[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\
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\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..
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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.]
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