?
+ Ms. Hung. Thank you. I am here on behalf of many families
+like mine. The Little Lobbyists families are families with----
+ Mr. Cardenas. Dozens or thousands?
+ Ms. Hung. Thousands, across the country, families with
+children with complex medical needs and disabilities. And these
+protections that we are talking about today, they are not just
+for these children. They are for everyone. They are for
+everybody. Any one of us could suddenly become sick or disabled
+with no notice whatsoever. Any one of us could go suddenly from
+healthy to unhealthy with no notice and have a preexisting
+condition. An accident could happen, a cancer diagnosis, a sick
+child.
+ There is no shame in being sick. There is no shame in being
+disabled. Let us not penalize that. There is no shame in
+Xiomara needing a ventilator to breathe or needing a wheelchair
+to go to the playground.
+ But there is shame in allowing insurance companies to
+charge her more money just because of it, more for her care,
+and there is shame in allowing families like mine to file for
+bankruptcy because we can't afford to care for our children.
+ It is that uncertainty that is being taken away or at risk
+right now. Our families are constantly thinking about that
+while we are at our children's bedside.
+ Mr. Cardenas. I just want to state with the balance of my
+time that this court case could be the most destructive thing
+that could have ever happened in American history when it comes
+to the life and well-being of American citizens.
+ I yield back the balance of my time.
+ Ms. Eshoo. I thank the gentleman.
+ I now would like to recognize my friend from Florida, Mr.
+Bilirakis.
+ Mr. Bilirakis. Thank you, Madam Chair, and congratulations
+on chairing the best subcommittee in Congress, that's for
+sure--the most important.
+ Ms. Eshoo. Oh, thank you.
+ Mr. Bilirakis. Mr. Miller, the Texas court decision hinges
+on the individual mandate being reduced to zero in the law. Can
+you explain the court's reasoning in their decision?
+ Mr. Miller. Well, I mean, we have to go back to a lot of
+convoluted reasoning in prior decisions in order to get there.
+So this is a legacy of trying to save the Affordable Care Act
+by any means possible, and it gets you into a little bit of a
+bizarre world.
+ But if you take the previous opinions at their face--it was
+somewhat of a majority of one by Chief Justice Roberts--he
+basically saved the ACA, which otherwise would have gone down
+before any of this was implemented, by having a construction
+which said, ``I found out it is a tax after all,'' and he had
+three elements as to what that tax was.
+ The problem is, once you put the percentage at zero and the
+dollar amount at zero, it is not a tax anymore. It is not
+bringing in revenue. You don't pay for it in the year you file
+your taxes. It is not calculated the way taxes are.
+ So that previous construction, if you just look in a
+literal way at the law, doesn't hold anymore. What we do about
+it is another issue beyond that. But on the merits, we have got
+a constitutional problem, and in that sense that court decision
+was accurate. People then say, ``Where do you go next?,'' and
+that is the mess we are in.
+ Mr. Bilirakis. Yes. Could legislation be passed that would
+address the court's concern, such as reimposing the individual
+mandate?
+ Mr. Miller. All kinds of legislation. You are open for
+business every day, but sometimes business doesn't get
+conducted successfully. There are a wide range of things that I
+can imagine and you can imagine that would deal with this in
+either direction.
+ You have to pass something. What we are doing is we are
+passing the buck. We are trying to uphold some odd contraption,
+which is the only one we have got, as opposed to taking some
+new votes and saying, ``What are you in favor of and what are
+you against?'' and be accountable for it and build a better
+system.
+ Mr. Bilirakis. Thank you.
+ Mr. Roy, you have written extensively on how to build a
+better healthcare system. The goal of the individual mandate,
+when the Democrats--now the majority party--passed the ACA, was
+to create a penalty to really force people to buy insurance.
+ Are there alternative ways to provide high-quality
+insurance at low prices without a punitive individual mandate?
+ Mr. Roy. Absolutely. So, as we have discussed already and I
+know you haven't necessarily been here for some of that
+discussion, simply the fact that there is a limited open
+enrollment period in the ACA prevents the gaming of jumping in
+and out of the system, and that is a standard practice with
+employer-based insurance. It is a standard practice in the
+private sector parts of Medicare. That is a key element.
+ Another key element is to reform the age bands--the 3-to-1
+age bands in the ACA--because that actually is the primary
+driver of healthy and particularly younger people dropping out
+of the market.
+ Another key piece is to actually lower, of course, the
+underlying cost of healthcare so that premiums will go down and
+making sure that the structure of the financial assistance that
+you provide to lower-income people actually matches up with the
+premium costs that are affordable to them.
