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[House Report 116-49]
[From the U.S. Government Publishing Office]

116th Congress   }                                      {       Report
                        HOUSE OF REPRESENTATIVES
 1st Session     }                                      {       116-49

======================================================================

 
             STATE ALLOWANCE FOR A VARIETY OF EXCHANGES ACT

                                _______
                                

  May 3, 2019.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

 Mr. Pallone, from the Committee on Energy and Commerce, submitted the 
                               following

                              R E P O R T

                             together with

                            DISSENTING VIEWS

                        [To accompany H.R. 1385]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Energy and Commerce, to whom was referred 
the bill (H.R. 1385) to amend the Patient Protection and 
Affordable Care Act to preserve the option of States to 
implement health care marketplaces, and for other purposes, 
having considered the same, report favorably thereon with an 
amendment and recommend that the bill as amended do pass.

                                CONTENTS

                                                                   Page
Purpose and Summary..............................................     2
Background and Need for the Legislation..........................     2
Committee Hearings...............................................     3
Committee Consideration..........................................     3
Committee Votes..................................................     4
Oversight Findings...............................................     6
New Budget Authority, Entitlement Authority, and Tax Expenditures     6
Congressional Budget Office Estimate.............................     6
Federal Mandates Statement.......................................     7
Statement of General Performance Goals and Objectives............     7
Duplication of Federal Programs..................................     7
Committee Cost Estimate..........................................     7
Earmarks, Limited Tax Benefits, and Limited Tariff Benefits......     8
Advisory Committee Statement.....................................     8
Applicability to Legislative Branch..............................     8
Section-by-Section Analysis of the Legislation...................     8
Changes in Existing Law Made by the Bill, as Reported............     8
Dissenting Views.................................................    22

    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 ``State Allowance for a Variety of 
Exchanges Act'' or the ``SAVE Act''.

SEC. 2. PRESERVING STATE OPTION TO IMPLEMENT HEALTH CARE MARKETPLACES.

  (a) In General.--Section 1311 of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18031) is amended--
          (1) in subsection (a)--
                  (A) in paragraph (4)(B), by striking ``under this 
                subsection'' and inserting ``under this paragraph or 
                paragraph (1)''; and
                  (B) by adding at the end the following new paragraph:
          ``(6) Additional planning and establishment grants.--
                  ``(A) In general.--There shall be appropriated to the 
                Secretary, out of any moneys in the Treasury not 
                otherwise appropriated, $200,000,000 to award grants to 
                eligible States for the uses described in paragraph 
                (3).
                  ``(B) Duration and renewability.--A grant awarded 
                under subparagraph (A) shall be for a period of two 
                years and may not be renewed.
                  ``(C) Limitation.--A grant may not be awarded under 
                subparagraph (A) after December 31, 2022.
                  ``(D) Eligible state defined.--For purposes of this 
                paragraph, the term `eligible State' means a State 
                that, as of the date of the enactment of this 
                paragraph, is not operating an Exchange (other than an 
                Exchange described in section 155.200(f) of title 45, 
                Code of Federal Regulations).''; and
          (2) in subsection (d)(5)(A)--
                  (A) by striking ``operations.--In establishing an 
                Exchange under this section'' and inserting 
                ``operations.--
                          ``(i) In general.--In establishing an 
                        Exchange under this section (other than in 
                        establishing an Exchange pursuant to a grant 
                        awarded under subsection (a)(6))''; and
                  (B) by adding at the end the following:
                          ``(ii) Additional planning and establishment 
                        grants.--In establishing an Exchange pursuant 
                        to a grant awarded under subsection (a)(6), the 
                        State shall ensure that such Exchange is self-
                        sustaining beginning on January 1, 2024, 
                        including allowing the Exchange to charge 
                        assessments or user fees to participating 
                        health insurance issuers, or to otherwise 
                        generate funding, to support its operations.''.
  (b) Clarification Regarding Failure To Establish Exchange or 
Implement Requirements.--Section 1321(c) of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18041(c)) is amended--
          (1) in paragraph (1), by striking ``If'' and inserting 
        ``Subject to paragraph (3), if''; and
          (2) by adding at the end the following new paragraph:
          ``(3) Clarification.--This subsection shall not apply in the 
        case of a State that elects to apply the requirements described 
        in subsection (a) and satisfies the requirement described in 
        subsection (b) on or after January 1, 2014.''.

                          Purpose and Summary

    H.R. 1385, the ``State Allowance for a Variety of Exchanges 
Act'' or the ``SAVE Act'', was introduced on February 27, 2019, 
by Reps. Andy Kim (D-NJ) and Brian K. Fitzpatrick (R-PA) and 
referred to the Committee on Energy and Commerce.
    The goal of H.R. 1385 is to provide states with $200 
million in federal funds to establish state-based marketplaces.

                  Background and Need for Legislation

    The Affordable Care Act (ACA) provided states the option to 
establish their own marketplaces or rely on the Federally-
Facilitated Marketplace (FFM). The law also provided grants to 
states to support the planning and establishment of state-based 
marketplaces. These grants, however, could be awarded only up 
until January 1, 2015. Accordingly, states no longer have 
access to federal funds to establish a state-based marketplace.
    States that operate their own marketplaces have greater 
control over their insurance markets and can tailor consumer 
outreach and financial assistance to meet the needs of their 
population. Enrollment in state-based marketplaces has remained 
stable and premiums are lower overall, compared to the FFM.\1\ 
Moreover, state-based marketplaces that opted for longer open 
enrollment periods beyond the FFM's shortened six-week period 
experienced higher enrollment gains in 2018.\2\
---------------------------------------------------------------------------
    \1\The Commonwealth Fund, Health Insurance Markets Perform Better 
in States That Run Their Own Marketplaces (Mar 7, 2018) 
(www.commonwealthfund.org/blog/2018/health-insurance-markets-perform-
better-states-run-their-own-marketplaces).
    \2\Urban Institute, What Explains 2018's Marketplace Enrollment 
Rates? (June 2018) (www.urban.org/sites/default/files/publication/
98650/marketplace2018_2001877.pdf).
---------------------------------------------------------------------------

                           Committee Hearings

    For the purposes of section 103(i) of H. Res. 6 of the 
116th Congress, the following hearing was used to develop or 
consider H.R. 1385:
    On March 6, 2019, the Subcommittee on Health held a 
legislative hearing entitled, ``Strengthening Our Health Care 
System: Legislation to Lower Consumer Costs and Expand 
Access.'' The hearing focused on H.R. 1385 and two other bills. 
The Subcommittee received testimony from the following 
witnesses:
           Peter Lee, Executive Director, Covered 
        California;
           Audrey Morse Gasteier, Chief of Policy, 
        Massachusetts Health Connector; and
           J.P. Wieske, Vice President, State Affairs, 
        Council for Affordable Health Coverage.

