U.S. GOVERNMENT PUBLISHING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Publishing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001

21–102 2016

THE CHALLENGES OF 

THE AFFORDABLE CARE ACT 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON WAYS AND MEANS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED THIRTEENTH CONGRESS 

FIRST SESSION 

DECEMBER 4, 2013 

Serial No. 113–HL09 

Printed for the use of the Committee on Ways and Means 

( 


dkrause on DSKHT7XVN1PROD with LOCATORS
ii 

COMMITTEE ON WAYS AND MEANS 

DAVE CAMP, Michigan, Chairman 

SAM JOHNSON, Texas 

KEVIN BRADY, Texas 

PAUL RYAN, Wisconsin 

DEVIN NUNES, California 

PATRICK J. TIBERI, Ohio 

DAVID G. REICHERT, Washington 

CHARLES W. BOUSTANY, JR., Louisiana 

PETER J. ROSKAM, Illinois 

JIM GERLACH, Pennsylvania 

TOM PRICE, Georgia 

VERN BUCHANAN, Florida 

ADRIAN SMITH, Nebraska 

AARON SCHOCK, Illinois 

LYNN JENKINS, Kansas 

ERIK PAULSEN, Minnesota 

KENNY MARCHANT, Texas 

DIANE BLACK, Tennessee 

TOM REED, New York 

TODD YOUNG, Indiana 

MIKE KELLY, Pennsylvania 

TIM GRIFFIN, Arkansas 

JIM RENACCI, Ohio 

SANDER M. LEVIN, Michigan 

CHARLES B. RANGEL, New York 

JIM MCDERMOTT, Washington 

JOHN LEWIS, Georgia 

RICHARD E. NEAL, Massachusetts 

XAVIER BECERRA, California 

LLOYD DOGGETT, Texas 

MIKE THOMPSON, California 

JOHN B. LARSON, Connecticut 

EARL BLUMENAUER, Oregon 

RON KIND, Wisconsin 

BILL PASCRELL, JR., New Jersey 

JOSEPH CROWLEY, New York 

ALLYSON SCHWARTZ, Pennsylvania 

DANNY DAVIS, Illinois 

LINDA SA ́ NCHEZ, California 

JENNIFER M. SAFAVIAN, Staff Director and General Counsel 

JANICE MAYS, Minority Chief Counsel 

SUBCOMMITTEE ON HEALTH 

KEVIN BRADY, Texas, Chairman 

SAM JOHNSON, Texas 

PAUL RYAN, Wisconsin 

DEVIN NUNES, California 

PETER J. ROSKAM, Illinois 

JIM GERLACH, Pennsylvania 

TOM PRICE, Georgia 

VERN BUCHANAN, Florida 

ADRIAN SMITH, Nebraska 

JIM MCDERMOTT, Washington 

MIKE THOMPSON, California 

RON KIND, Wisconsin 

EARL BLUMENAUER, Oregon 

BILL PASCRELL, JR., New Jersey 


dkrause on DSKHT7XVN1PROD with LOCATORS
iii 

C O N T E N T S 

Page 

Advisory of December 4, 2013 announcing the hearing ....................................... 2 

WITNESSES 

Christopher Carlson, Principal and Consulting Actuary, Oliver Wyman Actuarial Consulting, Incorporated ............................................................................ 28 

Scott Gottlieb, M.D., Resident Fellow, The American Enterprise Institute ....... 17 

Honorable Mike Kreidler, Insurance Commissioner, Washington State Office 

of the Insurance Commissioner .......................................................................... 36 

Grace-Marie Turner, President and Trustee, Galen Institute ............................. 7 


dkrause on DSKHT7XVN1PROD with LOCATORS

dkrause on DSKHT7XVN1PROD with LOCATORS
(1) 

THE CHALLENGES OF 

THE AFFORDABLE CARE ACT 

WEDNESDAY, DECEMBER 4, 2013 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON WAYS AND MEANS, 

SUBCOMMITTEE ON HEALTH, 

Washington, DC. 

The Subcommittee met, pursuant to call, at 10:05 a.m., in Room 

1100, Longworth House Office Building, Hon. Kevin Brady [Chairman of the Subcommittee] presiding. 