+ And a big part of it is, again, making the insurance
+product a little bit more flexible so plans have the room to
+innovate and make insurance coverage less expensive than it is
+today.
+ Mr. Bilirakis. All right. Thank you very much.
+ I yield back, Madam Chair, the rest of my time.
+ Ms. Eshoo. Thank you, Mr. Bilirakis.
+ I now would like to recognize the gentleman from Oregon,
+Mr. Schrader.
+ Mr. Schrader. Thank you, Madam Chair. I appreciate that.
+ I think sometimes we forget that the ACA was a response to
+a bipartisan concern about the construction of the healthcare
+marketplace prior to the ACA.
+ It was a pretty universal opinion, not a partisan issue,
+that healthcare costs were completely out of control. Whether
+you were upper middle class or low income or extremely wealthy,
+it was unsustainable.
+ And the ACA may not be perfect but, as pointed out at the
+hearings, it gave millions of Americans healthcare that didn't
+have it before. It started to begin the discussion that we are
+talking about here: How do you create universal access in an
+affordable way to every American?
+ Certainly, I am one of the folks that believe healthcare is
+a right, not a privilege, in the greatest country in the world.
+We are discussing about different ways to get at it.
+ I think one of the most important things that doesn't get
+talked about a lot is the importance of the essential health
+benefits. It gets demonized because, well, geez, ``I am not a
+woman so I shouldn't have to pay for maternity. You know, I am
+invincible. I am never really going to get sick, so I don't
+need to pay for, you know, emergency healthcare.''
+ Those things are ancillary. I guess, Ms. Young, talk to us
+a little bit about why the essential health benefits are part
+of the Affordable Care Act, and there have been some attempts
+by the administration and different Members not, I think,
+realizing how important they are with these often, you know,
+cheaper plans. Just get the cost down--they are ignoring maybe
+the health aspects of that. Could you talk a little bit about
+that?
+ Ms. Young. Absolutely.
+ Prior to the Affordable Care Act, insurers could choose
+what benefits they were going to place in their benefit
+policies.
+ The Affordable Care Act essential health benefit
+requirements require that all insurers in the individual and
+small group markets cover a core set of 10 benefits--things
+like hospitalizations and doctors visits as well as maternity
+care, mental health and substance use disorder, prescription
+drugs, outpatient services.
+ So, really, ensuring that the insurance that people are
+buying offers a robust set of benefits that provides them
+meaningful protection if they get sick.
+ If you return to a universe where an issuer can choose what
+benefits they are going to put inside of a policy, you could
+have an insurance benefit that, for example, excludes coverage
+for cancer services and another policy that excludes coverage
+for mental health needs, and one that excludes coverage for a
+particular kind of drug.
+ Mr. Schrader. And that might be in the fine print and
+people may not realize that as they sign up for policies.
+ Ms. Young. That is correct, yes. So it would require
+consumers to really pile through the insurance--different
+policies to understand what they were buying.
+ It also provides a back-door path to underwriting because
+insurers, for example, that exclude coverage for cancer from
+their benefit won't attract any consumers who have a history of
+cancer, who have reason to believe that they may need cancer
+coverage.
+ And so it really takes our insurance market from one that
+successfully pools together the healthy and the sick to one
+that becomes more fragmented.
+ Mr. Schrader. Right. Well, and another piece of the
+Affordable Care Act that gets overlooked--and, again, it has
+been alluded to by different Members and some of you on the
+panel--is the innovation, the flexibility--I mean, the Center
+for Medical Innovation, the accountable care organizations.
+ Instead of--you know, it seems to me we are focused just on
+cost: How do I itemize this cost? We ask you guys these
+questions--the rate bands and all that stuff. We should be
+concerned about healthcare.
+ I mean, the goal here is to provide better health. It's not
+to support the insurance industry or my veterinary office or
+whoever. The goal is to provide better healthcare, and the way
+you do that is by, I think, you know, having the experts in
+different communities figure out what is the best healthcare
+delivery system.
+ Do you need more dentists in one community? Need more
+mental health experts in another community?
+ I am very concerned that, if the Affordable Care Act is
+undone, that a lot of this innovation that has been spawned,
+the accountable care organizations that are going, would begin
+to dissolve. There would be no framework for them to operate
+in.
+ Just recently in Oregon, where I come from, we had a record
+number of organizations step up to participate in what we call
+our coordinated care organizations that deal with the Medicaid
+population and have over 24 different organizations vying for
+that book of business.
+ Could you talk just real briefly--I am sorry, timewise--
+real briefly about, you know, what would happen if those all
+went away?
