99–006 

112TH CONGRESS REPT. 112–40 " ! HOUSE OF REPRESENTATIVES 1st Session Part 1 

PROTECT LIFE ACT 

MARCH 17, 2011.—Ordered to be printed 

Mr. UPTON, from the Committee on Energy and Commerce, 

submitted the following 

R E P O R T 

together with 

DISSENTING VIEWS 

[To accompany H.R. 358] 

[Including cost estimate of the Congressional Budget Office] 

The Committee on Energy and Commerce, to whom was referred 

the bill (H.R. 358) to amend the Patient Protection and Affordable 

Care Act to modify special rules relating to coverage of abortion 

services under such Act, having considered the same, report favorably thereon with an amendment and recommend that the bill as 

amended do pass. 

CONTENTS 

Page 

Amendment .............................................................................................................. 2 

Purpose and Summary ............................................................................................ 3 

Background and Need for Legislation .................................................................... 4 

Hearings ................................................................................................................... 5 

Committee Consideration ........................................................................................ 6 

Committee Votes ...................................................................................................... 6 

Committee Oversight Findings ............................................................................... 11 

Statement of General Performance Goals and Objectives .................................... 11 

New Budget Authority, Entitlement Authority, and Tax Expenditures ............. 11 

Earmark ................................................................................................................... 11 

Committee Cost Estimate ....................................................................................... 11 

Congressional Budget Office Estimate ................................................................... 11 

Federal Mandates Statement ................................................................................. 12 

Advisory Committee Statement .............................................................................. 12 

Applicability to Legislative Branch ........................................................................ 12 

Section-by-Section Analysis of the Legislation ...................................................... 12 

Changes in Existing Law Made by the Bill, as Reported ..................................... 15 

Dissenting Views ..................................................................................................... 21 


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AMENDMENT

The amendment is as follows: 

Strike all after the enacting clause and insert the following: 

SECTION 1. SHORT TITLE. 

This Act may be cited as the ‘‘Protect Life Act’’. 

SEC. 2. MODIFYING SPECIAL RULES RELATING TO COVERAGE OF ABORTION SERVICES 

UNDER THE PATIENT PROTECTION AND AFFORDABLE CARE ACT TO CONFORM TO 

LONG-STANDING FEDERAL POLICY. 

(a) IN GENERAL.—Section 1303 of the Patient Protection and Affordable Care Act 

(Public Law 111–148), as amended by section 10104(c) of such Act, is amended— 

(1) by redesignating subsections (c) and (d) as subsections (e) and (f), respectively; 

(2) by redesignating paragraph (4) of subsection (b) as subsection (d) and 

transferring such subsection (d) after the subsection (c) inserted by paragraph 

(4) of this subsection with appropriate indentation (and conforming the style of 

the heading to a subsection heading); 

(3) by amending subsection (b) to read as follows: 

‘‘(b) SPECIAL RULES RELATING TO TRAINING IN AND COVERAGE OF ABORTION SERVICES.—Nothing in this Act (or any amendment made by this Act) shall be construed 

to require any health plan to provide coverage of or access to abortion services or 

to allow the Secretary or any other Federal or non-Federal person or entity in implementing this Act (or amendment) to require coverage of, access to, or training in 

abortion services.’’; 

(4) by inserting after subsection (b) the following new subsection: 

‘‘(c) LIMITATION ON ABORTION FUNDING.— 

‘‘(1) IN GENERAL.—No funds authorized or appropriated by this Act (or an 

amendment made by this Act), including credits applied toward qualified health 

plans under section 36B of the Internal Revenue Code of 1986 or cost-sharing 

reductions under section 1402 of this Act, may be used to pay for any abortion 

or to cover any part of the costs of any health plan that includes coverage of 

abortion, except— 

‘‘(A) if the pregnancy is the result of an act of rape or incest; or 

‘‘(B) in the case where a pregnant female suffers from a physical disorder, 

physical injury, or physical illness that would, as certified by a physician, 

place the female in danger of death unless an abortion is performed, including a life-endangering physical condition caused by or arising from the 

pregnancy itself. 

‘‘(2) OPTION TO PURCHASE SEPARATE COVERAGE OR PLAN.—Nothing in this subsection shall be construed as prohibiting any non-Federal entity (including an 

individual or a State or local government) from purchasing separate coverage 

for abortions for which funding is prohibited under this subsection, or a qualified health plan that includes such abortions, so long as— 

‘‘(A) such coverage or plan is paid for entirely using only funds not authorized or appropriated by this Act; and 

‘‘(B) such coverage or plan is not purchased using— 

‘‘(i) individual premium payments required for a qualified health plan 

offered through an Exchange towards which a credit is applied under 

section 36B of the Internal Revenue Code of 1986; or 

‘‘(ii) other non-Federal funds required to receive a Federal payment, 

including a State’s or locality’s contribution of Medicaid matching 

funds. 

‘‘(3) OPTION TO OFFER COVERAGE OR PLAN.—Nothing in this subsection or section 1311(d)(2)(B)(i) shall restrict any non-Federal health insurance issuer offering a qualified health plan from offering separate coverage for abortions for 

which funding is prohibited under this subsection, or a qualified health plan 

that includes such abortions, so long as— 

‘‘(A) premiums for such separate coverage or plan are paid for entirely 

with funds not authorized or appropriated by this Act; 

‘‘(B) administrative costs and all services offered through such coverage 

or plan are paid for using only premiums collected for such coverage or 

plan; and 

‘‘(C) any such non-Federal health insurance issuer that offers a qualified 

health plan through an Exchange that includes coverage for abortions for 

which funding is prohibited under this subsection also offers a qualified 

health plan through the Exchange that is identical in every respect except 


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that it does not cover abortions for which funding is prohibited under this 

subsection.’’; 

(5) in subsection (e), as redesignated by paragraph (1)— 

(A) in the heading, by striking ‘‘REGARDING ABORTION’’; 

(B) in the heading of each of paragraphs (1) and (2), by striking each 

place it appears ‘‘REGARDING ABORTION’’; 

(C) in paragraph (1), by striking ‘‘regarding the prohibition of (or requirement of) coverage, funding, or’’ and inserting ‘‘protecting conscience rights, 

restricting or prohibiting abortion or coverage or funding of abortion, or establishing’’; and 

(D) in paragraph (2)(A), by striking ‘‘Nothing’’ and inserting ‘‘Subject to 

subsection (g), nothing’’; 

(6) in subsection (f), as redesignated by paragraph (1), by striking ‘‘Nothing’’ 

and inserting ‘‘Subject to subsection (g), nothing’’; and 

(7) by adding at the end the following new subsection: 

‘‘(g) NONDISCRIMINATION ON ABORTION.— 

‘‘(1) NONDISCRIMINATION.—A Federal agency or program, and any State or 

local government that receives Federal financial assistance under this Act (or 

an amendment made by this Act), may not subject any institutional or individual health care entity to discrimination, or require any health plan created 

or regulated under this Act (or an amendment made by this Act) to subject any 

institutional or individual health care entity to discrimination, on the basis that 

the health care entity refuses to— 

‘‘(A) undergo training in the performance of induced abortions; 

‘‘(B) require or provide such training; 

‘‘(C) perform, participate in, provide coverage of, or pay for induced abortions; or 

‘‘(D) provide referrals for such training or such abortions. 

‘‘(2) DEFINITION.—In this subsection, the term ‘health care entity’ includes an 

individual physician or other health care professional, a hospital, a providersponsored organization, a health maintenance organization, a health insurance 

plan, or any other kind of health care facility, organization, or plan. 

‘‘(3) REMEDIES.— 

‘‘(A) IN GENERAL.—The courts of the United States shall have jurisdiction 

to prevent and redress actual or threatened violations of this section by 

issuing any form of legal or equitable relief, including— 

‘‘(i) injunctions prohibiting conduct that violates this subsection; and 

‘‘(ii) orders preventing the disbursement of all or a portion of Federal 

financial assistance to a State or local government, or to a specific offending agency or program of a State or local government, until such 

time as the conduct prohibited by this subsection has ceased. 

‘‘(B) COMMENCEMENT OF ACTION.—An action under this subsection may 

be instituted by— 

‘‘(i) any health care entity that has standing to complain of an actual 

or threatened violation of this subsection; or 

‘‘(ii) the Attorney General of the United States. 

‘‘(4) ADMINISTRATION.—The Secretary shall designate the Director of the Office for Civil Rights of the Department of Health and Human Services— 

‘‘(A) to receive complaints alleging a violation of this subsection; and 

‘‘(B) to pursue investigation of such complaints in coordination with the 

Attorney General.’’. 

(b) CONFORMING AMENDMENT.—Section 1334(a)(6) of such Act is amended to read 

as follows: 

‘‘(6) COVERAGE CONSISTENT WITH FEDERAL POLICY.—In entering into contracts 

under this subsection, the Director shall ensure that no multi-State qualified 

health plan offered in an Exchange provides coverage for abortions for which 

funding is prohibited under section 1303(c) of this Act.’’. 

PURPOSE AND SUMMARY

H.R. 358, Protect Life Act, amends the Patient Protection and Affordable Care Act (PPACA) to prevent federal funding of abortion 

or abortion coverage. It also ensures that nothing in PPACA can 

be construed to require coverage of, or access to, abortion and to 

ensure that nothing in PPACA allows anyone implementing 

PPACA to require ‘‘coverage of, access to, or training in abortion 

services.’’ 


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The bill contains the Hyde limitation on funding for abortion and 

abortion coverage (life of the mother, rape and incest exceptions) 

consistent with the policies applied to Medicaid, the Federal Employee Health Benefits Program, and other federal programs. 