[The advisory announcing the hearing follows:] 


dkrause on DSKHT7XVN1PROD with LOCATORS
2 

ADVISORY 

FROM THE COMMITTEE ON WAYS AND MEANS 

SUBCOMMITTEE ON HEALTH 

FOR IMMEDIATE RELEASE CONTACT: (202) 225–3625 

Wednesday, November 27, 2013 

No. HL–09 

Chairman Brady Announces Hearing on the 

Challenges of the Affordable Care Act 

House Ways and Means Health Subcommittee Chairman Kevin Brady (R–TX) 

today announced that the Subcommittee on Health will hold a hearing on the status 

of the implementation of the Affordable Care Act (ACA). This hearing will allow the 

Subcommittee to focus on the immediate and long-term challenges Americans face 

in finding affordable, quality health coverage as a result of the ACA. The hearing 

will take place on Wednesday, December 4, 2013, in 1100 Longworth House 

Office Building, beginning at 10:00 a.m. 

In view of the limited time available to hear from witnesses, oral testimony at 

this hearing will be from invited witnesses only. However, any individual or organization not scheduled for an appearance may submit a written statement for consideration by the Committee and for inclusion in the printed record of the hearing. 

BACKGROUND: 

The American people are understandably concerned and focused on what the 

Obama Administration has called the ‘‘fumbled’’ rollout of the healthcare.gov system 

used to enroll American individuals and families into the Federal health insurance 

exchanges. The Administration has responded with a ‘‘tech surge’’ in an attempt to 

fix the consumer, security, verification, billing and payment flaws plaguing the 

healthcare.gov Web site. However, the ACA is more than a Web site and many of 

the law’s major provisions, which are scheduled to go into effect in just under a 

month, will both impact the ability of individual Americans to maintain health care 

they can afford and access to their current doctors. 

Millions of Americans have received notices from their insurers informing them 

that because of the ACA their current plan is being cancelled, and they must now 

find a new health plan. Americans are also discovering that the premiums offered 

in the exchanges are higher than the Administration originally promised and for 

many, more expensive than their current plans. Employers are increasing out-ofpocket costs, dropping spousal coverage and reducing hours for their workers. Enrollment in the new exchanges has fallen well below the Administration’s projections and many analysts have expressed concern that the young and healthy will 

not sign up in sufficient numbers to prevent premium spikes in 2015. Additionally, 

serious concerns also remain that the healthcare.gov system is incapable of securely 

handling an expected surge in volume in December while accurately verifying eligibility and fulfilling the necessary steps to carry out billing and payment functions. 

The hearing will examine and analyze the impact of the ACA on the healthcare 

system and explore ways to mitigate the adverse impacts of the law on the American people. 

In announcing the hearing, Chairman Brady stated, ‘‘We are no longer debating what will happen when the President’s healthcare law goes into effect. 

The Affordable Care Act, as it was written and is being implemented, is 

having the negative consequences on the American people we long predicted it would. Despite the President’s many promises to the contrary, 

they are being forced to find a new and more expensive plan because the 

plan they have and like has been canceled. Individuals are being forced to 


dkrause on DSKHT7XVN1PROD with LOCATORS
3 

buy coverage from a Web site that does not work. This is unfair to the 

American people. But let’s be honest—the problems we are seeing today are 

likely to get even worse. Some people will face a gap in coverage, premiums will likely spike even higher in 2015, and more and more people 

with employer-provided coverage will be adversely affected by the law. 

This hearing provides all of us an opportunity to get a better perspective 

on these challenges so that we can facilitate solutions to mitigate some of 

this pain.’’ 

FOCUS OF THE HEARING: 

The hearing will focus on the challenges of the ACA on the healthcare system and 

explore ways to mitigate the adverse impacts of the law on the American people. 

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS: 

Please Note: Any person(s) and/or organization(s) wishing to submit for the hearing record must follow the appropriate link on the hearing page of the Committee 

website and complete the informational forms. From the Committee homepage, 

http://waysandmeans.house.gov, select ‘‘Hearings.’’ Select the hearing for which you 

would like to submit, and click on the link entitled, ‘‘Click here to provide a submission for the record.’’ Once you have followed the online instructions, submit all requested information. ATTACH your submission as a Word document, in compliance 

with the formatting requirements listed below, by the close of business on 

Wednesday, December 18, 2013. Finally, please note that due to the change in 

House mail policy, the U.S. Capitol Police will refuse sealed-package deliveries to 

all House Office Buildings. For questions, or if you encounter technical problems, 

please call (202) 225–1721 or (202) 225–3625. 

FORMATTING REQUIREMENTS: 

The Committee relies on electronic submissions for printing the official hearing record. As always, submissions will be included in the record according to the discretion of the Committee. 