+ Ms. Young. As you note, the Affordable Care Act introduced
+a number of reforms and how Medicare pays to incentivize more
+value-based and coordinated care.
+ If the district court's decision were to be upheld, then
+the legislative basis for some of those programs would
+disappear and there would really be chaos in Medicare payment
+if that decision were upheld.
+ Mr. Schrader. OK. Thank you, and I yield back, Madam Chair.
+ Ms. Eshoo. I thank the gentleman.
+ I can't help but think that this was a very important
+exchange in your expressed viewpoints and counterpoint to Mr.
+Miller's description of the ACA as an odd contraption.
+ I now would like to----
+ Mr. Miller. I would respond on that if I had the
+opportunity.
+ Ms. Eshoo. I am sure you would.
+ Let us see, who is next? Now I would like to recognize Mr.
+Carter from Georgia.
+ Mr. Carter. Well, thank you, and thank all of you for being
+here. Very, very interesting subject matter that we have as our
+first hearing of the year. I find it very interesting.
+ Mr. Miller, let me ask you, just to reiterate and make sure
+I understand. I am not a lawyer. I am a pharmacist, so I
+don't----
+ Mr. Miller. Good for you.
+ Mr. Carter. Yes. I don't know much about law or lawyers
+and----
+ Mr. Miller. It is a dangerous weapon.
+ Mr. Carter. Well, let me ask you something. Right now, this
+court case, how many patients is it impacting?
+ Mr. Miller. Well, people hypothetically might react
+thinking it is real, but otherwise, nobody.
+ Mr. Carter. But it is my understanding it is still in
+litigation.
+ Mr. Miller. Correct. Correct. And it is going to take a
+while, and it is going to end up differently than where it
+starts. But we are doing this, you know, make believe because
+it scores a lot of points.
+ Mr. Carter. Well, I--make believe--I mean, we are in
+Congress. We are not supposed to be make believe.
+ Mr. Miller. Well----
+ Mr. Carter. I mean, I am trying to understand why this is
+the first hearing, when it is not impacting a single patient at
+this time, it is still in litigation, we don't know how it is
+going to turn out, we don't know how long it is going to take.
+Judging by other court cases that we have seen, it may take a
+long, long time.
+ Mr. Miller. Well, to be fair, I used to run hearings in
+Congress on staff.
+ Mr. Carter. Well----
+ Mr. Miller. The majority can run any kind of hearing it
+wants to.
+ Mr. Carter [continuing]. We are not here to be fair. So
+anyway, I am trying to figure out why this is the first
+hearing. I mean, you know, earlier the chairman of the full
+committee berates our Republican leader because he asked for a
+hearing on something that he is opposed to and that I am
+opposed to, and I am just trying to figure it out.
+ You know, one of the things that we do agree on is that
+preexisting conditions need to be covered. Isn't it possible
+for us to still be working on preexisting conditions now and
+legislating preexisting conditions while this is under
+litigation?
+ Mr. Miller. What you need are majorities who are willing to
+either spend money----
+ Mr. Carter. Well----
+ Mr. Miller [continuing]. Change rules and move things
+around. But that has been hard for Congress to do.
+ Mr. Carter. Well, I think that the record will show that,
+you know, one of the first bills that we proposed in the
+Republican Party, in the Republican conference, was for
+preexisting conditions--Chairman Walden. In fact, I know he did
+because I cosponsored it.
+ Mr. Miller. Mm-hmm. Yes. It was one of the more thorough
+ones, actually.
+ Mr. Carter. It is something that--we have concentrated on
+that. So thank you for that. I just want to make sure.
+ Mr. Roy, I want to ask you, did you testify before the
+Oversight Committee recently?
+ Mr. Roy. Last week, yes.
+ Mr. Carter. What were they talking about in the Oversight
+Committee? What were you testifying about?
+ Mr. Roy. Prescription drug prices. The high cost of
+prescription drugs.
+ Mr. Carter. Prescription drugs. Go figure. Here we are in
+the committee and the subcommittee with the most jurisdiction
+over healthcare issues, and Oversight has already addressed
+prescription drug pricing?
+ Mr. Roy. Well, you have 2 years in this committee, and I
+look forward to hopefully being invited to talk----
+ Mr. Carter. Well, I do too. I am just baffled by the fact
+that, you know, drug pricing is one of the issues--is the issue
+that most citizens when polled identify as being something that
+Congress needs to be active on, and I am just trying to figure
+out. In Oversight they have already addressed it.