H.R. 358 states that no funds authorized or appropriated by 

PPACA, including tax credits and cost-sharing reductions, may be 

used to pay for abortion or abortion coverage except in cases of 

rape, incest, or to save the life of the mother. 

It specifies that any non-Federal entity (including individuals 

and State or local government) may purchase a separate elective 

abortion rider, or may purchase insurance coverage that includes 

elective abortion, so long as the coverage is not paid for with 

PPACA funds, and is not paid for using individual, State or local 

funds required to receive federal financial assistance. 

The bill also provides that insurance issuers may offer health 

plans that include elective abortion and may offer separate elective 

abortion riders, so long as they ensure PPACA funds are not used 

for premiums or administrative costs. The legislation clarifies that 

issuers who offer elective abortion coverage must also offer a qualified health benefits plan that is identical except that it does not 

cover elective abortion. 

H.R. 358 ensures nonpreemption of State laws ‘‘protecting conscience rights, restricting or prohibiting abortion or coverage or 

funding of abortion, or establishing procedural requirements on 

abortion.’’ For the provision regarding Federal laws, a technical reference is included to ensure there is no conflict between this provision and the ‘‘Hyde-Weldon’’ conscience provision that was added to 

the Hyde amendment in FY2005. 

The bill states that Federal programs and state or local governments that receive Federal financial assistance under PPACA may 

not subject any health care entity to discrimination or require any 

health plan to subject any entity to discrimination on the basis that 

the entity refuses to (A) undergo training in abortion, (B) require 

or provide such training, (C) perform, participate in, provide coverage of, or pay for abortions, or (D) provide referrals for training 

or abortion. 

It defines ‘‘health care entity’’ to include individual health care 

professionals, hospitals, insurance plans, or ‘‘any other kind of 

health care facility, organization or plan.’’ 

The bill designates the Office for Civil Rights (OCR) at HHS to 

receive complaints and pursue investigations in coordination with 

the Attorney General. Under conscience regulations issued in January 2009, OCR is designated to receive complaints. However, this 

designation is not contained in Hyde-Weldon and could be rescinded in the future absent this new language. 

Finally, the Protect Life Act requires the Director of the Office 

of Personnel Management to ensure that no multi-State plan covers elective abortion. 

BACKGROUND AND NEED FOR LEGISLATION

PPACA does not contain comprehensive anti-mandate provisions 

with respect to abortion for qualified health benefits plans, nor 

does it clearly prohibit other methods of mandating abortion coverage—such as through preventive care requirements. 


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PPACA establishes ‘‘allocation accounts’’ to segregate federal 

funds from premium funds that can be used for abortion coverage. 

Under this system, the plan issuer is required to collect the enrollee’s portion of the premium in two payments. One payment goes 

into an account for abortion coverage and the other payment goes 

into an account for all other coverage. This has sometimes been referred to as the ‘‘abortion surcharge.’’ 

PPACA requires the Director of the Office of Personnel Management to ensure that one multi-State plan does not cover elective 

abortion, while allowing all others to to offer plans that do cover 

abortion. Individuals who prefer the overall coverage in a plan that 

covers elective abortion must write a check to pay the abortion surcharge in order to take advantage of the coverage in that plan. A 

significant dilemma arises, however, when individuals who have a 

strong moral objection to abortion are forced to directly finance 

abortion coverage in order to purchase a health care plan they believe best provides for their needs and the needs of their family 

members. The Protect Life Act, by contrast, does not permit the use 

of any taxpayers’ funds to subsidize abortion coverage. 

Article 1, Section 8 of the United States Constitutions provides 

to Congress the power to allocate federal funds, and by extension 

the power to limit federal funding for certain activities. PPACA 

contains a definition of services that hinges on the Hyde amendment being retained each year through the appropriations process. 

This leaves the door open for the Hyde limitations to be dropped 

by a determined majority in one chamber of Congress or by a presidential veto. The Protect Life Act provides greater certainty that 

the Hyde limitations will continue to apply to PPACA. 

After passage of PPACA, the President signed an Executive 

Order to address certain concerns about abortion funding. While 

there are different views about the effect of the Executive Order, 

it should be noted that a sitting president can change his mind and 

rescind it, a future president can have a different opinion, or opponents of the Executive Order can prevail in court by arguing that 

certain elements of the Executive Order do not have a sufficient 

legislative foundation to survive. The Protect Life Act provides 

greater certainty and permanence than any Executive Order. 

The legislation also provides for increased conscience provisions 

in the law. The Committee is aware that a significant number of 

physicians would likely leave the medical profession rather than 

compromise their beliefs by performing acts they believe to be unethical, undermining access to care for significant numbers of patients. The Protect Life Act will allow these professionals to continue their work without concerns in this area. 

HEARINGS

The Subcommittee on Health on February 9, 2011 held a hearing 

on H.R. 358, the Protect Life Act. The Subcommittee received testimony from: 

• Helen Alvare, Associate Professor of Law, George Mason 

University School of Law 

• Sara Rosenbaum, Chair, Department of Health Policy, 

George Washington University 

• Douglas Johnson, Federal Legislative Director, National 

Right to Life Committee 


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COMMITTEE CONSIDERATION

On February 11, 2011, the Subcommittee on Health met in open 

markup session and approved H.R. 358, the Protect Life Act for 

Full Committee consideration, by a record vote of 14 yeas and 9 

nays. 

COMMITTEE VOTES

Clause 3(b) of rule XIII of the Rules of the House of Representatives requires the Committee to list the record votes on the motion 

to report legislation and amendments thereto. A motion by Mr. 

Upton to order H.R. 358, reported to the House, as amended, was 

agreed to by a record vote of 33 yeas and 19 nays. 


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COMMITTEE OVERSIGHT FINDINGS

Pursuant to clause 3(c)(1) of rule XIII of the Rules of the House 

of Representatives, the Committee held a legislative hearing and 

made findings that are reflected in this report. 

STATEMENT OF GENERAL PERFORMANCE GOALS AND OBJECTIVES

H.R. 358 amends PPACA to prevent federal funding of abortion 

or abortion coverage. It also ensures that nothing in PPACA can 

be construed to require coverage of, or access to abortion and to ensure that nothing in PPACA allows anyone implementing PPACA 

to require ‘‘coverage of, access to, or training in abortion services.’’ 

NEW BUDGET AUTHORITY, ENTITLEMENT AUTHORITY, AND TAX

EXPENDITURES

In compliance with clause 3(c)(2) of rule XIII of the Rules of the 

House of Representatives, the Committee finds that H.R. 358, Protect Life Act, would result in no new or increased budget authority, 

entitlement authority, or tax expenditures or revenues. 

EARMARK

In compliance with clause 9(e), 9(f), and 9(g) of rule XXI, the 

Committee finds that H.R 358, the Protect Life Act, contains no 

earmarks. 

COMMITTEE COST ESTIMATE

The Committee adopts as its own the cost estimate prepared by 

the Director of the Congressional Budget Office pursuant to section 

402 of the Congressional Budget Act of 1974. 

CONGRESSIONAL BUDGET OFFICE ESTIMATE

Pursuant to clause 3(c)(3) of rule XIII of the Rules of the House 

of Representatives, the following is the cost estimate provided by 

the Congressional Budget Office pursuant to section 402 of the 

Congressional Budget Act of 1974: 

U.S. CONGRESS, 

CONGRESSIONAL BUDGET OFFICE, 

Washington, DC, February 28, 2011. 

Hon. FRED UPTON, 

Chairman, Committee on Energy and Commerce, 

House of Representatives, Washington, DC. 

DEAR MR. CHAIRMAN: The Congressional Budget Office has prepared the enclosed cost estimate for H.R. 358, Protect Life Act. 

If you wish further details on this estimate, we will be pleased 

to provide them. 

Sincerely, 

DOUGLAS W. ELMENDORF. 

Enclosure. 

H.R. 358—Protect Life Act 

H.R. 358 would amend section 1303 of the Patient Protection and 

Affordable Care Act (Public Law 111–148) to prohibit the use of 


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federal funds provided under that Act to pay for abortion services 

or health costs of any health plan that provides abortion services, 

except in cases of rape or incest, or when the life of the pregnant 

woman is in danger. The bill would require that qualified health 

plans offering coverage of abortion services, other than under those 

excepted circumstances, through health insurance exchanges collect 

separate premiums for such coverage. In addition, any such plans 

would have to provide identical plans without such abortion coverage through the exchanges. The bill would preserve state conscience protection laws and expand nondiscrimination rules for 

health care providers that decline to engage in abortion-related activities. 

Current federal law prohibits the use of federal funds to pay for 

abortion services and requires that qualified health plans providing 

abortion services under circumstances aside from those listed above 

collect separate premiums. Similarly, current federal and state 

laws protect the right of health care providers to decline to engage 

in abortion-related activities. 

CBO estimates that enacting H.R. 358 could affect direct spending; therefore, pay-as-you-go procedures apply. However, because 

H.R. 358 overlaps current federal and state laws, CBO expects that 

enactment would have little effect on coverage offered by qualified 

health plans. Consequently, CBO estimates that the federal budgetary effects would be negligible for each year. 

H.R. 358 contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act and would 

impose no costs on state, local, or tribal governments. 

FEDERAL MANDATES STATEMENT

The Committee adopts as its own the estimate of Federal mandates prepared by the Director of the Congressional Budget Office 

pursuant to section 423 of the Unfunded Mandates Reform Act. 