                        Committee Consideration

    H.R. 1385, the ``State Allowance for a Variety of Exchanges 
Act'' or the ``SAVE Act'', was introduced on February 27, 2019, 
by Rep. Kim (D-NJ), and referred to the Committee on Energy and 
Commerce. The bill was subsequently referred to the 
Subcommittee on Health on February 28, 2019. Following 
legislative hearings, on March 26, 2019, the Subcommittee met 
in open markup session, pursuant to notice, on H.R. 1385 for 
consideration of the bill. During markup, an amendment offered 
by Mr. Bucshon (R-IN) was defeated by a record vote of 10 yeas 
to 18 nays. Subsequently, the Subcommittee on Health agreed to 
a motion by Ms. Eshoo, Chairwoman of the Subcommittee, to 
favorably forward H.R. 1385 to the full Committee on Energy and 
Commerce, without amendment, by a voice vote.
    On April 3, 2019, the full Committee met in open markup 
session, pursuant to notice, to consider H.R. 1385. During the 
markup, Mr. Pallone (D-NJ) offered an amendment to the bill 
that was agreed to by a voice vote. At the conclusion of 
consideration of the bill, the Committee on Energy and Commerce 
agreed to a motion by Mr. Pallone, Chairman of the Committee, 
to order H.R. 1385 favorably reported to the House, amended, by 
a record vote of 29 yeas to 22 nays.

                            Committee Votes

    Clause 3(b) of rule XIII of the Rules of the House of 
Representatives requires the Committee to list each record vote 
on the motion to report legislation and amendments thereto. The 
Committee advises that a record vote was taken on final passage 
of H.R. 1385. A motion by Mr. Pallone to order H.R. 1385 
favorably reported to the House, amended, was agreed to by a 
record vote of 29 yeas to 22 nays. The following is that record 
vote taken during Committee consideration, including the names 
of those members voting for and against:

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                           Oversight Findings

    Pursuant to clause 3(c)(1) of rule XIII and clause 2(b)(1) 
of rule X of the Rules of the House of Representatives, the 
oversight findings and recommendations of the Committee are 
reflected in the descriptive portion of the report.

   New Budget Authority, Entitlement Authority, and Tax Expenditures

    Pursuant to 3(c)(2) of rule XIII of the Rules of the House 
of Representatives, the Committee adopts as its own the 
estimate of new budget authority, entitlement authority, or tax 
expenditures or revenues contained in 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

    With respect to the requirements of clause (3)(c)(3) of 
rule XIII of the Rules of the House of Representatives and 
section 402 of the Congressional Budget Act of 1974, the 
Committee has received the following cost estimate for H.R. 
1385 from the Director of the Congressional Budget Office:

                                     U.S. Congress,
                               Congressional Budget Office,
                                    Washington, DC, April 25, 2019.
Hon. Frank Pallone, Jr.,
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. 1385, the State 
Allowance for a Variety of Exchanges Act.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Lisa Ramirez-
Branum.
            Sincerely,
                                                        Keith Hall,
                                                              Director.
    Enclosure.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    No Under the Affordable Care Act (ACA), HHS was authorized 
to provide grant funds to states to plan and establish on-line 
platforms--also known as health care marketplaces--where people 
without health care insurance could find information about 
health insurance options and also purchase health care 
insurance. The authority for HHS to award such grants expired 
at the end of 2014.
    H.R. 1385 would appropriate $200 million to HHS to provide 
grants to states that, as of the date of enactment of the bill, 
were not operating a health care marketplace. The bill also 
would limit a grant to a period of two years and would prohibit 
HHS from awarding a grant after December 31, 2022. CBO 
estimates that enacting the bill would increase direct spending 
by $196 million over the 2019-2029 period.
    Details of the estimated budgetary effect of H.R. 1385 are 
shown in Table 1. The costs of the legislation fall within 
budget function 550.

                                                   TABLE 1.--ESTIMATED BUDGETARY EFFECTS OF H.R. 1385
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                     By fiscal year, millions of dollars--
                                                      --------------------------------------------------------------------------------------------------
                                                        2019   2020   2021   2022   2023   2024   2025   2026   2027   2028   2029  2019-2024  2019-2029
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                              Increases in Direct Spending
 
Budget Authority.....................................    200      0      0      0      0      0      0      0      0      0      0       200        200
Estimated Outlays....................................      0     86     80     16     14      0      0      0      0      0      0       196        196
--------------------------------------------------------------------------------------------------------------------------------------------------------

    The CBO staff contact for this estimate is Lisa Ramirez-
Branum. The estimate was reviewed by Leo Lex, Deputy Assistant 
Director for Budget Analysis.

                       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.

         Statement of General Performance Goals and Objectives

    Pursuant to clause 3(c)(4) of rule XIII, the general 
performance goal or objective of this legislation is to provide 
states with $200 million in federal funds to establish state-
based marketplaces.

                    Duplication of Federal Programs

    Pursuant to clause 3(c)(5) of rule XIII, no provision of 
H.R. 1385 is known to be duplicative of another Federal 
program, including any program that was included in a report to 
Congress pursuant to section 21 of Public Law 111-139 or the 
most recent Catalog of Federal Domestic Assistance.

                        Committee Cost Estimate

    Pursuant to clause 3(d)(1) of rule XIII, 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.