+ Mr. Roy. You know, one thing I will say about this topic,
+Mr. Carter, is that it is one of the real opportunities for
+bipartisan policy in this Congress. We have a Republican
+administration and a Democratic House where there has been a
+lot of interest in reducing the cost of prescription drugs, and
+I am optimistic that we really have an opportunity here to get
+legislation through Congress.
+ Mr. Carter. And I thank you for bringing that up because
+Representative Schrader and I have already cosponsored a bill
+to stop what I think is the gaming of the system of the generic
+manufacturers and the brand-name manufacturers of what they are
+doing in delaying generic products to get onto the market.
+ So, Madam Chair, I am just wondering when are we going to
+have----
+ Ms. Eshoo. Gentleman yield? Would the gentleman yield?
+ Mr. Carter. And if I could ask a question.
+ Ms. Eshoo. Mm-hmm.
+ Mr. Carter. When are we going to have a hearing on
+prescription drug costs?
+ Ms. Eshoo. I can't give you the date. But it is one of the
+top priorities of the majority. It is one of the issues that we
+ran on with the promise to lower prescription drug prices. I
+believe that there is a bipartisan appetite for this, and we
+will have hearings and we will address it and we welcome your
+participation.
+ Mr. Carter. Well, reclaiming my time. I appreciate that
+very much, Madam Chair, because it is a pressing issue and it
+is an issue that needs to be addressed now and today, unlike
+what we are discussing here today that is not impacting one
+single person at this point.
+ So, you know, with all due respect, Madam Chair, I hope
+that we can get to prescription drug pricing ASAP because it is
+something that we need to be and that we are working on.
+ And, Mr. Roy, you could not be more correct. This is a
+bipartisan issue. I practiced pharmacy for over 30 years. Never
+did I once see someone say, ``Oh, this is the price for the
+Democrat, this is the price for the Republican, this is the
+price for this person and that person.'' It was always the
+same. It was always high. That is why we need to be addressing
+this.
+ So I thank you for being here. I thank all of you for being
+here and, Madam Chair, I yield back.
+ Ms. Eshoo. I thank the gentleman.
+ I now would like to recognize a new member of the
+subcommittee, Ms. Barragan from California. Welcome.
+ Ms. Barragan. I thank you. Thank you, Ms. Chairwoman.
+ My friend from Georgia asked why we are having this as the
+first hearing, and I just have to say something because, you
+know, I am in my second term, and in my first term when the
+Republicans were in the majority they spent all of their time
+trying to take away healthcare coverage for millions of
+Americans.
+ They talk about preexisting conditions and talk about
+saving people with preexisting conditions. But this very
+lawsuit is going to put those people at stake.
+ So why are we having this hearing? Well, because you guys
+have been working to take away these coverages and we are
+trying to highlight the importance of this lawsuit.
+ Now, you had 2 years and, yes, you could have started with
+prescription drug prices and reducing those, and that wasn't
+done. So you are darn right the Democrats are going to take it
+up.
+ You are darn right that we are going to have hearings on
+this, and I am proud to say that our chairwoman and our
+chairman have been working hard to make sure we are going to
+work to bring down prescription drug prices. But the hypocrisy
+that I hear on the other side of the aisle can't just go
+completely unanswered in silence.
+ So, with that said, I am going to move on to what my
+comments have been. I want to thank you all for your testimony
+here today. It has been really helpful to hear us understand
+the potentially devastating impact of this lawsuit and of the
+district court's decision.
+ The court's decision would not only eliminate protections
+for preexisting conditions but would also adversely impact the
+Medicaid program and end the Medicaid expansion.
+ Now, the Affordable Care Act's expansion of Medicaid filled
+a major gap in insurance coverage and resulted in 13 million
+more Americans having access to care.
+ I represent a district that is a majority minority--about
+88 percent black and brown people of color and, you know, black
+and brown Americans still have some of the highest uninsured
+rates in the country. Both groups have seen their uninsured
+numbers fall dramatically with the ACA. You know, between 2013
+and 2016, more than 4 million Latinos and 1.9 million blacks
+have secured affordable health coverage. Ultimately, black and
+brown Americans have benefitted the most from the ACA's
+Medicaid expansion program.
+ Ms. Young, I would like to ask, can you briefly summarize
+the impact of the lawsuit on Medicaid beneficiaries and, in
+particular, the expansion population?
+ Ms. Young. Medicaid expansion is, as you note, a very
+important part of the Affordable Care Act's coverage expansion,
+and it is benefitting millions of people in the 37 States that
+have expanded or are in the process of expanding this year.
+ Medicaid expansion has been associated with better
+financial security, and failure to expand is associated with
+higher rates of rural hospital closures and other difficult
+impacts in communities.