ADVISORY COMMITTEE STATEMENT

No advisory committees within the meaning of section 5(b) of the 

Federal Advisory Committee Act were created by this legislation. 

APPLICABILITY TO LEGISLATIVE BRANCH

The Committee finds that the legislation does not relate to the 

terms and conditions of employment or access to public services or 

accommodations within the meaning of section 102(b)(3) of the Congressional Accountability Act. 

SECTION-BY-SECTION ANALYSIS OF THE LEGISLATION

Section 1—Short title: Protect Life Act 

Section 2—Modifying special rules relating to coverage of abortion 

services under PPACA to conform to long-standing federal policy 

Subsection (a) contains modifications to Section 1303 regarding 

abortion and abortion coverage. Subsection (b) contains a modification to Section 1334 regarding multi-State plans. 


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Subsection (a), paragraph (3) adds anti-mandate language to ensure that nothing in PPACA can be construed to require coverage 

of, or access to abortion and to ensure that nothing in PPACA allows anyone implementing PPACA to require ‘‘coverage of, access 

to, or training in abortion services.’’ It also deletes the ‘‘voluntary 

choice in coverage’’ language and the accounting system currently 

contained in PPACA that was intended to prevent direct taxpayer 

funding of abortion. 

Specific provisions deleted from PPACA include the prohibition 

on mandating abortion as a part of the essential benefits plan and 

the provison that the issuer of a qualified health benefits plan shall 

choose whether to provide abortion services. This is not a comprehensive anti-mandate provision and only applies to abortion 

mandates in the context of the essential benefits package and 

qualified health benefits plans. This language does not clearly prohibit other methods of mandating abortion coverage—such as 

through preventive care requirements. 

The definition of abortion services in PPACA that hinges on the 

Hyde amendment being retained is also deleted. This definition is 

used as a ‘‘key’’ to decipher other sections of the accounting system 

but the accounting system would disappear altogether if the Hyde 

amendment is deleted in the future. 

The provision in PPACA that health plans that cover elective 

abortion shall not use federal tax credits or cost sharing assistance 

for abortion is likewise deleted. This provision does not prevent 

funding for abortion coverage. It simply triggers the accounting 

system for insurance coverage that includes abortion. 

The PPACA ‘‘allocation accounts’’ to segregate funds are deleted. 

Under this process, the plan issuer is required to collect the enrollee’s portion of the premium in two payments. One payment would 

go into an account for abortion coverage—this payment is sometimes described as the abortion surcharge—and the other payment 

would go into an account for all other coverage. Under this scheme, 

a person would be required to pay the abortion fee even if they did 

not want coverage of abortion. 

The directive in PPACA that State health insurance commissioners ensure compliance with the accounting system becomes 

moot and is therefore deleted, along with the allowance for individuals or health plans to appeal compliance actions by the commissioners in court. 

An additional deletion from PPACA is the stipulation that health 

plans that cover elective abortion may notify the enrollee of abortion coverage ‘‘only as part of the summary of benefits and coverage 

explanation, at the time of enrollment . . . ’’ Similarly, the directive 

that the summary of benefits and coverage explanation, advertising 

for plans, and information on the Exchange may only provide information about the total cost of the plan is deleted. 

Subsection (a), paragraph (4) of H.R. 358 inserts language that 

prohibits funding for abortion and abortion coverage consistent 

with the policies applied to Medicaid, Children’s Health Insurance 

Program, the Federal Employees Health Benefits Program, and 

other federal programs. 

The limitation on abortion funding in paragraph (4) states that 

no funds authorized or appropriated by PPACA, including tax credits and cost-sharing reductions, may be used to pay for abortion or 


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abortion coverage except in cases of rape, incest or to save the life 

of the mother. 

However, the limitation specifies that any non-Federal entity (including individuals and State or local government) may purchase 

a separate elective abortion rider, or may purchase insurance coverage that includes elective abortion, so long as the coverage is not 

paid for with PPACA funds, and is not paid for using individual, 

State or local funds required to receive federal financial assistance. 

(e.g., the coverage cannot be paid for with the PPACA premium assistance, nor can it be paid for with the portion of the premium 

that must be paid in order to receive PPACA premium assistance.) 

The limitation further specifies that insurance issuers may offer 

health plans that include elective abortion and may offer separate 

elective abortion riders, so long as they ensure PPACA funds are 

not used for premiums or administrative costs. The Act further 

clarifies that issuers that offer elective abortion coverage must also 

offer a qualified health benefits plan that is identical except that 

it does not cover elective abortion. 

Subsection (a), paragraph (5) adjusts the current statutory language regarding preemption of state or federal laws to close loopholes. The state nonpreemption language currently contained in 

(c)(1) [redesignated at (e)(1) in the Protect Life Act] does not protect state conscience protection laws, and instead protects state 

laws requiring the provision of abortion and abortion funding. The 

Protect Life Act changes this language by removing protections for 

laws favoring abortion and instead ensures nonpreemption of State 

laws ‘‘protecting conscience rights, restricting or prohibiting abortion or coverage or funding of abortion, or establishing procedural 

requirements on abortion.’’ For the provision regarding Federal 

laws, a technical reference (‘‘subject to subsection (g)’’) is added to 

ensure there is no conflict between this provision and the ‘‘HydeWeldon’’ conscience provision added in subsection (g). 

Subsection (a), paragraph (6) inserts ‘‘Subject to subsection (g)’’ 

before the clause regarding emergency services including the Emergency Medical Treatment and Active Labor Act (EMTALA). There 

is not a conflict between the conscience clause and EMTALA because EMTALA references stabilizing the woman and her ‘‘unborn 

child.’’ The language clarifies that the general reference to ‘‘emergency services as required by State or Federal law’’ should not be 

construed to allow states to override conscience protections by labeling broad abortion mandates as ‘‘emergency service’’ requirements. 

Subsection (a), paragraph (7) adds a new subsection (g), ‘‘Nondiscrimination on Abortion,’’ which is very similar to the HydeWeldon conscience provision. It states that Federal programs and 

state or local governments that receive Federal financial assistance 

under PPACA may not subject any health care entity to discrimination or require any health plan to subject any entity to discrimination on the basis that the entity refuses to (a) undergo training in 

abortion, (b) require or provide such training, (c) perform, participate in, provide coverage of, or pay for abortions, or (d) provide referrals for training or abortion. 

New subsection (g) in paragraph (7) includes a remedies section 

so that individuals who have been discriminated against or are 

under threat of discrimination may seek redress in court. The OfVerDate Mar 15 2010 23:36 Mar 21, 2011 Jkt 099006 PO 00000 Frm 00014 Fmt 6659 Sfmt 6602 E:\HR\OC\HR040P1.XXX HR040P1

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fice for Civil Rights at HHS is designated to receive complaints 

under this subsection and pursue investigations in coordination 

with the Attorney General. 

Subsection (b) changes language in Section 1334 regarding multiState plans run by the Director of the Office of Personnel Management. Currently PPACA includes a provision requiring the Director 

to ensure that at least one multi-State plan does not cover elective 

abortion. This permits the Director to offer additional multi-State 

plans that do cover abortion. The Protect Life Act replaces the current language with a new (a)(6) that instructs the Director to ensure that no multi-State plan covers elective abortion. 

CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

In compliance with clause 3(e) of rule XIII of the Rules of the 

House of Representatives, changes in existing law made by the bill, 

as reported, are shown as follows (existing law proposed to be omitted is enclosed in black brackets, new matter is printed in italic, 

existing law in which no change is proposed is shown in roman): 

PATIENT PROTECTION AND AFFORDABLE CARE ACT 

* * * * * * * 

TITLE I—QUALITY, AFFORDABLE HEALTH CARE FOR ALL 

AMERICANS 

* * * * * * * 

SUBTITLE D—AVAILABLE COVERAGE CHOICES FOR ALL AMERICANS

PART 1—ESTABLISHMENT OF QUALIFIED HEALTH PLANS 

* * * * * * * 

SEC. 1303. SPECIAL RULES. 

(a) * * * 

ø(b) SPECIAL RULES RELATING TO COVERAGE OF ABORTION SERVICES.— 

ø(1) VOLUNTARY CHOICE OF COVERAGE OF ABORTION SERVICES.— 

ø(A) IN GENERAL.—Notwithstanding any other provision 

of this title (or any amendment made by this title)— 

ø(i) nothing in this title (or any amendment made by 

this title), shall be construed to require a qualified 

health plan to provide coverage of services described 

in subparagraph (B)(i) or (B)(ii) as part of its essential 

health benefits for any plan year; and 

ø(ii) subject to subsection (a), the issuer of a qualified health plan shall determine whether or not the 

plan provides coverage of services described in subparagraph (B)(i) or (B)(ii) as part of such benefits for 

the plan year. 

ø(B) ABORTION SERVICES.— 

ø(i) ABORTIONS FOR WHICH PUBLIC FUNDING IS PROHIBITED.—The services described in this clause are 

abortions for which the expenditure of Federal funds 

appropriated for the Department of Health and 


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Human Services is not permitted, based on the law as 

in effect as of the date that is 6 months before the beginning of the plan year involved. 

ø(ii) ABORTIONS FOR WHICH PUBLIC FUNDING IS ALLOWED.—The services described in this clause are 

abortions for which the expenditure of Federal funds 

appropriated for the Department of Health and 

Human Services is permitted, based on the law as in 

effect as of the date that is 6 months before the beginning of the plan year involved. 