      Earmarks, Limited Tax Benefits, and Limited Tariff Benefits

    Pursuant to clause 9(e), 9(f), and 9(g) of rule XXI, the 
Committee finds that H.R. 1385 contains no earmarks, limited 
tax benefits, or limited tariff benefits.

                      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

    Section 1 designates that the short title of the Act may be 
cited as the ``State Allowance for a Variety of Exchanges Act'' 
or the ``SAVE Act''.

Section 2. Preserving state option to implement health care 
        marketplaces

    Section 2 amends Section 1331 of the ACA. Section 2 
appropriates $200 million and provides the Secretary of the 
Department of Health and Human Services the authority to award 
grants to eligible states for the purposes of establishing a 
state-based exchange. This section defines eligible states as 
states currently on the FFM and state-based exchanges on the 
FFM platform. The section requires that the grants be available 
for a period of two years and includes a limitation that the 
grants may not be awarded after December 21, 2022. The section 
also requires states receiving grant funding to ensure that the 
state exchange is self-sustaining beginning on January 1, 2024.

         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, and 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 2--CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH 
                           BENEFIT EXCHANGES

SEC. 1311. AFFORDABLE CHOICES OF HEALTH BENEFIT PLANS.

  (a) Assistance to States to Establish American Health Benefit 
Exchanges.--
          (1) Planning and establishment grants.--There shall 
        be appropriated to the Secretary, out of any moneys in 
        the Treasury not otherwise appropriated, an amount 
        necessary to enable the Secretary to make awards, not 
        later than 1 year after the date of enactment of this 
        Act, to States in the amount specified in paragraph (2) 
        for the uses described in paragraph (3).
          (2) Amount specified.--For each fiscal year, the 
        Secretary shall determine the total amount that the 
        Secretary will make available to each State for grants 
        under this subsection.
          (3) Use of funds.--A State shall use amounts awarded 
        under this subsection for activities (including 
        planning activities) related to establishing an 
        American Health Benefit Exchange, as described in 
        subsection (b).
          (4) Renewability of grant.--
                  (A) In general.--Subject to subsection 
                (d)(4), the Secretary may renew a grant awarded 
                under paragraph (1) if the State recipient of 
                such grant--
                          (i) is making progress, as determined 
                        by the Secretary, toward--
                                  (I) establishing an Exchange; 
                                and
                                  (II) implementing the reforms 
                                described in subtitles A and C 
                                (and the amendments made by 
                                such subtitles); and
                          (ii) is meeting such other benchmarks 
                        as the Secretary may establish.
                  (B) Limitation.--No grant shall be awarded 
                [under this subsection] under this paragraph or 
                paragraph (1) after January 1, 2015.
          (5) Technical assistance to facilitate participation 
        in SHOP exchanges.--The Secretary shall provide 
        technical assistance to States to facilitate the 
        participation of qualified small businesses in such 
        States in SHOP Exchanges.
          (6) Additional planning and establishment grants.--
                  (A) In general.--There shall be appropriated 
                to the Secretary, out of any moneys in the 
                Treasury not otherwise appropriated, 
                $200,000,000 to award grants to eligible States 
                for the uses described in paragraph (3).
                  (B) Duration and renewability.--A grant 
                awarded under subparagraph (A) shall be for a 
                period of two years and may not be renewed.
                  (C) Limitation.--A grant may not be awarded 
                under subparagraph (A) after December 31, 2022.
                  (D) Eligible state defined.--For purposes of 
                this paragraph, the term ``eligible State'' 
                means a State that, as of the date of the 
                enactment of this paragraph, is not operating 
                an Exchange (other than an Exchange described 
                in section 155.200(f) of title 45, Code of 
                Federal Regulations).
  (b) American Health Benefit Exchanges.--
          (1) In general.--Each State shall, not later than 
        January 1, 2014, establish an American Health Benefit 
        Exchange (referred to in this title as an ``Exchange'') 
        for the State that--
                  (A) facilitates the purchase of qualified 
                health plans;
                  (B) provides for the establishment of a Small 
                Business Health Options Program (in this title 
                referred to as a ``SHOP Exchange'') that is 
                designed to assist qualified employers in the 
                State who are small employers in facilitating 
                the enrollment of their employees in qualified 
                health plans offered in the small group market 
                in the State; and
                  (C) meets the requirements of subsection (d).
          (2) Merger of individual and SHOP Exchanges.--A State 
        may elect to provide only one Exchange in the State for 
        providing both Exchange and SHOP Exchange services to 
        both qualified individuals and qualified small 
        employers, but only if the Exchange has adequate 
        resources to assist such individuals and employers.
  (c) Responsibilities of the Secretary.--
          (1) In general.--The Secretary shall, by regulation, 
        establish criteria for the certification of health 
        plans as qualified health plans. Such criteria shall 
        require that, to be certified, a plan shall, at a 
        minimum--
                  (A) meet marketing requirements, and not 
                employ marketing practices or benefit designs 
                that have the effect of discouraging the 
                enrollment in such plan by individuals with 
                significant health needs;
                  (B) ensure a sufficient choice of providers 
                (in a manner consistent with applicable network 
                adequacy provisions under section 2702(c) of 
                the Public Health Service Act), and provide 
                information to enrollees and prospective 
                enrollees on the availability of in-network and 
                out-of-network providers;
                  (C) include within health insurance plan 
                networks those essential community providers, 
                where available, that serve predominately low-
                income, medically-underserved individuals, such 
                as health care providers defined in section 
                340B(a)(4) of the Public Health Service Act and 
                providers described in section 
                1927(c)(1)(D)(i)(IV) of the Social Security Act 
                as set forth by section 221 of Public Law 111-
                8, except that nothing in this subparagraph 
                shall be construed to require any health plan 
                to provide coverage for any specific medical 
                procedure;
                  (D)(i) be accredited with respect to local 
                performance on clinical quality measures such 
                as the Healthcare Effectiveness Data and 
                Information Set, patient experience ratings on 
                a standardized Consumer Assessment of 
                Healthcare Providers and Systems survey, as 
                well as consumer access, utilization 
                management, quality assurance, provider 
                credentialing, complaints and appeals, network 
                adequacy and access, and patient information 
                programs by any entity recognized by the 