+ If this decision were to be upheld, then the Federal
+funding for Medicaid expansion would no longer be provided and
+States would only be able to receive their normal match rate
+for covering the population that is currently covered through
+expansion. That is an impact of billions of dollars across the
+country and a very large impact in individual States.
+ States will have the choice between somehow finding State
+money to make up that gap or ending the expansion and removing
+those people from the Medicaid rolls or potentially cutting
+provider rates or making other changes in the benefit package
+or some combination.
+ So you are looking at a potentially loss of--see very
+significant losses of coverage in that group as well as an
+additional squeeze on providers.
+ Ms. Barragan. Thank you.
+ Ms. Hung, how has Medicaid helped your family afford
+treatment, and why is Medicaid and Medicaid expansion so
+important for children with complex medical needs and their
+families?
+ Ms. Hung. Medicaid is a lifesaving program. I say this
+without exaggeration. Medicaid is the difference between life
+and death. It covers what health insurance doesn't cover for a
+lot of children with complex medical needs.
+ Notably, it covers long-term services and supports,
+including home and community-based services that enable
+children's independence. For a lot of families who do have
+health insurance like mine, health insurance doesn't really
+cover certain DME--durable medical equipment--certain
+specialists, the ability to go out of State.
+ And so that is the difference for a lot of our families.
+ Ms. Barragan. Great. Well, thank you all. I yield back.
+ Ms. Eshoo. Thank you very much.
+ Now, the patient gentleman from Montana, Mr. Gianforte.
+ Mr. Gianforte. Thank you, Madam Chair, and thank you to the
+panelists for your testimony today.
+ Every day, I hear from Montanans who ask me why their
+healthcare costs keep going up and continue to increase while
+their coverage seems to shrink at the same time.
+ While we look for long-term solutions to make healthcare
+costs more affordable and accessible, I remain firmly committed
+to protecting those with preexisting conditions.
+ In fact, I don't know anyone on this committee, Republican
+or Democrat, who doesn't want to protect patients with
+preexisting conditions. Insuring Americans with preexisting
+conditions can keep their health insurance and access care is
+not controversial.
+ It shouldn't be. We all agree on it. Which brings us to
+today. In the ruling in Texas v. Azar, it has not ended
+Obamacare. It hasn't stripped coverage of preexisting
+conditions, and it hasn't impacted 2019 premiums.
+ While we sit here today talking about it, the Speaker has
+moved to intervene in the case and the judge ruling has been
+appealed. The case is working itself through the courts.
+ We could have settled this with a legislative solution less
+than a month ago. One of the earliest votes we took in this
+Congress was to lock in protection for patients with
+preexisting conditions.
+ Unfortunately, Democrats rejected that measure. And yet,
+here we are in full political theater talking about something
+we all agree on--protecting Americans with preexisting
+conditions.
+ We should be focused instead on the rising cost of
+prescription drugs, telehealth, rural access to healthcare, and
+other measures to make healthcare more affordable and
+accessible.
+ I hope this committee will hold hearings and take action on
+these issues important to hardworking Montanans. I can
+understand, however, why my friends on the other side of the
+aisle do not want to take that path.
+ Some of their party's rising stars and others jockeying for
+Democratic nomination in 2020 have said we should do away with
+private insurance. They advocate for a so-called Medicare for
+All. In reality, Medicare for none.
+ Their plan would gut Medicare and the VA as we know it, and
+force 225,000 Montanan seniors who rely on Medicare to the back
+of the line. Montana seniors have earned these benefits, and
+lawmakers shouldn't undermine Medicare and threaten healthcare
+coverage for Montana seniors.
+ Since we all agree we should protect patients with
+preexisting conditions, let us discuss our different ideas for
+making healthcare more affordable and accessible.
+ We should put forward our ideas: on the one hand, Medicare
+for All, a Government-run single-payer healthcare system that
+ends employer-sponsored health plans; on the other, a health
+insurance system that protects patients with preexisting
+conditions, increases transparency, choice, and preserves rural
+access to care and lowers cost.
+ I look forward to a constructive conversation about our
+diverging approaches to fixing our healthcare system. In the
+meantime, I would like to direct a question to Mr. Miller, if I
+could.
+ Under Medicare for All, Mr. Miller, do you envision access
+to care would be affected for seniors and those with
+preexisting conditions in rural areas in particular?
+ Mr. Miller. Well, that is a particular aspect. I think, in
+general, the world that seniors are currently used to would be
+downgraded. You are taking--spreading the money a little wider
+and thinner in order to help some. This is the story of the
+ACA.