ø(2) PROHIBITION ON THE USE OF FEDERAL FUNDS.— 

ø(A) IN GENERAL.—If a qualified health plan provides 

coverage of services described in paragraph (1)(B)(i), the 

issuer of the plan shall not use any amount attributable 

to any of the following for purposes of paying for such 

services: 

ø(i) The credit under section 36B of the Internal 

Revenue Code of 1986 (and the amount (if any) of the 

advance payment of the credit under section 1412 of 

the Patient Protection and Affordable Care Act). 

ø(ii) Any cost-sharing reduction under section 1402 

of the Patient Protection and Affordable Care Act (and 

the amount (if any) of the advance payment of the reduction under section 1412 of the Patient Protection 

and Affordable Care Act). 

ø(B) ESTABLISHMENT OF ALLOCATION ACCOUNTS.—In the 

case of a plan to which subparagraph (A) applies, the 

issuer of the plan shall— 

ø(i) collect from each enrollee in the plan (without 

regard to the enrollee’s age, sex, or family status) a 

separate payment for each of the following: 

ø(I) an amount equal to the portion of the premium to be paid directly by the enrollee for coverage under the plan of services other than services described in paragraph (1)(B)(i) (after reduction for credits and cost-sharing reductions described in subparagraph (A)); and 

ø(II) an amount equal to the actuarial value of 

the coverage of services described in paragraph 

(1)(B)(i), and 

ø(ii) shall deposit all such separate payments into 

separate allocation accounts as provided in subparagraph (C). 

In the case of an enrollee whose premium for coverage 

under the plan is paid through employee payroll deposit, 

the separate payments required under this subparagraph 

shall each be paid by a separate deposit. 

ø(C) SEGREGATION OF FUNDS.— 

ø(i) IN GENERAL.—The issuer of a plan to which subparagraph (A) applies shall establish allocation accounts described in clause (ii) for enrollees receiving 

amounts described in subparagraph (A). 

ø(ii) ALLOCATION ACCOUNTS.—The issuer of a plan to 

which subparagraph (A) applies shall deposit— 


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ø(I) all payments described in subparagraph 

(B)(i)(I) into a separate account that consists solely of such payments and that is used exclusively 

to pay for services other than services described in 

paragraph (1)(B)(i); and 

ø(II) all payments described in subparagraph 

(B)(i)(II) into a separate account that consists solely of such payments and that is used exclusively 

to pay for services described in paragraph 

(1)(B)(i). 

ø(D) ACTUARIAL VALUE.— 

ø(i) IN GENERAL.—The issuer of a qualified health 

plan shall estimate the basic per enrollee, per month 

cost, determined on an average actuarial basis, for including coverage under the qualified health plan of the 

services described in paragraph (1)(B)(i). 

ø(ii) CONSIDERATIONS.—In making such estimate, 

the issuer— 

ø(I) may take into account the impact on overall 

costs of the inclusion of such coverage, but may 

not take into account any cost reduction estimated 

to result from such services, including prenatal 

care, delivery, or postnatal care; 

ø(II) shall estimate such costs as if such coverage were included for the entire population covered; and 

ø(III) may not estimate such a cost at less than 

$1 per enrollee, per month. 

ø(E) ENSURING COMPLIANCE WITH SEGREGATION REQUIREMENTS.— 

ø(i) IN GENERAL.—Subject to clause (ii), State health 

insurance commissioners shall ensure that health 

plans comply with the segregation requirements in 

this subsection through the segregation of plan funds 

in accordance with applicable provisions of generally 

accepted accounting requirements, circulars on funds 

management of the Office of Management and Budget, 

and guidance on accounting of the Government Accountability Office. 

ø(ii) CLARIFICATION.—Nothing in clause (i) shall prohibit the right of an individual or health plan to appeal such action in courts of competent jurisdiction. 

ø(3) RULES RELATING TO NOTICE.— 

ø(A) NOTICE.—A qualified health plan that provides for 

coverage of the services described in paragraph (1)(B)(i) 

shall provide a notice to enrollees, only as part of the summary of benefits and coverage explanation, at the time of 

enrollment, of such coverage. 

ø(B) RULES RELATING TO PAYMENTS.—The notice described in subparagraph (A), any advertising used by the 

issuer with respect to the plan, any information provided 

by the Exchange, and any other information specified by 

the Secretary shall provide information only with respect 

to the total amount of the combined payments for services 


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described in paragraph (1)(B)(i) and other services covered 

by the plan.¿ 

(b) SPECIAL RULES RELATING TO TRAINING IN AND COVERAGE OF

ABORTION SERVICES.—Nothing in this Act (or any amendment 

made by this Act) shall be construed to require any health plan to 

provide coverage of or access to abortion services or to allow the Secretary or any other Federal or non-Federal person or entity in implementing this Act (or amendment) to require coverage of, access to, 

or training in abortion services. 

(c) LIMITATION ON ABORTION FUNDING.— (1) IN GENERAL.—No funds authorized or appropriated by 

this Act (or an amendment made by this Act), including credits 

applied toward qualified health plans under section 36B of the 

Internal Revenue Code of 1986 or cost-sharing reductions under 

section 1402 of this Act, may be used to pay for any abortion 

or to cover any part of the costs of any health plan that includes 

coverage of abortion, except— 

(A) if the pregnancy is the result of an act of rape or incest; or 

(B) in the case where a pregnant female suffers from a 

physical disorder, physical injury, or physical illness that 

would, as certified by a physician, place the female in danger of death unless an abortion is performed, including a 

life-endangering physical condition caused by or arising 

from the pregnancy itself. 

(2) OPTION TO PURCHASE SEPARATE COVERAGE OR PLAN.— Nothing in this subsection shall be construed as prohibiting any 

non-Federal entity (including an individual or a State or local 

government) from purchasing separate coverage for abortions 

for which funding is prohibited under this subsection, or a 

qualified health plan that includes such abortions, so long as— 

(A) such coverage or plan is paid for entirely using only 

funds not authorized or appropriated by this Act; and 

(B) such coverage or plan is not purchased using— 

(i) individual premium payments required for a 

qualified health plan offered through an Exchange towards which a credit is applied under section 36B of 

the Internal Revenue Code of 1986; or 

(ii) other non-Federal funds required to receive a 

Federal payment, including a State’s or locality’s contribution of Medicaid matching funds. 

(3) OPTION TO OFFER COVERAGE OR PLAN.—Nothing in this 

subsection or section 1311(d)(2)(B)(i) shall restrict any non-Federal health insurance issuer offering a qualified health plan 

from offering separate coverage for abortions for which funding 

is prohibited under this subsection, or a qualified health plan 

that includes such abortions, so long as— 

(A) premiums for such separate coverage or plan are paid 

for entirely with funds not authorized or appropriated by 

this Act; 

(B) administrative costs and all services offered through 

such coverage or plan are paid for using only premiums 

collected for such coverage or plan; and 

(C) any such non-Federal health insurance issuer that offers a qualified health plan through an Exchange that inVerDate Mar 15 2010 23:36 Mar 21, 2011 Jkt 099006 PO 00000 Frm 00018 Fmt 6659 Sfmt 6603 E:\HR\OC\HR040P1.XXX HR040P1

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cludes coverage for abortions for which funding is prohibited under this subsection also offers a qualified health 

plan through the Exchange that is identical in every respect 

except that it does not cover abortions for which funding is 

prohibited under this subsection. 

ø(4) NO DISCRIMINATION ON BASIS OF PROVISION OF ABORTION¿ (d) 

NO DISCRIMINATION ON BASIS OF PROVISION OF ABORTION.—No 

qualified health plan offered through an Exchange may discriminate against any individual health care provider or health care facility because of its unwillingness to provide, pay for, provide coverage of, or refer for abortions 

ø(c)¿ (e) APPLICATION OF STATE AND FEDERAL LAWS øREGARDING

ABORTION¿.— (1) NO PREEMPTION OF STATE LAWS øREGARDING ABOR- TION¿.—Nothing in this Act shall be construed to preempt or 

otherwise have any effect on State laws øregarding the prohibition of (or requirement of) coverage, funding, or¿ protecting 

conscience rights, restricting or prohibiting abortion or coverage 

or funding of abortion, or establishing procedural requirements 

on abortions, including parental notification or consent for the 

performance of an abortion on a minor. 

(2) NO EFFECT ON FEDERAL LAWS øREGARDING ABORTION¿.— (A) IN GENERAL.—øNothing¿ Subject to subsection (g), 

nothing in this Act shall be construed to have any effect 

on Federal laws regarding— 

(i) * * * 

* * * * * * * 

ø(d)¿ (f) APPLICATION OF EMERGENCY SERVICES LAWS.—øNothing¿ 

Subject to subsection (g), nothing in this Act shall be construed to 

relieve any health care provider from providing emergency services 

as required by State or Federal law, including section 1867 of the 

Social Security Act (popularly known as ‘‘EMTALA’’). 

(g) NONDISCRIMINATION ON ABORTION.— (1) NONDISCRIMINATION.—A Federal agency or program, and 

any State or local government that receives Federal financial 

assistance under this Act (or an amendment made by this Act), 

may not subject any institutional or individual health care entity to discrimination, or require any health plan created or regulated under this Act (or an amendment made by this Act) to 

subject any institutional or individual health care entity to discrimination, on the basis that the health care entity refuses to— 

(A) undergo training in the performance of induced abortions; 

(B) require or provide such training; 

(C) perform, participate in, provide coverage of, or pay for 

induced abortions; or 

(D) provide referrals for such training or such abortions. 