                Secretary for the accreditation of health 
                insurance issuers or plans (so long as any such 
                entity has transparent and rigorous 
                methodological and scoring criteria); or
                  (ii) receive such accreditation within a 
                period established by an Exchange for such 
                accreditation that is applicable to all 
                qualified health plans;
                  (E) implement a quality improvement strategy 
                described in subsection (g)(1);
                  (F) utilize a uniform enrollment form that 
                qualified individuals and qualified employers 
                may use (either electronically or on paper) in 
                enrolling in qualified health plans offered 
                through such Exchange, and that takes into 
                account criteria that the National Association 
                of Insurance Commissioners develops and submits 
                to the Secretary;
                  (G) utilize the standard format established 
                for presenting health benefits plan options;
                  (H) provide information to enrollees and 
                prospective enrollees, and to each Exchange in 
                which the plan is offered, on any quality 
                measures for health plan performance endorsed 
                under section 399JJ of the Public Health 
                Service Act, as applicable; and
                  (I) report to the Secretary at least annually 
                and in such manner as the Secretary shall 
                require, pediatric quality reporting measures 
                consistent with the pediatric quality reporting 
                measures established under section 1139A of the 
                Social Security Act.
          (2) Rule of construction.--Nothing in paragraph 
        (1)(C) shall be construed to require a qualified health 
        plan to contract with a provider described in such 
        paragraph if such provider refuses to accept the 
        generally applicable payment rates of such plan.
          (3) Rating system.--The Secretary shall develop a 
        rating system that would rate qualified health plans 
        offered through an Exchange in each benefits level on 
        the basis of the relative quality and price. The 
        Exchange shall include the quality rating in the 
        information provided to individuals and employers 
        through the Internet portal established under paragraph 
        (4).
          (4) Enrollee satisfaction system.--The Secretary 
        shall develop an enrollee satisfaction survey system 
        that would evaluate the level of enrollee satisfaction 
        with qualified health plans offered through an 
        Exchange, for each such qualified health plan that had 
        more than 500 enrollees in the previous year. The 
        Exchange shall include enrollee satisfaction 
        information in the information provided to individuals 
        and employers through the Internet portal established 
        under paragraph (5) in a manner that allows individuals 
        to easily compare enrollee satisfaction levels between 
        comparable plans.
          (5) Internet portals.--The Secretary shall--
                  (A) continue to operate, maintain, and update 
                the Internet portal developed under section 
                1103(a) and to assist States in developing and 
                maintaining their own such portal; and
                  (B) make available for use by Exchanges a 
                model template for an Internet portal that may 
                be used to direct qualified individuals and 
                qualified employers to qualified health plans, 
                to assist such individuals and employers in 
                determining whether they are eligible to 
                participate in an Exchange or eligible for a 
                premium tax credit or cost-sharing reduction, 
                and to present standardized information 
                (including quality ratings) regarding qualified 
                health plans offered through an Exchange to 
                assist consumers in making easy health 
                insurance choices.
        Such template shall include, with respect to each 
        qualified health plan offered through the Exchange in 
        each rating area, access to the uniform outline of 
        coverage the plan is required to provide under section 
        2716 of the Public Health Service Act and to a copy of 
        the plan's written policy.
          (6) Enrollment periods.--The Secretary shall require 
        an Exchange to provide for--
                  (A) an initial open enrollment, as determined 
                by the Secretary (such determination to be made 
                not later than July 1, 2012);
                  (B) annual open enrollment periods, as 
                determined by the Secretary for calendar years 
                after the initial enrollment period;
                  (C) special enrollment periods specified in 
                section 9801 of the Internal Revenue Code of 
                1986 and other special enrollment periods under 
                circumstances similar to such periods under 
                part D of title XVIII of the Social Security 
                Act; and
                  (D) special monthly enrollment periods for 
                Indians (as defined in section 4 of the Indian 
                Health Care Improvement Act).
  (d) Requirements.--
          (1) In general.--An Exchange shall be a governmental 
        agency or nonprofit entity that is established by a 
        State.
          (2) Offering of coverage.--
                  (A) In general.--An Exchange shall make 
                available qualified health plans to qualified 
                individuals and qualified employers.
                  (B) Limitation.--
                          (i) In general.--An Exchange may not 
                        make available any health plan that is 
                        not a qualified health plan.
                          (ii) Offering of stand-alone dental 
                        benefits.--Each Exchange within a State 
                        shall allow an issuer of a plan that 
                        only provides limited scope dental 
                        benefits meeting the requirements of 
                        section 9832(c)(2)(A) of the Internal 
                        Revenue Code of 1986 to offer the plan 
                        through the Exchange (either separately 
                        or in conjunction with a qualified 
                        health plan) if the plan provides 
                        pediatric dental benefits meeting the 
                        requirements of section 1302(b)(1)(J)).
          (3) Rules relating to additional required benefits.--
                  (A) In general.--Except as provided in 
                subparagraph (B), an Exchange may make 
                available a qualified health plan 
                notwithstanding any provision of law that may 
                require benefits other than the essential 
                health benefits specified under section 
                1302(b).
                  (B) States may require additional benefits.--
                          (i) In general.--Subject to the 
                        requirements of clause (ii), a State 
                        may require that a qualified health 
                        plan offered in such State offer 
                        benefits in addition to the essential 
                        health benefits specified under section 
                        1302(b).
                          (ii) State must assume cost.--A State 
                        shall make payments--
                                  (I) to an individual enrolled 
                                in a qualified health plan 
                                offered in such State; or
                                  (II) on behalf of an 
                                individual described in 
                                subclause (I) directly to the 
                                qualified health plan in which 
                                such individual is enrolled;