The Committee will not alter the content of your submission, but we reserve the right to format 

it according to our guidelines. Any submission provided to the Committee by a witness, any supplementary materials submitted for the printed record, and any written comments in response 

to a request for written comments must conform to the guidelines listed below. Any submission 

or supplementary item not in compliance with these guidelines will not be printed, but will be 

maintained in the Committee files for review and use by the Committee. 

1. All submissions and supplementary materials must be provided in Word format and MUST 

NOT exceed a total of 10 pages, including attachments. Witnesses and submitters are advised 

that the Committee relies on electronic submissions for printing the official hearing record. 

2. Copies of whole documents submitted as exhibit material will not be accepted for printing. 

Instead, exhibit material should be referenced and quoted or paraphrased. All exhibit material 

not meeting these specifications will be maintained in the Committee files for review and use 

by the Committee. 

3. All submissions must include a list of all clients, persons and/or organizations on whose 

behalf the witness appears. A supplemental sheet must accompany each submission listing the 

name, company, address, telephone, and fax numbers of each witness. 

The Committee seeks to make its facilities accessible to persons with disabilities. 

If you are in need of special accommodations, please call 202–225–1721 or 202–226– 

3411 TDD/TTY in advance of the event (four business days notice is requested). 

Questions with regard to special accommodation needs in general (including availability of Committee materials in alternative formats) may be directed to the Committee as noted above. 

Note: All Committee advisories and news releases are available on the World 

Wide Web at http://www.waysandmeans.house.gov

f 

/. 

Chairman BRADY. Good morning, everyone. The Subcommittee 

will come to order. 


dkrause on DSKHT7XVN1PROD with LOCATORS
4 

Another day, another chance for the White House to fix their 

controversial healthcare law. Today families and patients abandoned by the new law learn that the Obama Administration 

launched a new and improved marketing campaign for the troubled 

law. Strange use of resources, given that the problems are with the 

policy, not with the politics. What is needed are real solutions, not 

more spin. 

The Affordable Care Act’s fundamental problem can’t be fixed 

with better marketing. The flaw is not the Web site; the flaw is the 

law itself. Improving the defective Web site won’t make 

ObamaCare premiums more affordable. Improving the defective 

Web site won’t prevent millions of Americans from walking to their 

mailbox only to find the healthcare plan they have and like is canceled because of the Affordable Care Act. Improving the defective 

Web site won’t keep President Obama’s promise that Americans 

will see a $2,500 reduction in their healthcare premiums, and won’t 

prevent middle-class families from experiencing more expensive 

premiums and higher deductibles they simply can’t squeeze from 

their already stretched budgets. 

And as one fellow Texan wrote to me, we are a family of three that paid $753 a month for health insurance when ObamaCare was 

enacted. We are now paying $1,117 a month for the same plan, a 

48 percent increase. 

My Democratic colleagues repeatedly promised the ObamaCare 

exchanges would deliver a new, competitive marketplace that made 

it easy to shop for insurance, but the reality is far from that. In 

the several thousand counties served by the Federal exchanges, 

over half have plans offered by just one or two insurance carriers. 

In about 530 counties, American families have only one choice, just 

one insurer in the exchange. So fixing a defective Web site won’t 

create competition and choice where none exists today. 

Now our small businesses have been told that the online shop exchanges they were told would come on, that they could count on for 

affordable healthcare options, has been canceled for next year. Does 

fixing a defective Web site restore that broken promise to our local 

businesses? 

We are all hoping for the best, but that November 30th deadline 

to fix the Web site problems has passed, and no one yet knows if 

the system has the capacity to enroll, actually determine subsidies, 

and complete a new insurance policy for all the millions of Americans abandoned when their policies were canceled by the President’s new healthcare law. To do so, the new improved Web site 

will need to enroll close to 100,000 people per day every day this 

month, and that is how many who selected a plan in all of October. 

Regrettably, at this point the American public has little confidence the Web site is ready for prime time and this latest promise 

will be kept. The clock is ticking. We are right in the middle of 

prime time for individuals, for families and small businesses to find 

affordable health care that begins on January 1st. What will these 

patients and families do when they show up to the hospital or need 

to reorder a lifesaving prescription on New Year’s Day, and their 

ObamaCare care plan isn’t yet available? This coverage gap is real, 

and the White House has said it has no plan B to prevent this 

frightening problem. 


dkrause on DSKHT7XVN1PROD with LOCATORS
5 

Looking forward, the flaws in the law may prove to be getting 

worse, not better. The young and healthy are not signing up, which 

is bad news. Connecticut, for example, 61 percent of the enrollees 

are between the age of 45 and 64; in California, 56 percent. And 

that is double their proportion of the State’s population. But without the right mix of the young and old, the healthy and sick, 

healthcare premiums for 2015 will skyrocket, access to care will become more limited, and insurers may no longer offer coverage. Plus 

the mandate on local businesses slams into effect in 2015, forcing 

local companies to consider cutting hours, or workers, or healthcare 

benefits to comply with the onerous law. 