(2) DEFINITION.—In this subsection, the term ‘‘health care entity’’ includes an individual physician or other health care professional, a hospital, a provider-sponsored organization, a 

health maintenance organization, a health insurance plan, or 

any other kind of health care facility, organization, or plan. 

(3) REMEDIES.— (A) IN GENERAL.—The courts of the United States shall 

have jurisdiction to prevent and redress actual or threatVerDate Mar 15 2010 23:36 Mar 21, 2011 Jkt 099006 PO 00000 Frm 00019 Fmt 6659 Sfmt 6603 E:\HR\OC\HR040P1.XXX HR040P1

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ened violations of this section by issuing any form of legal 

or equitable relief, including— 

(i) injunctions prohibiting conduct that violates this 

subsection; and 

(ii) orders preventing the disbursement of all or a 

portion of Federal financial assistance to a State or 

local government, or to a specific offending agency or 

program of a State or local government, until such 

time as the conduct prohibited by this subsection has 

ceased. 

(B) COMMENCEMENT OF ACTION.—An action under this 

subsection may be instituted by— 

(i) any health care entity that has standing to complain of an actual or threatened violation of this subsection; or 

(ii) the Attorney General of the United States. 

(4) ADMINISTRATION.—The Secretary shall designate the Director of the Office for Civil Rights of the Department of Health 

and Human Services— 

(A) to receive complaints alleging a violation of this subsection; and 

(B) to pursue investigation of such complaints in coordination with the Attorney General. 

* * * * * * * 

PART 4—STATE FLEXIBILITY TO ESTABLISH ALTERNATIVE 

PROGRAMS 

* * * * * * * 

SEC. 1334. MULTI-STATE PLANS. 

(a) OVERSIGHT BY THE OFFICE OF PERSONNEL MANAGEMENT.— 

(1) * * * 

* * * * * * * 

ø(6) ASSURED AVAILABILITY OF VARIED COVERAGE.—In entering into contracts under this subsection, the Director shall ensure that with respect to multi-State qualified health plans offered in an Exchange, there is at least one such plan that does 

not provide coverage of services described in section 

1303(b)(1)(B)(i).¿ 

(6) COVERAGE CONSISTENT WITH FEDERAL POLICY.—In entering into contracts under this subsection, the Director shall ensure that no multi-State qualified health plan offered in an Exchange provides coverage for abortions for which funding is 

prohibited under section 1303(c) of this Act. 

* * * * * * * 


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DISSENTING VIEWS 

We, the undersigned Members of the Committee on Energy and 

Commerce, oppose the passage of H.R. 358, Protect Life Act, and accordingly, submit the following comments to express our concerns 

about this deeply flawed and deeply divisive legislation. 

INTRODUCTION

For decades, the law of the land has been that no federal funds 

can be used for abortion services (with the exception of those in 

which the pregnancy threatens the life of the woman or is the result of rape or incest). There have been GAO audits, inspector general audits, and congressional hearings, and all have concluded 

that the law of the land is being obeyed. No federal funds are being 

used for abortion services. 

The Affordable Care Act continues that policy. In provisions that 

were probably more carefully scrutinized, edited, and debated than 

any others in the Act, the ban on federal payment for abortion 

services was clearly preserved. The Act goes so far as to require 

two separate premium payments for those people purchasing insurance that covers abortion services (other than in the case of rape 

or incest or to protect the life of the woman), providing a physical 

corollary to the legal requirement that federal funds be separately 

pooled—even at insurance companies. 

So the record is clear: For decades, the federal law has been that 

no federal funds can be used for abortion services and the Affordable Care Act maintains that policy and law. 

If this is the case, what is H.R. 358 all about? If no federal funds 

are or can be used, what is the purpose of this legislation? 

The answer is that this bill clearly goes further than the regulation of federal funds. Its effect would be to harass and intimidate 

women and their families in their use of their own money. It makes 

the job of private insurance companies so artificially complicated 

and unworkable as to force them from the market. It takes antiabortion politics far beyond where they have been for the decades 

of the Hyde Amendment and to put them right in the middle of private homes and workplaces and squarely in private citizens’ paychecks and premiums. Its very essence is to create an undue burden on how people can exercise their own choices with their own 

money, and it creates a substantial obstacle to a woman seeking 

abortion services. 

There are many particulars in the bill to which we object. But 

before discussing these, we feel it necessary to debunk the central 

argument made for the bill: It is not about the regulation of federal 

funds. For those members of Congress who have regularly said that 

they are opposed to federal funding of abortion, this bill is absolutely unnecessary. This bill should be supported only by those 

members who actually want to step far beyond that position and 


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1 ACA is comprised of two public laws, P.L. 111–148 and P.L. 111–152. 

2See, e.g., P.L. 111–148, Sections 1001 and 4101 (relating to preventive health care); Section 

1201 (relating to insurance coverage for women); and Section 1302 (relating to maternity benefits). 3P.L. 111–148, Section 1303 and Section 1334(a)(6). 

to overturn the privacy rights enumerated by the Supreme Court 

and to place the government between a woman and her doctor 

when making this most personal decision. 

CURRENT LAW

Enacted in 2010, the Patient Protection and Affordable Care Act 

(ACA) 1 makes significant changes to health coverage for women, 

expanding their access to care and broadening the health benefits 

many will receive.2

Coverage for abortion services, however, is given special and extensive consideration and is addressed separately under ACA.3 It 

was authored by Senator Ben Nelson, a member whose anti-abortion views are well known. It is carefully crafted to produce a delicately balanced approach to this issue. Among the ACA provisions 

related to abortion coverage are: 

• Prohibition of the requirement of abortion coverage as part 

of the essential health benefits package of any qualified health 

plan (ACA Section 1303(b)(A)(i)); 

• Permission for states to prohibit coverage for any abortions 

by all private plans in their state-based exchange (ACA Section 

1303(a)(1)); 

• Permission for private plans in a state exchange to offer 

abortion coverage beyond that permitted under federal law so 

long as— 

• No federal subsidies (for premiums or cost sharing) 

are used to purchase such coverage, i.e., only private dollars are used to purchase abortion coverage (ACA Section 

1303(b)(2)(A)); and 

• The plan collects two separate premium payments 

from all enrollees—one payment for the value of the abortion benefit and one payment for all other covered services 

(ACA Section 1303(b)(2)(B)); 

• Prohibition of discrimination by exchange-participating 

plans against any individual health care provider or health 

care facility because of its unwillingness to provide, pay for, 

provide coverage of, or refer for abortion (ACA Section 1303 

(b)(4)); and 

• Requirement that at least one multi-state plan within a 

state exchange not cover abortion services beyond those permitted under federal law (in cases of rape, incest and to save 

the life of the woman) (ACA Section 1334(a)(6)). 

In addition to these provisions, ACA allows for the following roles 

for states in addressing abortion coverage: 

• ACA has no effect on state laws regarding coverage, funding, or procedural requirements on abortion (such as parental 

notification or consent laws) (ACA Section 1303 (c)(1)); and 

• States can use state-only funds to pay for medically necessary abortions beyond those permitted under federal law 


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4Social Security Act, Section 1867 (42 U.S.C. 1395dd). 

5 Exec. Order 13535, 75 Fed. Reg. 15599 (Mar. 20, 2010). 

6The community health centers (CHC) program is authorized under section 330 of the Public 

Health Service Act. Under ACA, the CHC program is to receive mandatory funding support (in 

addition to discretionary spending support) over the next five years. 7Office of Management and Budget, Pre-Regulatory Model Guidelines Under Section 1303 of 

the Affordable Care Act (PL–111–148): Issued Pursuant to Executive Order 13535 (Mar. 24, 2010) 

(online at http://www.whitehouse.gov/sites/default/files/omb/assets/financiallpdf/segregation 

l2010-09-20.pdf). 

8See, e.g., Internal Memorandum from Committee Staff to Members of House Committee on 

Energy and Commerce, Full Committee Markup on February 15, 2011, in which Committee staff 

state: ‘‘The proposed legislation closely mirrors the Stupak-Pitts amendment that was adopted 

during the 111th Congress.’’ 9For the text of the Stupak amendment, see Congressional Record, H12921 (Nov. 7, 2009). 

under Medicaid or to pay for abortion coverage in plans offered 

in an exchange. 

The language also makes clear that Senator Nelson’s provisions 

have no effect on federal laws regarding— 

• Conscience protection; willingness or refusal to provide 

abortion; and discrimination on the basis of the willingness or 

refusal to provide, pay for, cover or refer for abortion or to provide or participate in training to provide abortion (ACA Section 

1303 (c)(2)); 

• Rights and obligations of employers and employees under 

Title VII of the 1964 Civil Rights Act (ACA Section 1303 (c)(3)); 

or 

• The obligation of health care providers to provide emergency services as required under either state or federal law, including the Emergency Medical Treatment and Active Labor 

Act (popularly known as ‘‘EMTALA’’) 4 (ACA Section 1303 (d)). 

Shortly after the enactment of ACA, President Obama signed Executive Order 13535 to ensure the enforcement and implementation 

of the abortion restrictions included in ACA.5 The Order reinforces 

the prohibition on the use of federal funds for abortion services 

under ACA; clarifies that such prohibition applies to community 

health centers receiving funds under ACA; 6 and directs the Office 

of Management and Budget (OMB) to develop a model set of guidelines for state health insurance commissioners to use in determining whether state exchange plans are complying with ACA’s 

public/private dollar segregation requirements. OMB published 

such pre-regulatory guidelines on September 20, 2010.7

COMPARISON BETWEEN 2009 STUPAK AMENDMENT AND H.R. 358 

Since its introduction, sponsors and supporters of H.R. 358 have 

argued that the legislation closely resembles the amendment offered by former Congressman Bart Stupak (D–MI) 8 and passed by 

the House during the 2009–2010 health reform debate.9 At best, 

this is an unintentional misreading of the Stupak amendment; at 

worse, it is an attempt to mislead Members into believing that a 

vote in support of H.R. 358 is a virtual instant replay of the debate 

and vote on the 2009 Stupak amendment. As the plain language 

of H.R. 358 makes clear, this is simply not the case. 