                        to defray the cost of any additional 
                        benefits described in clause (i).
          (4) Functions.--An Exchange shall, at a minimum--
                  (A) implement procedures for the 
                certification, recertification, and 
                decertification, consistent with guidelines 
                developed by the Secretary under subsection 
                (c), of health plans as qualified health plans;
                  (B) provide for the operation of a toll-free 
                telephone hotline to respond to requests for 
                assistance;
                  (C) maintain an Internet website through 
                which enrollees and prospective enrollees of 
                qualified health plans may obtain standardized 
                comparative information on such plans;
                  (D) assign a rating to each qualified health 
                plan offered through such Exchange in 
                accordance with the criteria developed by the 
                Secretary under subsection (c)(3);
                  (E) utilize a standardized format for 
                presenting health benefits plan options in the 
                Exchange, including the use of the uniform 
                outline of coverage established under section 
                2715 of the Public Health Service Act;
                  (F) in accordance with section 1413, inform 
                individuals of eligibility requirements for the 
                medicaid program under title XIX of the Social 
                Security Act, the CHIP program under title XXI 
                of such Act, or any applicable State or local 
                public program and if through screening of the 
                application by the Exchange, the Exchange 
                determines that such individuals are eligible 
                for any such program, enroll such individuals 
                in such program;
                  (G) establish and make available by 
                electronic means a calculator to determine the 
                actual cost of coverage after the application 
                of any premium tax credit under section 36B of 
                the Internal Revenue Code of 1986 and any cost-
                sharing reduction under section 1402;
                  (H) subject to section 1411, grant a 
                certification attesting that, for purposes of 
                the individual responsibility penalty under 
                section 5000A of the Internal Revenue Code of 
                1986, an individual is exempt from the 
                individual requirement or from the penalty 
                imposed by such section because--
                          (i) there is no affordable qualified 
                        health plan available through the 
                        Exchange, or the individual's employer, 
                        covering the individual; or
                          (ii) the individual meets the 
                        requirements for any other such 
                        exemption from the individual 
                        responsibility requirement or penalty;
                  (I) transfer to the Secretary of the 
                Treasury--
                          (i) a list of the individuals who are 
                        issued a certification under 
                        subparagraph (H), including the name 
                        and taxpayer identification number of 
                        each individual;
                          (ii) the name and taxpayer 
                        identification number of each 
                        individual who was an employee of an 
                        employer but who was determined to be 
                        eligible for the premium tax credit 
                        under section 36B of the Internal 
                        Revenue Code of 1986 because--
                                  (I) the employer did not 
                                provide minimum essential 
                                coverage; or
                                  (II) the employer provided 
                                such minimum essential coverage 
                                but it was determined under 
                                section 36B(c)(2)(C) of such 
                                Code to either be unaffordable 
                                to the employee or not provide 
                                the required minimum actuarial 
                                value; and
                          (iii) the name and taxpayer 
                        identification number of each 
                        individual who notifies the Exchange 
                        under section 1411(b)(4) that they have 
                        changed employers and of each 
                        individual who ceases coverage under a 
                        qualified health plan during a plan 
                        year (and the effective date of such 
                        cessation);
                  (J) provide to each employer the name of each 
                employee of the employer described in 
                subparagraph (I)(ii) who ceases coverage under 
                a qualified health plan during a plan year (and 
                the effective date of such cessation); and
                  (K) establish the Navigator program described 
                in subsection (i).
          (5) Funding limitations.--
                  (A) No Federal funds for continued 
                [operations.--] [In establishing an Exchange 
                under this section] operations._
                          (i) In general._In establishing an 
                        Exchange under this section (other than 
                        in establishing an Exchange pursuant to 
                        a grant awarded under subsection 
                        (a)(6)), the State shall ensure that 
                        such Exchange is self-sustaining 
                        beginning on January 1, 2015, including 
                        allowing the Exchange to charge 
                        assessments or user fees to 
                        participating health insurance issuers, 
                        or to otherwise generate funding, to 
                        support its operations.
                          (ii) Additional planning and 
                        establishment grants.--In establishing 
                        an Exchange pursuant to a grant awarded 
                        under subsection (a)(6), the State 
                        shall ensure that such Exchange is 
                        self-sustaining beginning on January 1, 
                        2024, including allowing the Exchange 
                        to charge assessments or user fees to 
                        participating health insurance issuers, 
                        or to otherwise generate funding, to 
                        support its operations.
                  (B) Prohibiting wasteful use of funds.--In 
                carrying out activities under this subsection, 
                an Exchange shall not utilize any funds 
                intended for the administrative and operational 
                expenses of the Exchange for staff retreats, 
                promotional giveaways, excessive executive 
                compensation, or promotion of Federal or State 
                legislative and regulatory modifications.
          (6) Consultation.--An Exchange shall consult with 
        stakeholders relevant to carrying out the activities 
        under this section, including--
                  (A) educated health care consumers who are 
                enrollees in qualified health plans;
                  (B) individuals and entities with experience 
                in facilitating enrollment in qualified health 
                plans;
                  (C) representatives of small businesses and 
                self-employed individuals;
                  (D) State Medicaid offices; and
                  (E) advocates for enrolling hard to reach 
                populations.
          (7) Publication of costs.--An Exchange shall publish 
        the average costs of licensing, regulatory fees, and 
        any other payments required by the Exchange, and the 
        administrative costs of such Exchange, on an Internet 