+ We can create winners, but we will also create losers. Now,
+the politics as to who you favor sort out differently in
+different folks. It is hard to get a balancing act where
+everybody comes out on top unless you make some harder
+decisions, which is to set priorities and understand where you
+need to subsidize and what you need to do to improve care and
+the health of people before they get sick.
+ Mr. Gianforte. So it is your belief that, if this Congress
+were to adopt a Medicare for All approach, seniors would be
+disadvantaged? It will be more difficult to access care?
+ Mr. Miller. They would be the first to be disadvantaged, as
+well as those with employer-based coverage because--if you
+swallowed it whole. I mean, there are lots of other problems
+Avik mentioned. It is not just the spending. It is actually the
+inefficiency of the tax extraction costs.
+ When you run that much money through the Government, you
+don't get what you think comes out of it.
+ Mr. Gianforte. One other topic, quickly, if I could.
+Telehealth is very important in rural areas. It is really vital
+to patients in Montana. How do you foresee telehealth services
+being affected under a single-payer system?
+ Mr. Miller. Well, Medicare has probably not been in the
+forefront of promoting telehealth. I think there is a lot more
+buzz about telehealth as a way to break down geographical
+barriers to care, to have more competitive markets.
+ And so, if past history is any guide of Medicare fee-for-
+service, it is not as welcoming to telehealth as private
+insurance would be.
+ Mr. Gianforte. OK. And I yield back.
+ Ms. Eshoo. I thank the gentleman.
+ I now would like to recognize the gentleman from Vermont,
+Mr. Welch.
+ Mr. Welch. Thank you. I will be brief. Just a few comments.
+ I think it is important that we had this hearing. This did
+not come out of thin air. I mean, I was on the committee when
+we wrote the Affordable Care Act. Very contentious. It was a
+party-line vote.
+ I was on the committee when we repealed it--this committee
+repealed the Affordable Care Act, and we never saw a bill. We
+never had a hearing.
+ And now we have a continuation of this effort by the
+Republican attorneys general to attack it, and we have the
+unusual decision by the administration where, instead of
+defending a Federal law, they are opposing a Federal law.
+ So it is why I have been continuing to get so many letters
+from Vermonters who are fearful that this access to healthcare
+that they have is really in jeopardy.
+ Loretta Heimbecker from Montgomery has a 21-year-old son
+who is making $11.50 an hour. He has got a medical condition
+from birth, and absent the access to healthcare he wouldn't be
+able to work and the mother would probably be broke.
+ I have got a cancer patient, Kathleen Voigt Walsh from
+Jericho, who would not have access to the treatment she needs
+absent this. I mean, Ms. Hung, you really, in your own personal
+presentation, have explained why people who really need it
+would be scared if we lost it.
+ And I also served in Congress when the essential agenda on
+the Republican side was to try to repeal it. I mean, it was a
+pretty weird place to be--Congress--when on a Friday afternoon,
+if there is nothing else to do, we would put a bill on the
+floor to repeal healthcare for the sixtieth time. I mean, we
+are just banging our head against the wall.
+ So thank you for having this hearing because I see it as a
+reassurance to a lot of people I represent that we mean
+business--that we are going to defend what we have.
+ Now, second, on some of the criticisms about this not being
+a hearing on prescription drugs, Mr. Roy, you were in--did a
+great job helping us start the process in Oversight and
+Government Reform.
+ But I know our chair of this subcommittee--this is the
+committee where there is actual jurisdiction--is totally
+committed to pursuing this, and I thank our chair.
+ And I have been hearing very good things from President
+Trump about the need to do this. So my hope is that we are
+going to get a lot of Republican support to do practical things
+so we are not getting ripped off, as the president has said, by
+us paying the whole cost of research--a lot of it, by the way,
+from taxpayers, not necessarily from the companies--and have to
+pay the highest prices.
+ So I am commenting and not asking questions. But I know
+that there has been extensive and excellent testimony. But I
+just want to say to the chair and I want to say to my
+colleagues, Republican and Democrat, if the net effect of this
+hearing is that we are affirming a bipartisan commitment not to
+mess with the Affordable Care Act, then I am going to be able
+to reassure my constituents that their healthcare is safe.
+ And if the criticism is essentially we have got to do more,
+we are ready to do more, right?
+ Madam Chair, so I thank you for this hearing, and I thank
+the witnesses for their excellent testimony and look forward to
+more down the line.
+ Ms. Eshoo. I thank the gentleman for his comments and his
+enrichment of the work at this subcommittee. I think it is
+important to note that, on the very first day of this Congress,
+that House Democrats voted to intervene in this case--the very
+first day of the Congress--as it moves through appeal.