The differences between the two pieces of legislation on a number of key issues are stark and meaningful and were confirmed by 

Committee counsel during the full Committee markup: 


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10 House Committee on Energy and Commerce, Markup of H.R. 358, Protect Life Act, et al, 

112th Cong., p. 50 (Feb. 15, 2011) (transcript of the proceeding). 11 Id., pp. 66–67. 12See, e.g., the opening statements of Rep. Pitts and Rep. Gingrey during the markups of H.R. 

358 in which they identify the federal funding question as the primary issue to be addressed 

by the legislation. • Rep. Pitts: ‘‘. . . the Protect Life Act, which, in short, would amend the [ACA] to continue 

the historical practice of prohibiting Federal funds from being used on abortion services.’’ (Subcommittee on Health, House Committee on Energy and Commerce, Markup of H.R. 358, Protect 

Life Act, et al, 112th Cong., p. 3 (Feb. 11, 2011) (transcript of the proceeding). • Rep. Gingrey: ‘‘The Protect Life Act is a piece of legislation that seeks to set right what 

the last Congress got wrong: ensure that abortions are not funded by taxpayer dollars. . . . And 

that is the simple crux of the issue here today.’’ (House Committee on Energy and Commerce, 

Markup of H.R. 358, Protect Life Act, et al, 112th Cong., p. 24 (Feb. 15, 2011) (transcript of the 

proceeding). 13 House Committee on Energy and Commerce, Markup of H.R. 358, Protect Life Act, et al, 

112th 1 Cong., pp. 79–80 (Feb. 15, 2011) (transcript of the proceeding). 14 As introduced, the purpose of H.R. 358 is ‘‘to amend [ACA] to modify special rules relating 

to coverage of abortion services under such Act.’’ 15 House Committee on Energy and Commerce, Markup of H.R. 358, Protect Life Act, et al, 

112th Cong., pp. 50–51 (Feb. 15, 2011) (transcript of the proceeding). 

The Stupak amendment limited its reach only to qualified health 

plans and had no effect on completely private plans 10

• The ACA distinguishes between ‘‘qualified health plans’’ and 

all other health plans. ‘‘Qualified health plans’’ are those that are 

part of state insurance exchanges through which people who received federal subsidies may purchase insurance. Other plans are 

outside the exchanges, are completely private, and do not cover individuals with a federal subsidy. H.R. 358 applies its restrictions 

on coverage of abortion services to ‘‘any health plan’’ not just to 

‘‘qualified health plans’’. 

The Stupak amendment limited its reach only to federal funding 

and insurance coverage of abortion 11

• Proponents of H.R. 358 contend that its central focus is the 

prohibition of federal funding for abortion under ACA.12 Yet, H.R. 

358 goes beyond this goal, including among its restrictions on abortion, ‘‘access to’’ abortion services. This is an undefined term in the 

legislation that leaves open the possibility of a very broad and 

sweeping interpretation that could include a wide variety of activities, ranging from the provision of factually accurate information 

about the availability of or limitations on insurance coverage for 

abortion services, the location of available abortion services, and 

procedural requirements applicable to such coverage or services, to 

the provision of transportation services. 

The Stupak amendment limited its reach only to state conscience 

protection laws that deal with abortion 13

• H.R. 358 expands protection of state conscience protection laws 

to include those that cover health and medical services other than 

abortion, going beyond the scope of both ACA Section 1303 and the 

bill’s stated purpose to address abortion coverage under the Act.14

The Stupak amendment protected all state laws that address insurance coverage for abortion services—both those that may restrict 

such coverage and those that may require it 15

• H.R. 358 protects only state laws that limit insurance coverage 

for abortion. Indeed, it specifically takes away ACA’s state preempVerDate Mar 15 2010 02:26 Mar 22, 2011 Jkt 099006 PO 00000 Frm 00024 Fmt 6604 Sfmt 6602 E:\HR\OC\HR040P1.XXX HR040P1

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16 Id., p. 52. 17The Congressional Budget Office (CBO) also recognized this extension of non-discrimination 

policy in its cost estimate letter to the Committee: ‘‘The bill would . . . expand nondiscrimination 

rules for health care providers that decline to engage in abortion-related activities.’’ Letter from 

Douglas W. Elmendorf, Director, CBO to Chairman Fred Upton (Feb. 28, 2011). 18 House Committee on Energy and Commerce, Markup of H.R. 358, Protect Life Act, et al, 

112th Cong., pp. 53–54 (Feb. 15, 2011) (transcript of proceeding). 19See H.R. 3, No Taxpayer Funding for Abortion Act; H.R. 217, Title X [Family Planning] 

Abortion Provider Prohibition Act; Amendment No. 11 to H.R. 1, Full-Year Continuing Appropriations Act, 2011 (Congressional Record, H776 (Feb. 14, 2011)) (regarding Planned Parenthood); and Amendment No. 182 to H.R. 1, Full-Year Continuing Appropriations Act, 2011 (Congressional Record, H786 (Feb. 14, 2011)) (regarding the papillomavirus vaccine) for additional 

examples of legislative efforts to curtail women’s access to reproductive health services. 

tion protection for state laws that require such coverage, undoing 

the law’s neutral approach to state abortion law. 

The Stupak amendment did not contain anv private right of action 16

• H.R. 358 creates a new federal private cause of action for 

health care providers to assert a conscience objection to abortion. 

The new private right of action would empower federal courts to 

reach ‘‘actual’’ and ‘‘threatened’’ violations—both undefined terms— 

of a new conscience clause that is also created in the legislation.17

Moreover, H.R. 358 does not extend similar enforcement rights to 

health care providers that allege discrimination because they provide abortion services. 

The Stupak amendment did not create any exception to the obligation of hospitals to comply with EMTALA; instead, it left that 

obligation intact 18

• H.R. 358 creates an exception to the ACA statement that nothing in ACA’s provisions on abortion are to be construed to relieve 

any health care provider from the provisions of EMTALA, requiring 

appropriate treatment and referral for emergency patients, including pregnant women. 

ANALYSIS AND IMPACT OF H.R. 358 

As noted above, ACA’s abortion provisions reflect both an excruciatingly difficult and delicately balanced compromise that was 

reached during the 2009–2010 health reform debate. Clearly, it 

was no member’s first choice. But, in the spirit of conciliation and 

in the broader interest of keeping health reform basically intact 

and on track, we have been willing to stand by the law as enacted. 

H.R. 358 would undo this compromise. The overall impact of the 

legislation—to erode the right of choice that is protected by the 

Constitution—is far more expansive than the disruption of health 

reform. In our view, H.R. 358 is part of a larger, broad-ranging effort to restrict women’s access to reproductive health services.19

While we are prepared at this time to continue to support health 

reform’s abortion provisions, we are not prepared to further restrict 

women’s access to this legal medical service. Nor are we prepared, 

in the guise of a debate over federal funding of abortion, to allow 

for limitations on the availability of other health services—especially contraception and other reproductive health services. H.R. 

358 is designed to achieve both of these goals. As such, we believe 


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20 CBO estimates that approximately 63% of all individuals participating in state exchanges 

will receive some level of subsidized support. (Letter from Douglas W. Elmendorf, Director, CBO 

to Speaker Nancy Pelosi (Mar. 20, 2010)) (on line at http://www.cbo.gov/ftpdocs/113xx/doc11379/ 

AmendReconProp.pdf). 21 Insurers Report on Use of Abortion Riders, Washington Post (Mar. 14, 2010). 22Subcommittee on Health, Committee on Energy and Commerce, Hearing on H.R. ll, Protect Life Act, 112th Cong., p. 50 (Feb. 9, 2011) (transcript of the proceeding). 

the legislation makes significant and overreaching changes in at 

least the following three ways: 

H.R. 358 Would effectively shut down the private insurance market 

for abortion coverage 

H.R. 358 prohibits the use of any funds authorized or appropriated under ACA to pay for abortion or to cover any part of the 

costs of any health plan in an exchange that includes abortion coverage—unless the pregnancy is the result of an act of rape or incest 

or is necessary to save the life of the woman. Such funds are defined to include both tax credits applied toward ACA qualified 

health plans and ACA cost-sharing reductions. This is a wholly 

new approach to the treatment of private health insurance under 

federal law. 

In effect, these restrictions would preclude any plan offering 

abortion coverage from accepting any customer who receives any 

level of ACA subsidization. This would represent the vast majority 

of the population purchasing private insurance through exchanges.20

The legislation does permit insurance companies participating in 

an exchange to offer a qualified health plan for unsubsidized individuals that includes abortion coverage, but only under very restrictive conditions. Significant administrative requirements must 

be met and a company offering a comprehensive plan must also 

provide an identical plan that excludes abortion coverage. Neither 

the Health Subcommittee hearings nor the legislation has given 

any attention to the complex problems of adverse selection and actuarial soundness that such parallel plan requirements pose. 