        website to educate consumers on such costs. Such 
        information shall also include monies lost to waste, 
        fraud, and abuse.
  (e) Certification.--
          (1) In general.--An Exchange may certify a health 
        plan as a qualified health plan if--
                  (A) such health plan meets the requirements 
                for certification as promulgated by the 
                Secretary under subsection (c)(1); and
                  (B) the Exchange determines that making 
                available such health plan through such 
                Exchange is in the interests of qualified 
                individuals and qualified employers in the 
                State or States in which such Exchange 
                operates, except that the Exchange may not 
                exclude a health plan--
                          (i) on the basis that such plan is a 
                        fee-for-service plan;
                          (ii) through the imposition of 
                        premium price controls; or
                          (iii) on the basis that the plan 
                        provides treatments necessary to 
                        prevent patients' deaths in 
                        circumstances the Exchange determines 
                        are inappropriate or too costly.
          (2) Premium considerations.--The Exchange shall 
        require health plans seeking certification as qualified 
        health plans to submit a justification for any premium 
        increase prior to implementation of the increase. Such 
        plans shall prominently post such information on their 
        websites. The Exchange shall take this information, and 
        the information and the recommendations provided to the 
        Exchange by the State under section 2794(b)(1) of the 
        Public Health Service Act (relating to patterns or 
        practices of excessive or unjustified premium 
        increases), into consideration when determining whether 
        to make such health plan available through the 
        Exchange. The Exchange shall take into account any 
        excess of premium growth outside the Exchange as 
        compared to the rate of such growth inside the 
        Exchange, including information reported by the States.
          (3) Transparency in coverage.--
                  (A) In general.--The Exchange shall require 
                health plans seeking certification as qualified 
                health plans to submit to the Exchange, the 
                Secretary, the State insurance commissioner, 
                and make available to the public, accurate and 
                timely disclosure of the following information:
                          (i) Claims payment policies and 
                        practices.
                          (ii) Periodic financial disclosures.
                          (iii) Data on enrollment.
                          (iv) Data on disenrollment.
                          (v) Data on the number of claims that 
                        are denied.
                          (vi) Data on rating practices.
                          (vii) Information on cost-sharing and 
                        payments with respect to any out-of-
                        network coverage.
                          (viii) Information on enrollee and 
                        participant rights under this title.
                          (ix) Other information as determined 
                        appropriate by the Secretary.
                  (B) Use of plain language.--The information 
                required to be submitted under subparagraph (A) 
                shall be provided in plain language. The term 
                ``plain language'' means language that the 
                intended audience, including individuals with 
                limited English proficiency, can readily 
                understand and use because that language is 
                concise, well-organized, and follows other best 
                practices of plain language writing. The 
                Secretary and the Secretary of Labor shall 
                jointly develop and issue guidance on best 
                practices of plain language writing.
                  (C) Cost sharing transparency.--The Exchange 
                shall require health plans seeking 
                certification as qualified health plans to 
                permit individuals to learn the amount of cost-
                sharing (including deductibles, copayments, and 
                coinsurance) under the individual's plan or 
                coverage that the individual would be 
                responsible for paying with respect to the 
                furnishing of a specific item or service by a 
                participating provider in a timely manner upon 
                the request of the individual. At a minimum, 
                such information shall be made available to 
                such individual through an Internet website and 
                such other means for individuals without access 
                to the Internet.
                  (D) Group health plans.--The Secretary of 
                Labor shall update and harmonize the 
                Secretary's rules concerning the accurate and 
                timely disclosure to participants by group 
                health plans of plan disclosure, plan terms and 
                conditions, and periodic financial disclosure 
                with the standards established by the Secretary 
                under subparagraph (A).
  (f) Flexibility.--
          (1) Regional or other interstate Exchanges.--An 
        Exchange may operate in more than one State if--
                  (A) each State in which such Exchange 
                operates permits such operation; and
                  (B) the Secretary approves such regional or 
                interstate Exchange.
          (2) Subsidiary Exchanges.--A State may establish one 
        or more subsidiary Exchanges if--
                  (A) each such Exchange serves a 
                geographically distinct area; and
                  (B) the area served by each such Exchange is 
                at least as large as a rating area described in 
                section 2701(a) of the Public Health Service 
                Act.
          (3) Authority to contract.--
                  (A) In general.--A State may elect to 
                authorize an Exchange established by the State 
                under this section to enter into an agreement 
                with an eligible entity to carry out 1 or more 
                responsibilities of the Exchange.
                  (B) Eligible entity.--In this paragraph, the 
                term ``eligible entity'' means--
                          (i) a person--
                                  (I) incorporated under, and 
                                subject to the laws of, 1 or 
                                more States;
                                  (II) that has demonstrated 
                                experience on a State or 
                                regional basis in the 
                                individual and small group 
                                health insurance markets and in 
                                benefits coverage; and
                                  (III) that is not a health 
                                insurance issuer or that is 
                                treated under subsection (a) or 
                                (b) of section 52 of the 
                                Internal Revenue Code of 1986 
                                as a member of the same 
                                controlled group of 
                                corporations (or under common 
                                control with) as a health 
                                insurance issuer; or
                          (ii) the State medicaid agency under 
                        title XIX of the Social Security Act.
  (g) Rewarding Quality Through Market-Based Incentives.--
          (1) Strategy described.--A strategy described in this 
        paragraph is a payment structure that provides 
        increased reimbursement or other incentives for--
                  (A) improving health outcomes through the 
                implementation of activities that shall include 