Today’s hearing is not about a new and improved marketing 

campaign. It is not merely about a defective Web site. It is about 

the real-life impact of a law that is not living up to the promises 

made to the American people by President Obama and my Democratic colleagues. 

Before I recognize Ranking Member McDermott for the purposes 

of his opening statement, I ask unanimous consent that all Members’ written statements be included in the record. Without objection, so ordered. 

And I will recognize Ranking Member Dr. McDermott for the 

opening statement. 

Mr. MCDERMOTT. Thank you, Mr. Chairman. 

I want to welcome all our witnesses, and especially my fellow 

Washingtonian Congressman Kreidler, now Commissioner Kreidler. 

As we look at the progress of the Affordable Care Act, I would 

like us to remember how it got here. With the way we talk about 

the ACA, one might wonder why would we ever abandon the old 

system in the first place? I will tell you why: It was unhealthy, it 

was unfair, and it was unsustainable. Healthcare costs, one of the 

largest contributing factors to our national debt, were out of control. People were going bankrupt. The cost of providing care to the 

uninsured added an extra $1,000 a year to each family’s household 

bills through higher taxes, premiums, and healthcare costs. Coverage was dropped when customers needed it most, and over the 

country those with preexisting conditions were just out of luck. So 

let us keep those conditions in mind as we discuss our progress. It 

wasn’t the Democrats that wanted a better system, it was America. 

Are we as a society better off now? The answer is a resounding 

yes. We have made huge improvements in the system. It hasn’t 

been perfect, and I am sure we will hear some interesting and upsetting testimony today about our witnesses’—from our witnesses, 

though what I have read, many of their assertions are unreliable, 

if not untrue. Even with glitches, the ACA reforms are making the 

insurance industry more accessible, fair, and cost-efficient than 

ever before. 

Looking at our progress, I am less concerned about Web sites 

than the reality that we are creating two separate Americas. While 

one-half of our country moves ahead with affordable health insurance, the other half is being left behind. Places like Indiana, Georgia, Florida have chosen not to expand Medicaid, leaving hundreds 

of thousands of people who are most vulnerable with no help available. Texas has over a million people that could be insured at no 

cost to the State if the Governor chose to expand Medicaid. Instead, 


dkrause on DSKHT7XVN1PROD with LOCATORS
6 

Texans who need it most, the working poor, families on minimum 

wage, and veterans trying to get back on their feet get nothing. 

It is hard to imagine a reason for this other than simple spite. 

It is cruel and fiscally irresponsible. Hospitals in these States will 

lose billions of dollars in revenue as they provide more uncompensated care instead of accepting a half a billion Federal dollars. Mississippi has transferred 4.4 million from its State budget, including 

education funding, to pay hospitals for uncompensated care. Some 

hospitals have had to close facilities and service lines. 

And if that weren’t enough, Republicans are urging constituents 

to turn down affordable care. Oklahoma has filed a lawsuit arguing 

that Oklahomans are not entitled to the tax credits through the exchange. Tennessee, among others, is trying to create penalties to 

make it as hard as possible for churches and nonprofits to help people sign up. A good Samaritan, even a friend or a neighbor, caught, 

quote, ‘‘facilitating enrollment,’’ close quote, without being vetted, 

fingerprinted, and registered with the State, could be fined $1,000 

for each offense. All this to make the President look bad. 

Now, fortunately, we have an unbiased witness here today who 

is actually making this all work. Commissioner Kreidler can speak 

directly to what happens when a State cares about its people. He 

has actual experience in the front lines of implementation. Washington State has reached nearly 175,000 enrollments through our 

State exchange, and those numbers are growing every day. Each— 

our exchange is robust and, with the exception of a few issues, has 

run pretty smoothly. 

I had a constituent call my office irate that his insurance company had canceled his plan and offered him a new one at double 

the price. The next day he called back. He went to the exchange 

and found a better plan with his old insurance company for less 

than he was paying before. 