Similarly, H.R. 358 allows individuals and state and local governments to purchase separate abortion coverage—a so-called 

‘‘rider’’ policy—so long as this coverage is not purchased using ACA 

authorized or appropriated funds (including ACA tax credits and 

cost-sharing reductions). But as the data clearly illustrate, these 

policies—in the very few states where they are even offered—simply do not work.21 This point is underscored by the testimony of 

Mr. Douglas Johnson of the National Right to Life Committee, who 

stated at the Health Subcommittee hearings: ‘‘Now, there is nothing . . . to stop any private individual from going out and purchasing abortion coverage with their own resources on the private 

market if they choose to do so. I suspect from the data we have seen 

that very few people do that [emphasis supplied].’’ 22 Again, neither 

the hearings nor the legislation has given any attention to the 

practical insurance problems that rider plans raise. 

Taken together, then, these provisions establish numerous disincentives for companies to provide abortion coverage as part of 

their basic plan—they are administratively burdensome, unworkable, and unreasonable. Over and above their practical problems, 

they put private companies at great risk for exposure both to seVerDate Mar 15 2010 02:26 Mar 22, 2011 Jkt 099006 PO 00000 Frm 00026 Fmt 6604 Sfmt 6602 E:\HR\OC\HR040P1.XXX HR040P1

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23 ‘‘The best available evidence—based on studies conducted by the Guttmacher Institute and 

the Kaiser Family Foundation—suggests that most Americans with employer-based insurance 

currently have coverage for abortion.’’ (Guttmacher Institute, Memo on Private Insurance Coverage of Abortion (Jan. 19, 2011)). 24See, e.g., statements of the American College of Gynecologists and Obstetricians (ACOG 

Statement of Policy: Abortion Policy); the American Medical Association (Statement on Abortion 

Policy) (on line at https://ss13.ama-assn.org/apps/ecomm/PolicyFinderForm.pl?site=www.amaassn.org&uri=%2fama1%2fpub%2fupload%2fmm%2fPolicyFinder%2fpolicyfiles%2fHnE%2fH5.995.HTM); and the American Academy of Family Physicians (Statement on Reproductive 

Decisions) (on line at http://www.aafp.org/online/en/home/policy/policies/r/ 

reproductdecisions.html). 25 At the Health Subcommittee markup, Rep. Waxman offered an amendment to set the effective date for H.R. 358 at the time (before January 1, 2014, the effective date of health reform) 

that the Secretary of Health and Human Services certifies that the availability of abortion coverage in private health plans for individuals who will not receive ACA subsidies will not be affected. Members in opposition of the amendment argued against its adoption on that grounds 

that ‘‘. . . we see no plausible connection between the availability of abortion coverage in the 

private insurance market and this pending legislation.’’ (Subcommittee on Health, House Committee on Energy and Commerce, Markup on H.R. 358, Protect Life Act, et al., 112th Cong., p. 

87 (Feb. 11, 2011) (transcript of the proceeding)). Supporters of the bill cannot have it both 

ways—if the legislation does not impact the availability of abortion coverage in the private market, they should be comfortable supporting an amendment requiring the certification of such 

coverage. Their rejection of the Waxman amendment suggests that those in opposition are at 

least skeptical of their own assertions about the impact of the legislation on the availability of 

abortion coverage. 26Subcommittee on Health, House Committee on Energy and Commerce, Hearing on H.R. ll, Protect Life Act, 112th Cong., p. 37 (Feb. 9, 2011) (transcript of the proceeding). 27See, e.g., the state conscience protection law for Illinois (745 ILCS 70/3 and 70/11.2) which 

provides for refusal rights in the case of family planning (and other) health services, and for 

Mississippi (Miss. Code Ann. Sections 41–107–3 and 41–107–09) and Pennsylvania (40 P.S. Section 991–2171) which allow health care providers, including health insurers, to refuse to provide 

or pay for any health service as a matter of conscience. 

vere penalties in the case of a violation and to organized boycotts 

by organizations opposed to abortion. And, by requiring that abortion coverage stand separate and alone from the comprehensive 

package of services companies currently and routinely offer to their 

customers,23 H.R. 358 effectively places a stigma—a bull’s eye in 

fact—on a health service which remains legal in this country and 

is regarded as medically appropriate by numerous national medical 

organizations.24

Despite the protestations of H.R. 358’s supporters,25 we believe 

the net effect of these provisions is, for all practical purposes, to 

shut down the private insurance market for abortion coverage. Indeed, as Professor Sara Rosenbaum testified at the Health Subcommittee hearing on H.R. 358, ‘‘. . . health plans could be expected to exit this optional coverage market entirely [emphasis supplied].’’ 26 Such a result would mean the end of abortion coverage 

for millions of women and their families who already have this insurance benefit and for millions of others who would commonly expect it to be part of a comprehensive health insurance policy. In 

turn, families who may experience the unanticipated event of abortion could face significant out-of-pocket expenses. 

H.R. 358 Would undercut the purpose of ACA’s essential benefits 

package 

H.R. 358 safeguards state ‘‘conscience-protection’’ laws (also 

known as ‘‘refusal-protection’’ laws) that speak to health and medical services other than abortion—a broad extension of ACA’s state 

‘‘non-preemption’’ language. Such laws often refer to specific services that are covered; others are much wider in scope, allowing for 

great leeway in how they may be carried out.27

This far-reaching expansion of current law has enormous implications for the ACA essential benefits package, the contents of 


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28 ACA Section 1311(3). 29 House Committee on Energy and Commerce, Markup on H.R. 358, Protect Life Act, et al., 

112 Cong., pp. 76–80 (Feb. 15, 2011) (transcript of the proceeding). 30Social Security Act, Section 1867 (U.S.C. 1395dd). 31 House Committee on Energy and Commerce, Markup on H.R. 358, Protect Life Act, et al., 

112th Cong., pp. 53–54 (Feb. 15, 2011) (transcript of the proceeding); Subcommittee on Health, 

House Committee on Energy and Commerce, Markup on H.R. 358, Protect Life Act, et al., 112th 

Cong., pp. 76–79 (Feb. 11, 2011) (transcript of the proceeding). 

which serve as a floor for the coverage that must be provided in 

any qualified plan offered by an insurance company in a state exchange.28 For example, under ACA, the essential benefits package 

may include coverage of contraception services as a minimum 

standard of insurance. Under H.R. 358, however, an insurance 

company located in a state with a sweeping refusal-protection statute in place (or one that targets family planning services specifically) could try to drop contraceptive coverage from the essential 

benefits package under the protection of that state law. Additionally, a state could pass a new law to take advantage of this loophole. 

It is unclear whether or not a company would be successful in 

this kind of effort to chip away at the essential benefits package. 

What is clear, however, is that—at best—the state conscience protection provisions in H.R. 358 pose a potential conflict with ACA’s 

requirements regarding the essential benefits package and, at 

worse, they provide a mechanism through which insurance companies could circumvent ACA law. In either case, we believe the result is an upending of one of most important and fundamental features of ACA—coverage of and access to a core set of health care 

services. 

It bears repeated mention that this is clearly not a provision related to abortion. The ACA already prohibits making abortion services part of the minimum benefits package and protects state laws 

regarding abortion coverage. Despite the bill’s misleading title, the 

legislation is a direct mechanism for allowing state laws to trump 

benefits decisions in areas other than abortion.29

H.R. 358 Would undermine EMTALA’s protections for women with 

life threatening conditions 

EMTALA establishes three basic obligations for all hospitals that 

participate in Medicare: (1) to screen an individual who comes to 

the emergency department to determine whether the individual 

has an emergency medical condition; (2) to stabilize any emergency 

medical condition in individuals in the hospital; and (3) to provide 

an appropriate transfer to another health care facility in some 

cases. EMTALA does not recognize any exceptions to these requirements.30

H.R. 358 breaks with this structure and inserts language that 

appears to allow a construction that would place ‘‘conscienceclause’’/’’refusal protection’’ concerns above those of the emergency 

stabilization and treatment requirements of EMTALA. The effect of 

this language is, at best, ambiguous. During the markups on the 

legislation, Committee staff responded to questions from members 

about this language and repeatedly noted that it does not amend 

the underlying provisions of EMTALA.31 One interpretation of this 

response is that the basic EMTALA guarantees remain intact and 


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32Subcommittee on Health, House Committee on Energy and Commerce, Markup on H.R. 358, 

Protect Life Act, et al., 112th Cong., p. 80 (Feb. 11, 2011) (transcript of the proceeding). 33 Examples of medical conditions that pose a major threat to maternal health: 

• Pre-eclampsia. According to a standard textbook on obstetrics, women with severe pre-eclampsia with a pregnancy of a gestational age of under 23 weeks should be offered the option 

to terminate the pregnancy. (Steven Gabbe, Obstetrics: Normal and Problem Pregnancies, Fifth 

Edition, 2007) • Pulmonary hypertension. The American College of Cardiology and the American Health Association expert consensus guidelines ‘‘recommend that pregnancy be avoided or terminated 

early in women with PAH [pulmonary arterial hypertension].’’ (ACCF/AHA 2009 Expert Consensus Document on Pulmonary Hypertension: A Report of the American College of Cardiology 

Foundation Task Force on Expert Consensus Documents and the American Heart Association Developed in Collaboration with the American College of Chest Physicians; American Thoracic Society, Inc.; and the Pulmonary Hypertension Association (Mar. 30, 2009)) (on line at http:// 

content.onlinejacc.org/cgi/content/ful1/53/17/1573). 34 Hospital Nun Rebuked for Allowing Abortion in Phoenix, USA Today (May 18, 2010) (on 

line at http://www.usatoday.com/news/religion/2010-05-18-nun-abortionlN.htm?loc= 

interstitialskip). 35See U.S. Conf. of Catholic Bishops: Committee on Doctrine, The Distinction Between Direct 

Abortion and Legitimate Medical Procedures, (June 23, 2010) (on line at http://www.usccb.org/ 

doctrine/direct-abortion-statement2010-06-23pdf). 

the new language in H.R. 358 is cosmetic only and should result 

in no change in policy. 