                quality reporting, effective case management, 
                care coordination, chronic disease management, 
                medication and care compliance initiatives, 
                including through the use of the medical home 
                model, for treatment or services under the plan 
                or coverage;
                  (B) the implementation of activities to 
                prevent hospital readmissions through a 
                comprehensive program for hospital discharge 
                that includes patient-centered education and 
                counseling, comprehensive discharge planning, 
                and post discharge reinforcement by an 
                appropriate health care professional;
                  (C) the implementation of activities to 
                improve patient safety and reduce medical 
                errors through the appropriate use of best 
                clinical practices, evidence based medicine, 
                and health information technology under the 
                plan or coverage;
                  (D) the implementation of wellness and health 
                promotion activities; and
                  (E) the implementation of activities to 
                reduce health and health care disparities, 
                including through the use of language services, 
                community outreach, and cultural competency 
                trainings.
          (2) Guidelines.--The Secretary, in consultation with 
        experts in health care quality and stakeholders, shall 
        develop guidelines concerning the matters described in 
        paragraph (1).
          (3) Requirements.--The guidelines developed under 
        paragraph (2) shall require the periodic reporting to 
        the applicable Exchange of the activities that a 
        qualified health plan has conducted to implement a 
        strategy described in paragraph (1).
  (h) Quality Improvement.--
          (1) Enhancing patient safety.--Beginning on January 
        1, 2015, a qualified health plan may contract with--
                  (A) a hospital with greater than 50 beds only 
                if such hospital--
                          (i) utilizes a patient safety 
                        evaluation system as described in part 
                        C of title IX of the Public Health 
                        Service Act; and
                          (ii) implements a mechanism to ensure 
                        that each patient receives a 
                        comprehensive program for hospital 
                        discharge that includes patient-
                        centered education and counseling, 
                        comprehensive discharge planning, and 
                        post discharge reinforcement by an 
                        appropriate health care professional; 
                        or
                  (B) a health care provider only if such 
                provider implements such mechanisms to improve 
                health care quality as the Secretary may by 
                regulation require.
          (2) Exceptions.--The Secretary may establish 
        reasonable exceptions to the requirements described in 
        paragraph (1).
          (3) Adjustment.--The Secretary may by regulation 
        adjust the number of beds described in paragraph 
        (1)(A).
  (i) Navigators.--
          (1) In general.--An Exchange shall establish a 
        program under which it awards grants to entities 
        described in paragraph (2) to carry out the duties 
        described in paragraph (3).
          (2) Eligibility.--
                  (A) In general.--To be eligible to receive a 
                grant under paragraph (1), an entity shall 
                demonstrate to the Exchange involved that the 
                entity has existing relationships, or could 
                readily establish relationships, with employers 
                and employees, consumers (including uninsured 
                and underinsured consumers), or self-employed 
                individuals likely to be qualified to enroll in 
                a qualified health plan.
                  (B) Types.--Entities described in 
                subparagraph (A) may include trade, industry, 
                and professional associations, commercial 
                fishing industry organizations, ranching and 
                farming organizations, community and consumer-
                focused nonprofit groups, chambers of commerce, 
                unions, resource partners of the Small Business 
                Administration, other licensed insurance agents 
                and brokers, and other entities that--
                          (i) are capable of carrying out the 
                        duties described in paragraph (3);
                          (ii) meet the standards described in 
                        paragraph (4); and
                          (iii) provide information consistent 
                        with the standards developed under 
                        paragraph (5).
          (3) Duties.--An entity that serves as a navigator 
        under a grant under this subsection shall--
                  (A) conduct public education activities to 
                raise awareness of the availability of 
                qualified health plans;
                  (B) distribute fair and impartial information 
                concerning enrollment in qualified health 
                plans, and the availability of premium tax 
                credits under section 36B of the Internal 
                Revenue Code of 1986 and cost-sharing 
                reductions under section 1402;
                  (C) facilitate enrollment in qualified health 
                plans;
                  (D) provide referrals to any applicable 
                office of health insurance consumer assistance 
                or health insurance ombudsman established under 
                section 2793 of the Public Health Service Act, 
                or any other appropriate State agency or 
                agencies, for any enrollee with a grievance, 
                complaint, or question regarding their health 
                plan, coverage, or a determination under such 
                plan or coverage; and
                  (E) provide information in a manner that is 
                culturally and linguistically appropriate to 
                the needs of the population being served by the 
                Exchange or Exchanges.
          (4) Standards.--
                  (A) In general.--The Secretary shall 
                establish standards for navigators under this 
                subsection, including provisions to ensure that 
                any private or public entity that is selected 
                as a navigator is qualified, and licensed if 
                appropriate, to engage in the navigator 
                activities described in this subsection and to 
                avoid conflicts of interest. Under such 
                standards, a navigator shall not--
                          (i) be a health insurance issuer; or
                          (ii) receive any consideration 
                        directly or indirectly from any health 
                        insurance issuer in connection with the 
                        enrollment of any qualified individuals 
                        or employees of a qualified employer in 
                        a qualified health plan.
          (5) Fair and impartial information and services.--The 
        Secretary, in collaboration with States, shall develop 
        standards to ensure that information made available by 
        navigators is fair, accurate, and impartial.
          (6) Funding.--Grants under this subsection shall be 
        made from the operational funds of the Exchange and not 
        Federal funds received by the State to establish the 
        Exchange.
  (j) Applicability of Mental Health Parity.--Section 2726 of 
the Public Health Service Act shall apply to qualified health 
plans in the same manner and to the same extent as such section 
applies to health insurance issuers and group health plans.
  (k) Conflict.--An Exchange may not establish rules that 
conflict with or prevent the application of regulations 
promulgated by the Secretary under this subtitle.