As the home of companies like Microsoft, Amazon, Starbucks, 

Washington State knows about launching big projects. The Boeing 

787 wasn’t built in a day. Success doesn’t come without bumps. It 

takes commitment; it takes investment and patience. If Bill Gates 

had stopped at the first hiccup, where would the personal computer 

be today? We knew this wouldn’t be easy, but it is worth it, and 

this is the reform that America wants and needs. 

I yield back. 

Chairman BRADY. Thank you, Dr. McDermott. 

Today we will hear from four witnesses: Grace-Marie Turner, 

president and trustee of the Galen Institute; Dr. Scott Gottlieb, 

resident fellow at the American Enterprise Institute; Chris Carlson, principal at Oliver Wyman Actuarial Consulting, Incorporated. 

And I would like to turn to our Ranking Member to introduce our 

fourth witness. 

Mr. MCDERMOTT. Thank you, Mr. Chairman. 

I mentioned Commissioner Kreidler. He was a Member in 19— 

he came in in the sweep of 1992, when a lot of Democrats came 

in here, and the Clintons were elected, and we thought we were 

going to have health care. And he was here to work on that. He 

and I had worked in the legislature for a number of years on this 

whole issue and put together the Washington Basic Health Plan 

and other things. 


dkrause on DSKHT7XVN1PROD with LOCATORS
7 

Two years later, he was back in the State of Washington doing 

other things after the failure of the Clinton effort. He since then 

has become the longest sitting insurance commissioner elected— 

elected commissioner in the country, and knows all the ins and 

outs of this issue, and will be a good witness today for people to 

find out what happens in a State where they went from the first 

day to make it happen, and they have done a very good job. So it 

is my great pleasure to introduce Mike Kreidler. 

Chairman BRADY. Right. Thank you, Doctor. 

Ms. Turner, you are recognized. And we reserve 5 minutes for 

each of the opening statements. 

STATEMENT OF GRACE-MARIE TURNER, PRESIDENT AND 

TRUSTEE, GALEN INSTITUTE 

Ms. TURNER. Thank you, Mr. Chairman. Thank you, Chairman 

Brady, Ranking Member McDermott, distinguished Members of the 

Committee, for the opportunity to testify today. 

All eyes have been focused recently on the Web site, but there 

are many challenges that I would like to talk about that are in 

store that will impact tens of millions of Americans who are not affected directly by the law, according to the President. He says 85 

to 90 percent of Americans who already have health insurance, for 

them their only impact is that their insurance will be stronger, better, more secure than it was before; they don’t have to worry about 

anything else. But that is really not their experience. 

I will focus primarily on the impact on the 150 Americans who 

have coverage through their employers; employers have been providing health insurance voluntarily for more than 70 years. They 

see it as a way of attracting good workers. But the ACA places significant burdens on them that are really forcing them to rethink 

their arrangements. 

Small businesses are hit especially hard. An estimate in the June 

2010 Federal Register predicted that up to 80 percent of small 

business plans could be lost because they don’t comply with the 

ACA’s requirements. Many employees will find that their new 

ACA-compliant coverage is more expensive and less attractive, 

higher premiums, higher deductibles, and narrower networks. 

The Congressional Budget Office estimated that as many as 11 

million workers could lose their health insurance simply because 

their employers find that they have no choice but to pay the fine 

and drop their health insurance coverage. The American Action 

Network suggests the number could be as high as 35 million people, in small businesses primarily. 

Many employers also are being forced to cut hours so that they 

can stay under the 50-employee, full-time employee cap. This is a 

significant income loss, obviously, for the employees, but it is also 

a painful decision for employers who really want to keep full-time 

workers and is disruptive for their businesses. 

I have spoken with the owners of many small businesses who say 

that the $2 to $3,000 fine would basically consume their entire 

profit margin, not just providing health insurance. And the 1-year 

delay really isn’t helping because they have to plan longer term for 

their—for business planning. A delay in the shop exchange was 


dkrause on DSKHT7XVN1PROD with LOCATORS
8 

really—that the chairman mentioned was yet another blow to 

them. 

I describe in my testimony, my written testimony, many of the 

new taxes and other mandates and penalties that employers face. 

In particular, the tax on individuals, a $63-per-person tax, that 

adds the cost of every health insurance policy, the tax that will cost 

families an additional $360. These add taxes and no new benefits, 

and it is simply pushing up the cost of coverage. 

Susan Carrick, who is head of human resources at the University 

of Virginia, described what her choices are. She said, when medical 

expenses go up, which they have and which they are, we can either 

increase premiums, or we can reduce what we pay out in the way 

of benefits. She said, the law is expected to cost $7.3 million to the 

University of Virginia’s health plan in 2014 alone. 