+ So we are the ones that are representing the Government,
+and I think that, for my colleagues on the other side of the
+aisle, you may not like my suggestion, but if you are for all
+of these things that you are talking about, write to the
+attorneys general and the Governors that brought the suit and
+say, ``We want it called off. We want to move on and strengthen
+the healthcare system in our country.'' You will find a partner
+in every single person on this side of the aisle.
+ With that, I would like to recognize Mr. O'Halleran--what
+State?
+ Mr. Burgess. Arizona.
+ Ms. Eshoo. Arizona--from the great State of Arizona--who
+is, I believe, waiving on to the subcommittee, and we have a
+wonderful rule in the full committee that, if you are not a
+member of a subcommittee you can still come and participate.
+But you are the last one to be called on. So thank you for your
+patience, and thank you for caring and showing up.
+ Mr. O'Halleran. I thank you, Madam Chair. I am also usually
+last in my house also to be called on.
+ Thank you, Madam Chair. Although I am not a permanent
+member of the subcommittee, I appreciate your invitation for me
+to join you today to discuss this issue that is so critical to
+families across Arizona, and thank you to the witnesses.
+ As some of you know, the district I represent is extremely
+large and diverse--the size of Pennsylvania. Twelve federally
+recognized Tribes are in my district.
+ Since I came to Congress 2 years ago, I have been focused
+on working across the aisle to solve healthcare issues. We face
+these issues together because it is one thing that I hear about
+every single corner of my rural district and one of the
+overriding issues in Congress.
+ A district where hospitals and the jobs they provide are
+barely hanging on and where decades of toxic legacy of uranium
+mining has left thousands with exposure-related cancers across
+Indian country.
+ A district where Medicaid expansion made the difference for
+some veterans getting coverage, some hospitals keeping their
+doors open, where essential health benefits meant some
+struggling with opiate addiction could finally get substance
+abuse treatment.
+ I am here because the lawsuit we are discussing today isn't
+about any of those policies and how they save taxpayer dollars
+and protect rural jobs. I am a former Republican State
+legislator. I know that this lawsuit is purely motivated not by
+what is best for the people we are representing but by
+politics.
+ Ms. Young, I have three questions for you. The first is,
+the first letter I ever sent as a Member of Congress was a
+bipartisan letter to congressional leadership about dangers of
+ACA repeal on the Indian Health Care Improvement Act, which was
+included in the ACA.
+ Madam Chair, I ask unanimous consent to enter my letter
+into the record.
+ Ms. Eshoo. So ordered.
+ [The information appears at the conclusion of the hearing.]
+ Mr. O'Halleran. Ms. Young, can you describe what the fate
+of this law would be if this lawsuit succeeds and what it means
+for Tribal communities?
+ Ms. Young. The district court's opinion as written struck
+down the entire Affordable Care Act so it would--even unrelated
+provisions like the Indian Health Care Improvement Act--so, if
+the decision were upheld, then the Indian Health Care
+Improvement Act would no longer have the force of law and the
+improvements included in that law, like better integration with
+the Veterans Health Service and better integration for
+behavioral health and other core benefits for the Indian Health
+Service, would be eliminated.
+ Mr. O'Halleran. Thank you, Ms. Young.
+ Are cancers caused by uranium exposure considered a
+preexisting condition?
+ Ms. Young. I suspect that under most medical underwriting
+screens they would be, yes.
+ Mr. O'Halleran. Thank you. And, Ms. Young, over 120 rural
+hospitals have closed since 2005. Right now, 673 additional
+facilities are vulnerable and could close. That is more than a
+third of rural hospitals in the United States.
+ If this lawsuit succeeds, do you anticipate rural hospitals
+and the jobs they provide would be endangered as a result of
+fewer people having health coverage?
+ Ms. Young. As you know, rural hospitals face a number of
+challenges and a number of difficult pressures. There has been
+research demonstrating that a State's failure to expand
+Medicaid is associated with higher rates of rural hospital
+closures. And so, if the Federal funding for Medicaid expansion
+were removed, then it is likely that that would place
+additional stress on rural hospitals.
+ Mr. O'Halleran. Thank you.
+ Madam Chair, this is why last year I led the fight to urge
+my State's attorney general to drop this partisan lawsuit. So
+much is at stake in Arizona for veterans, the Tribes, for jobs
+in rural communities like mine.
+ I am interested in finding bipartisan solutions to the
+problems we have got, and I will work with anyone here to do
+that. But this lawsuit doesn't take us in that direction. It
+takes us back, and my district can't afford that.