           *       *       *       *       *       *       *

            PART 3--STATE FLEXIBILITY RELATING TO EXCHANGES

SEC. 1321. STATE FLEXIBILITY IN OPERATION AND ENFORCEMENT OF EXCHANGES 
                    AND RELATED REQUIREMENTS.

  (a) Establishment of Standards.--
          (1) In general.--The Secretary shall, as soon as 
        practicable after the date of enactment of this Act, 
        issue regulations setting standards for meeting the 
        requirements under this title, and the amendments made 
        by this title, with respect to--
                  (A) the establishment and operation of 
                Exchanges (including SHOP Exchanges);
                  (B) the offering of qualified health plans 
                through such Exchanges;
                  (C) the establishment of the reinsurance and 
                risk adjustment programs under part V; and
                  (D) such other requirements as the Secretary 
                determines appropriate.
        The preceding sentence shall not apply to standards for 
        requirements under subtitles A and C (and the 
        amendments made by such subtitles) for which the 
        Secretary issues regulations under the Public Health 
        Service Act.
          (2) Consultation.--In issuing the regulations under 
        paragraph (1), the Secretary shall consult with the 
        National Association of Insurance Commissioners and its 
        members and with health insurance issuers, consumer 
        organizations, and such other individuals as the 
        Secretary selects in a manner designed to ensure 
        balanced representation among interested parties.
  (b) State Action.--Each State that elects, at such time and 
in such manner as the Secretary may prescribe, to apply the 
requirements described in subsection (a) shall, not later than 
January 1, 2014, adopt and have in effect--
          (1) the Federal standards established under 
        subsection (a); or
          (2) a State law or regulation that the Secretary 
        determines implements the standards within the State.
  (c) Failure To Establish Exchange or Implement 
Requirements.--
          (1) In general.--[If] Subject to paragraph (3), if--
                  (A) a State is not an electing State under 
                subsection (b); or
                  (B) the Secretary determines, on or before 
                January 1, 2013, that an electing State--
                          (i) will not have any required 
                        Exchange operational by January 1, 
                        2014; or
                          (ii) has not taken the actions the 
                        Secretary determines necessary to 
                        implement--
                                  (I) the other requirements 
                                set forth in the standards 
                                under subsection (a); or
                                  (II) the requirements set 
                                forth in subtitles A and C and 
                                the amendments made by such 
                                subtitles;
        the Secretary shall (directly or through agreement with 
        a not-for-profit entity) establish and operate such 
        Exchange within the State and the Secretary shall take 
        such actions as are necessary to implement such other 
        requirements.
          (2) Enforcement authority.--The provisions of section 
        2736(b) of the Public Health Services Act shall apply 
        to the enforcement under paragraph (1) of requirements 
        of subsection (a)(1) (without regard to any limitation 
        on the application of those provisions to group health 
        plans).
          (3) Clarification.--This subsection shall not apply 
        in the case of a State that elects to apply the 
        requirements described in subsection (a) and satisfies 
        the requirement described in subsection (b) on or after 
        January 1, 2014.
  (d) No Interference With State Regulatory Authority.--Nothing 
in this title shall be construed to preempt any State law that 
does not prevent the application of the provisions of this 
title.
  (e) Presumption for Certain State-Operated Exchanges.--
          (1) In general.--In the case of a State operating an 
        Exchange before January 1, 2010, and which has insured 
        a percentage of its population not less than the 
        percentage of the population projected to be covered 
        nationally after the implementation of this Act, that 
        seeks to operate an Exchange under this section, the 
        Secretary shall presume that such Exchange meets the 
        standards under this section unless the Secretary 
        determines, after completion of the process established 
        under paragraph (2), that the Exchange does not comply 
        with such standards.
          (2) Process.--The Secretary shall establish a process 
        to work with a State described in paragraph (1) to 
        provide assistance necessary to assist the State's 
        Exchange in coming into compliance with the standards 
        for approval under this section.

           *       *       *       *       *       *       *

                            DISSENTING VIEWS

    This bill provides $200 million for States to establish 
State-based Marketplaces (SBMs). The bill is not paid for.
    The Patient Protection and Affordable Care Act (PPACA) 
provided States with the option of building their own SBM or 
utilizing the Federally-facilitated marketplace (FFM).\1\ An 
unlimited authorization and appropriation was made available to 
States in the form of grants for the planning and establishment 
of SBMs. No funding was awarded after December 31, 2014, in 
accordance with the law. In 2018, 11 States and the District of 
Columbia operated SBMs,\2\ five States operated on a State-
based Marketplace-Federal Platform (SBM-FP), and six States 
operated on a State-Partnership Marketplace (SPM).\3\ According 
to the Congressional Research Service (CRS), 17 States were 
awarded roughly $4.5 billion in grants to plan and establish 
grants.\4\
---------------------------------------------------------------------------
    \1\Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 
124 Stat. 119, (2010) (as amended by Health Care and Education 
Reconciliation Act of 2010, Pub. L. No 111-152, 124 Stat. 1029 (2010)).
    \2\Henry J. Kaiser Family Foundation, State Health Insurance 
Marketplace Types, 2018, available at https://www.kff.org/health-
reform/state-indicator/state-health-insurance-marketplace-types/
?activeTab=map¤tTimeframe=0&selectedDistributions=marketplace-
type&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D 
(last visited April 17, 2019).
    \3\Id.
    \4\Congressional Research Service, Overview of Health Insurance 
Exchanges (June 20, 2018), available at https://www.crs.gov/Reports/
R44065#_Toc524344378.
---------------------------------------------------------------------------
    While Federal funding for the establishment of SBMs has 
expired, current law continues to allow States to establish 
their own exchange. New Jersey recently announced its intention 
to create a SBM, where the insurance commissioner said, ``We 
believe we can operate a State-based exchange and provide 
additional benefits to New Jersey residents with the funding we 
currently send to Washington, estimated to be over $50 million 
for 2019.''\5\
---------------------------------------------------------------------------
    \5\Ryan Hutchins, New Jersey Proposes State-Based Obamacare 
Exchange, Politico (Mar. 22, 2019), available at https://
www.politico.com/states/new-jersey/story/2019/03/22/new-jersey-
proposes-state-based-obamacare-exchange-929807.
---------------------------------------------------------------------------
    The Committee on Energy and Commerce issued a Majority 
Staff report entitled, ``Implementing Obamacare: A Review of 
CMS' Management of the State-Based Exchanges,'' on September 
13, 2016.\6\ Among the report's key findings in 2016:
---------------------------------------------------------------------------
    \6\Committee on Energy and Commerce, Implementing Obamacare A 
Review of CMS' Management of the State-Based Exchanges, (Sept. 13, 
2016), available at https://archives-energycommerce.house.gov/sites/
republicans.energycommerce.house.gov/files/documents/114/analysis/
20160916Review_of_CMS_Management_of_the_State_Based_Exchanges_0.pdf.
---------------------------------------------------------------------------
           The Centers for Medicare and Medicaid 
        Services (CMS) is not confident that the remaining SBEs 
        will be sustainable in the long term;
           As of September 2016, every SBE still relies 
        upon Federal establishment grant funds--20 months after 
        SBEs were to be self-sustaining by law; and,
           CMS eased the transition for failed SBEs to 
        join HealthCare.gov by allowing them to keep user fees 
        collected by insurance carriers intended to pay for the 
        use of HealthCare.gov.
    Any SBMs that would be funded by this bill is likely to 
face the same challenges numerous other states have faced and 
as many have proven, are not sustainable in the long term. In 
fact, when the 2016 Majority Staff report was issued, every SBM 
still relied on Federal establishment grant funds almost two 
years after the SBMs were supposed to be self-sustaining under 
the law. This bill is not paid for and states can pursue this 
option using state dollars if they wish. This bill is not a 
responsible use of taxpayer dollars.

                                   Greg Walden,
                                           Republican Leader, Committee 
                                               on Energy and Commerce.
                                   Michael C. Burgess, M.D.,
                                           Republican Leader, 
                                               Subcommittee on Health, 
                                               Committee on Energy and 
                                               Commerce.

                                  [all]
```