In addition, of course, millions of people with individual policies 

are really among the first targets of this law. They are losing their 

coverage. Five percent of Americans represents 15 million Americans that we think we really do—must attend to are having a difficult time finding coverage. 

I do believe that there are some near-term policy fixes that are 

going to be required. There—the House passed, of course, the Keep 

Your Coverage Act. The Senate has a similar measure that Senator 

Johnson is offering. And I think that if we can encourage the Senate to take that up, we need to give people a chance who have coverage that they like, who can’t get onto the exchange, who find the 

exchange coverage is more expensive, that they find that they are 

able to keep their policies. 

Second, and I think this is crucially important, those who are on 

high-risk plans now, either the 200,000 or so who are on the 35 

State high-risk pools, many of which are being closed, or the about 

100,000 who are on the Federal temporary high-risk plan, are desperately trying to get new coverage. Many of them have chronic illnesses, they are in the midst of chemotherapy, and they have a 

child with significant health problems. They need someplace to go 

for coverage. And I strongly encourage us to think about what we 

can do to extend those high-risk programs to make sure people who 

desperately need care are not forced to leave coverage. 

I see my time is up, Mr. Chairman. 

[The prepared statement of Ms. Turner follows:] 


dkrause on DSKHT7XVN1PROD with LOCATORS
9 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.001
10 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.002
11 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.003
12 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.004
13 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.005
14 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.006
15 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.007
16 

f 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.008
17 

Chairman BRADY. Yes. Thank you, Ms. Turner, very much. 

Dr. Gottlieb. 

STATEMENT OF SCOTT GOTTLIEB, M.D., RESIDENT FELLOW, 

THE AMERICAN ENTERPRISE INSTITUTE 

Dr. GOTTLIEB. Mr. Chairman, Mr. Ranking Member, thank you 

for the opportunity to testify today. My name is Scott Gottlieb. I 

am a physician and resident fellow at the American Enterprise Institute. I previously served at the FDA and CMS, and I also sit on 

the policy advisory boards to the Society of Hospitalist Medicine 

and the Leukemia and Lymphoma Society, as well as being a clinical assistant professor at the NYU School of Medicine. 

In time, the existing parts of this Web site will be fixed, but more 

significant challenges remain related to issues around provider access and the quality of the medical care. I fear many consumers 

who enroll in these plans will find themselves disappointed by the 

resulting health plans, or, worse, get caught in difficult financial 

and medical binds. And I want to focus on three significant but remaining challenges that I believe will lower the quality of the resulting care and hinder consumer access to needed medical services. I believe there are steps we could take today to mitigate these 

challenges, but unless we act quickly, the law does not provide 

flexibility to address some of these problems. 

First, the information infrastructure required for reconciling 

someone’s coverage with his health plan or his providers has not 

been constructed; in some cases, simply does not exist. As a result, 

it is likely that there will be delays in enabling premiums to be collected and paid to health plans, and, in turn, health plans are likely to withhold payments to providers. People signing up for coverage may not, as a practical matter, be covered starting January 

1st. This needs to be addressed by Congress immediately to avoid 

significant potential hardships. 

Second, it is now well established that more than 50 percent of 

the plans sold on healthcare.gov are narrow network options that 

offer a very limited choice of providers. I don’t think the full scope 

of how restrictive these networks have become is fully appreciated 

or the extent of the costs that will get transferred to patients. This 

is going to put particular hardship on patients with special medical 

needs and serious illnesses. And, once again, the statute and regulations do not afford easy ways to mitigate these challenges. 

To give you some context for how this is playing out at a practical level, we are providing from AEI today some data we developed on Blue Cross Blue Shield—one Blue Cross Blue Shield plan 

that operates in nine different States. We compared the exchange 

network to their commercial individual market PPOs, just six categories of specialists. We consistently found that the exchangebased plans offered just a fraction of the specialists available in 

competing non-exchange PPOs, and we looked at the most populous 

counties to give them the best chance at coming out ahead. 

Among some of our other anecdotal findings, we found a plan in 

Florida that currently has only 7 pediatricians in its network that 

serves a county that has 260,000 children, according to census 

data. In San Diego, we found a health plan doesn’t have a single 

pediatric cardiologist in its network. In San Bernardino County, we 


dkrause on DSKHT7XVN1PROD with LOCATORS
18 

found a plan with the nearest urologist that was offered was 80 

miles away, and the same plan has nine dermatologists in it, but 

none of these doctors seem to perform mole surgery for skin cancer, 

and most of them are at least 100 miles away from the county. 