+ Thank you, and I yield back.
+ Ms. Eshoo. I thank the gentleman for making the time to be
+here and to not only make his statement but ask the excellent
+questions that you have.
+ At this time I want to remind members that, pursuant to the
+committee rules, they have 10 business days to submit
+additional information or questions for the record to be
+answered----
+ Mr. Burgess. Madam Chair?
+ Ms. Eshoo. Yes.
+ Mr. Burgess. Could I seek recognition for a unanimous
+consent request?
+ Ms. Eshoo. Sure. Just a minute. Let me just finish this,
+all right?
+ I want to remind Members that, pursuant to committee rules,
+Members have 10 business days to submit additional questions
+for the record to be answered by the witnesses who have
+appeared, and I ask each of the witnesses to respond promptly
+to any such questions, and I see your heads nodding, so I am
+comforted by that, that these questions that you may receive.
+ And I would recognize the ranking member, and I also have a
+list of--to request unanimous consent for the record.
+ Mr. Burgess. Oh, I can go after you.
+ Ms. Eshoo. OK. The first, a statement for the record from
+the American Cancer Society Cancer Action Network and 33 other
+patient and consumer advocacy organizations; a statement for
+the record from the American Academy of Family Physicians; a
+statement for the record from the American College of
+Physicians; the Wall Street Journal editorial entitled ``Texas
+Obamacare Blunder.'' I think that was referenced by Mr. Lazarus
+earlier today.
+ Jonathan Adler and Abbe Gluck, New York Times op-ed
+entitled ``What the Lawless Obamacare Ruling Means''; a brief
+of the amicus curiae from the American Medical Association, the
+American Academy of Family Physicians, the American College of
+Physicians, the American Academy of Pediatrics, and the
+American Academy of Child and Adolescent Psychiatry.
+ Isn't it extraordinary what we have in this country? Just
+the listing of these organizations.
+ The U.S.A. Community Catalyst, the National Health Law
+Program, Center for Public Policy Priorities, and Center on
+Budget and Policy Priorities; the brief of the amici curiae
+from the American Cancer Society, the Cancer Action Network,
+the American Diabetes Association, the American Heart
+Association, the American Lung Association, and National
+Multiple Sclerosis Society supporting defendants; and a
+statement for the record from America's Health Insurance Plans.
+ So I am asking a unanimous consent request to enter the
+following items in the record. I hear no objections, and I will
+call on--recognize the ranking member.
+ [The information appears at the conclusion of the
+hearing.]\1\
+---------------------------------------------------------------------------
+ \1\ The amici briefs have been retained in committee files and also
+are available at https://docs.house.gov/Committee/Calendar/
+ByEvent.aspx?EventID=108843..
+---------------------------------------------------------------------------
+ Mr. Burgess. Thank you. First off, thank you for reminding
+me why I have not yet paid my AMA dues this year.
+ [Laughter.]
+ Mr. Burgess. I have a unanimous consent request. I would
+ask unanimous consent to place into the record the letter that
+was sent by Mr. Walden and myself regarding the Medicare for
+All hearing.
+ Ms. Eshoo. No objection.
+ [The information appears at the conclusion of the hearing.]
+ Ms. Eshoo. The only request that I would make is that maybe
+on your email mailing list that, when you notify the chairman
+of the full committee, that maybe my office can be notified as
+well.
+ Mr. Burgess. Welcome to the world that I inhabited 2 years
+ago.
+ Ms. Eshoo. That's why I think you will understand.
+ Mr. Burgess. I never found out until after the fact.
+ Ms. Eshoo. Right. Right.
+ Mr. Burgess. But I would take that up with your full
+committee chair. I am sure they will recognize the importance
+of including you in the email distribution list.
+ Ms. Eshoo. I thank the gentleman.
+ Let me just thank the witnesses. You have been here for
+almost 3 hours. We thank you for not only traveling to be here
+but for the work that you do that brings you here as witnesses.
+ Mr. Lazarus says he is retired, but he brings with him
+decades of experience. We appreciate it. To each witness,
+whether you are a majority or minority witness, we thank you,
+and do get a prompt reply to the questions because Members
+really benefit for that.
+ So our collective thanks to you, and to Ms. Hung, what a
+beautiful mother. You brought it all. I am glad that you are
+sitting in the center of the table, because you centered it all
+with your comments.
+ So with that, I will adjourn this subcommittee's hearing
+today.
+ Thank you.
+ [Whereupon, at 1:03 p.m., the committee was adjourned.]
+ [Material submitted for inclusion in the record follows:]
+ [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
+
+
+ [all]
+