Another possible interpretation is that this language actually 

makes ‘‘conscience-clause’’/’’refusal protection’’ objections predominate over the emergency needs of a patient.32 If this is the case, 

H.R. 358 would allow a hospital to assert an objection to abortion 

and turn away (without referral or appropriate transfer) a pregnant woman whose emergency medical condition requires pregnancy termination. 

Sponsors of H.R. 358 claim that this poses no problem since 

EMTALA already recognizes the needs for emergency examination 

and treatment of the woman’s ‘‘unborn child.’’ This constitutes a 

deliberate misreading of the statute. The effect of the reference to 

‘‘unborn child’’ in the definition of ‘‘emergency medical condition’’ is 

that a pregnant woman will be considered to have an ‘‘emergency 

medical condition’’ if her health or the health of her fetus is in serious jeopardy. The only other references to ‘‘unborn child’’ in the 

statute address the safety of a transfer for a woman in labor. 

But certainly EMTALA recognizes special needs during pregnancy and appropriately so. The practice of turning a patient away 

from a hospital without providing appropriate care (commonly 

known as ‘‘patient dumping’’) is as repugnant when it endangers a 

fetus or a newborn just as it is repugnant when it endangers an 

adult. But there are, in fact, medical conditions that occur during 

pregnancy in which termination of the pregnancy is one of or, indeed, the only response that will save the life of the woman.33 It 

is unfortunately true that the medical needs of the woman and her 

fetus are not always parallel or consistent. 

Indeed, religious organizations, seeking to provide guidance to 

their adherents, have struggled with these issues. A recent and 

well-publicized case of a pregnant woman with pulmonary hypertension dramatizes the ongoing nature of the problem.34 Theological debates continue about such topics as ‘‘intended’’ termination of pregnancy, about the ‘‘direct purpose’’ of a procedure or 

of a ‘‘proportionately serious’’ condition.35

But the appropriate venue for such debates is theological circles 

and ethics committees, not an ambulance or an emergency room. 

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36Letter from Sr. Carol Keehan, DC, President and CEO, Catholic Health Association of the 

United States to Rep. Joseph R. Pitts (Feb. 9, 2011). 

sonnel to provide appropriate treatment to a patient, the hospital 

may nonetheless undertake an appropriate transfer with appropriate informed consent. What is forbidden is abandoning the patient—for any reason. 

We believe that one interpretation of the bill’s amendment to the 

rule of construction of EMTALA would allow exactly that result— 

abandonment of the patient. It would allow a hospital to assert a 

religious objection to the medically necessary termination of a pregnancy and leave her without rights of transfer or referral. 

We want to be clear: No one has identified a problem that this 

provision of the bill is supposed to solve. Indeed, the Catholic 

Health Association has told the Congress that it has worked successfully within the current requirements of EMTALA for years 

and that they do not support this change.36 Since these hospitals, 

which have clear objections to abortion services, are living within 

the terms of the law now, we would expect Catholic hospitals to 

continue to do so—regardless of whether H.R. 358 gives them the 

unrequested legal permission to abandon patients. But as Members 

of Congress who also have a conscience and moral principles, we 

cannot agree that such permission to abandon patients should be 

granted in the law. 

FAILURE TO ARTICULATE CONSTITUTIONAL BASIS FOR H.R. 358 

In addition to our objections to the substance of the legislation, 

we must also protest the manner in which Republican members of 

the Committee have flouted their own newly adopted rules of the 

House regarding statements of constitutional authority. This is the 

first piece of health legislation considered in the new Congress 

after the adoption of the new rules. Yet the sponsor did not meet 

requirements set forth in the new House rule requiring the filing 

of a statement stating the specific constitutional authority for the 

bill. 

If this were a routine bill, we would probably be inclined simply 

to note the hypocrisy of enacting a rule one month and violating 

it the next. But this is not a routine bill. As noted above, this is 

a piece of legislation that reaches fundamental constitutional protections and unduly burdens them with substantial obstacles. 

The new addition to the House Rules is found in clause 7 of rule 

XII. It provides: ‘‘A bill or joint resolution may not be introduced 

unless the sponsor submits for printing in the Congressional 

Record a statement citing as specifically as practicable the power 

or powers granted in the Constitution to enact the bill or joint resolution.’’ 

The guidance supplied by the House Rules Committee on how a 

member is to comply with this new rule provides a number of illustrative examples, each of which makes very specific reference to a 

provision of the Constitution or to one of the amendments to the 

Constitution. They include the following examples: 

• ‘‘The constitutional authority on which this bill rests is the 

power of the Congress to make rules for the government and reguVerDate Mar 15 2010 02:26 Mar 22, 2011 Jkt 099006 PO 00000 Frm 00030 Fmt 6604 Sfmt 6602 E:\HR\OC\HR040P1.XXX HR040P1

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37The statement on the constitutional authority for H.R. 358 reads: ‘‘Congress has the power 

to enact this legislation pursuant to the following: The Protect Life Act would overturn an unconstitutional mandate regarding abortion in the Patient Protection and Affordable Care Act.’’ 

(Statement of Rep. Pitts, Congressional Record, H396 (Jan. 20, 2011)). 

lation of the land and naval forces, as enumerated in Article I, Section 8, Clause 14 of the United States Constitution. 

• ‘‘This bill is enacted pursuant to Section 2 of Amendment XV 

of the United States Constitution. 

• ‘‘This bill is enacted pursuant to the power granted to Congress under Article I, Section 8, Clause 3 of the United States Constitution. 

• ‘‘The Congress enacts this bill pursuant to Clause 1 of Section 

8 of Article I of the United States Constitution and Amendment 

XVI of the United States Constitution. 

• ‘‘This bill makes specific changes in existing law in a manner 

that returns power to the States and to the people in accordance 

with Amendment X of the United States Constitution.’’ 

The guidance of the House Rules Committee on Compliance with 

the rule states that ‘‘the adequacy and accuracy of the citation of 

constitutional authority is [a] [sic] matter for debate in the committee and in the House.’’ 

Moreover, the Frequently Asked Questions guidance provided by 

the House Rules Committee provides: 

‘‘Q: So why have this Rule at all? 

‘‘A: Just as a cost estimate from the Congressional Budget Office 

informs the debate on a proposed bill, a statement outlining the 

power under the Constitution that Congress has to enact the proposed bill will inform and provide the basis for debate. It also demonstrates to the American people that we in Congress understand 

that we have an obligation under our founding documents to stay 

within the role established therein for the legislative branch.’’ 

So the requirements of the new rule are clear: make reference to 

the Constitution as specifically as practicable. The examples are 

clear: they cite articles, sections, clauses and amendments directly 

and by number. And the rationale is clear: this is to inform the debate on a bill and to show the American people that we understand 

our role. Over and above that, the venue for debate on this statement is clear: the committee and the House. 

Thus, it came as some surprise that the statement of constitutional authority for H.R. 358 cites no provision of the Constitution 

or any amendment to the Constitution.37 None. And, while a debate on the ‘‘adequacy and accuracy’’ of the statement was attempted in the both Health Subcommittee and full Committee 

markup, Republicans shut off debate and ruled it out of order. 

Therefore, the statement did not ‘‘inform and provide the basis for 

debate.’’ Most significantly, it did not demonstrate ‘‘to the American 

people that we in Congress understand that we have an obligation 

under our founding documents to stay within the role established 

therein for the legislative branch.’’ 

This should matter to all members, regardless of their views of 

this particular legislation. If we believe the new rule helps the 

process of legislation, guides our decisions, and demonstrates responsibility to all Americans, then the statement accompanying 


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this bill and the process used to discuss it make a mockery of the 

rule. 

This is especially important because, with this legislation, the 

Congress is stepping far beyond its ‘‘obligation under our founding 

documents to stay within the role established therein for the legislative branch.’’ As discussed above, this legislation intrudes into 

the realms of personal privacy that the Supreme Court has said are 

protected by the Constitution. The legislation places an undue burden on this fundamental right to privacy, and it erects barriers to 

abortion services that are far beyond any previous laws, that will 

have a severe impact, and that are without justification. 

This is exactly the situation in which the new rule would have 

proven truly useful. The statement of constitutional authority submitted by the author of the bill would have had to ignore or distinguish a long list of Supreme Court opinions about the limits on legislation in this area. Instead, the statement actually filed is factually incorrect, vague, and tautological. The Republicans have failed 

entirely to address the fundamental concern that Congress does not 

have the constitutional authority to enact H.R. 358. 

HENRY A. WAXMAN. 

ANNA G. ESHOO. 

CHARLES A. GONZALEZ. 

ANTHONY D. WEINER. 

LOIS CAPPS. 

JANE HARMAN. 

GENE GREEN. 

JAN SCHAKOWSKY. 

DIANA DEGETTE. 

JAY INSLEE. 

JOHN BARROW. 

FRANK PALLONE, Jr. 

DORIS O. MATSUI. 

EDWARD J. MARKEY. 

ELIOT L. ENGEL. 

EDOLPHUS TOWNS. 

TAMMY BALDWIN. 

BOBBY L. RUSH. 

G.K. BUTTERFIELD. 

JOHN D. DINGELL. 

MIKE DOYLE. 

Æ 


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