The problems are made worse by incomplete oversight that has 

been applied to resulting plans. Review of plan design, network 

adequacy was rushed and done poorly. With lax oversight there is 

a risk that plans can inadvertently or sometimes intentionally 

game the risk pool by their choice of providers and their design of 

networks. 

And, finally, keep in mind that these narrow networks do not 

just affect providers. The same constructs will also hamper patient 

access, especially drugs. If you are on a non-formulary medicine, 

you could be saddled with much or all of the cost of the medicine. 

This is going to be a particular burden to patients with significant 

conditions, like cancer. These cuts won’t count against out-of-pocket 

limits, deductibles, or lifetime caps. 

Third and finally, there is already evidence that providers are reluctant to sign contracts with the ObamaCare plans, and when 

they do, reimbursement is being reduced even off the levels that 

were initially negotiated under some ObamaCare contracts. There 

should be every reason to expect that the same sort of problems 

with access and quality that challenged the Medicaid program will 

also challenge ObamaCare. 

People who will make out worse under ObamaCare seem to be 

getting short shrift in a lot of the policy discussions. There seems 

to be a perception among some that these folks are mostly wealthy 

or upper-middle-class families. That is not entirely true. Many of 

these families are solidly middle class, and many struggle financially. Nor are the misperceptions of their relative wealth an excuse to ignore their plight. 

The fact is that in aiding those who are burdened in the old insurance markets, and some people will clearly be helped under 

ObamaCare, it didn’t require us to harm those who were doing reasonably well under those old structures. And even those who were 

previously uninsured or only intermittently insured will find many 

of the bronze plans that they are being incentivized to join providing lower-quality access. 

Thank you. 

[The prepared statement of Dr. Gottlieb follows:] 


dkrause on DSKHT7XVN1PROD with LOCATORS
19 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.009
20 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.010
21 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.011
22 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.012
23 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.013
24 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.014
25 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.015
26 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.016
27 

f 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.017
28 

Chairman BRADY. Thank you, Doctor. 

Mr. Carlson. 

STATEMENT OF CHRISTOPHER CARLSON, PRINCIPAL AND 

CONSULTING ACTUARY, OLIVER WYMAN ACTUARIAL CONSULTING, INCORPORATED 

Mr. CARLSON. Good morning, Chairman Brady, Ranking Member McDermott, and Members of the Subcommittee. My name is 

Chris Carlson, and I am the principal and consulting actuary at 

Oliver Wyman. I would like to thank you for affording me an opportunity to share my perspective on the Affordable Care Act. 

My testimony will focus on the consequences of the difficulties 

encountered in implementing the ACA. The specific issues that I 

will address are, first, the enrollment issues which have led to initial enrollment in individual policies falling well below original estimates; second, the extension of current individual policies that do 

not meet the requirements of the ACA’s minimum coverage requirements; and, third, I will discuss the premium rates that are 

available to individuals on the exchanges. 

First, regarding the low initial enrollment, it is too early to make 

any speculation about the final enrollment numbers for 2014, but 

given the low enrollment numbers that we have seen, there is an 

expectation that the enrollment will be less than expected. In fact, 

Goldman, Sachs & Company has revised down projection estimates 

of the Federal exchange enrollees from 7 million to 5 million. 

Also, early indications are that the younger enrollees, who are 

crucial to the goal of having a balanced risk pool, may be enrolling 

in rates less than expected. If younger individuals do not enroll at 

the expected levels, the subsidies that are built into the rates that 

allow for premium rates to be lower at the older ages will not be 

realized, putting a strain on the overall risk pool. 

Next I will briefly discuss the President’s use of non-enforcement 

of existing law to allow for the extension of current policies that do 

not meet the minimum coverage requirements under the ACA. 

There are a number of potential outcomes that could result from 

this extension. First, studies prepared by the Society of Actuaries 

show that those currently insured in most States have better morbidity risk than the new enrollees expected for 2014. Therefore, it 

was expected that premiums would go up because of this increased 

morbidity risk. Furthermore, many current policies do not provide 

sufficient benefits to meet the minimum coverage requirements of 

the ACA. Therefore, individuals who are currently insured in less 

than sufficient policies would see further increases due to an increase in benefits for the exchange policies. While this generally is 

a trade-off between premium for additional benefits, those opting 

to drop current, less generous policies are those that are likely to 

need that additional benefit coverage. Both of these factors lead to 

an expectation that the pool of members enrolling in the ACAqualified plans on the exchanges will have higher morbidity risk 

than if the extension of policies was not allowed. 

In addition, since insurers have not been given the opportunity 

to revise the premium rates on the exchanges, it is likely that these 

policies will be underpriced. As a result, we have seen hesitation 


dkrause on DSKHT7XVN1PROD with LOCATORS
29 

from some State insurance regulators to allow for the extension of 

these policies. 

It is too early to provide any empirical data to estimate the impacts of the exchanges on the expected costs for 2014; however, the 

American Academy of Actuaries has identified three primary consequences of the extension of current policies. One, premiums for 

2014 may not adequately cover the cost of providing benefits for an 

enrollee population with higher claims than anticipated; costs to 

the Federal Government could increase as higher-than-expected average medical claims are more likely to trigger the risk-corridor 

payments; and, third, relaxing the plan cancellation requirements 

could increase premiums for 2015. Insurers could not increase premium in future years to make up for prior losses; however, assumptions regarding the composition of the risk pool would reflect 

this plan experience for 2014. 

There has been much written and said about the premium rates 

on the exchanges. Depending on the point of view, premium rates 

are either much higher than expected or much lower than expected. However, I will repeat what was said in the hearing of the 

House Energy and Subcommittee on Oversight and Investigations 

by Cori Uccello, an actuary of the American Academy of Actuaries: 

‘‘How premiums will change depends on many factors. The new 

benefit requirements that may lead to higher premiums but lower 

out-of-pocket costs, how each State’s current issue and rating rules 

compare to those beginning in 2014, and each individual’s demographic characteristics and health status.’’ 

All of these things remain true. I will highlight a couple of these 

items that merit specific attention. First, individuals who are seeing the greatest increases in premiums are those who had the least 

amount of coverage; therefore, the initial premiums for additional 

benefits. 

Second, any consideration of the increase in premium rates is 

considered prior to the availability of the premium subsidies that 

would reduce the actual out-of-pocket costs for individuals. 

That concludes my oral testimony, and I thank you for inviting 

me, and I look forward to answering any questions. 

[The prepared statement of Mr. Carlson follows:] 


dkrause on DSKHT7XVN1PROD with LOCATORS
30 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.018
31 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.019
32 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.020
33 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.021
34 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.022
35 

f 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.023
36 

Chairman BRADY. Thank you, Mr. Carlson. 

Congressman Kreidler, welcome back. 

STATEMENT OF THE HONORABLE MIKE KREIDLER, INSURANCE COMMISSIONER, WASHINGTON STATE OFFICE OF THE 

INSURANCE COMMISSIONER 

Mr. KREIDLER. Thank you, Chairman Brady. Thank you, Mr. 

Chairman, and Ranking Member McDermott, and Committee 

Members. 

I would like to try to cover a couple of topics here, the challenges 

that we have in the State of Washington, the—how it is currently 

working in the State of Washington, and the need going forward 

for collaboration. 

My name is Mike Kreidler. I am the Washington State insurance 

commissioner, and in this capacity as insurance commissioner for 

the State of Washington, I have had lots of conversations with people that contact—we get 100,000 phone calls a year through my office. Over the years this became clear that there were a lot of people out there that were really hurting, who were with limited access to health insurance. It was either unaffordable to them, or 

they would find out the existing policy they had when they had a 

major incident in their life, having bad luck that their policy was 

significantly inadequate to meet their needs. 

What I see right now with the Affordable Care Act are the tools, 

the tools that we need in order to help make sure that people have 

access to health insurance that is affordable to them. And that is 

partly because of subsidies that are available to them; also increased access in the State of Washington to the Medicaid program. 

All of these are making it possible to help. If it isn’t the Affordable 

Care Act, then let us name something else that is going to accomplish essentially the same purposes as the Affordable Care Act. 

Washington has significant problems with the current system 

without the reforms. We have got over a million people without 

health insurance. In addition to that, we have got 2- to 300,000 

people who do have insurance, but it is inadequate insurance, 

meaning that when they have a medical crisis in their lives, it is 

not going to meet their needs. Such things as pharmacy coverage, 

80 percent, approximately half—80 percent of the individual market in the State of Washington doesn’t cover pharmaceutical, much 

less maternity. 

Going forward, as you look at the Affordable Care Act, there are 

a lot of people that refer to it as somehow a government takeover 

of our health insurance system. This is built on the private insurance system. It is built on what I saw when I was a Member here, 

Mr. Chairman, that was put forward with the Dole-Chafee bill that 

had 20 Republican sponsors in the Senate on it. It is very—very 

comparable with the philosophy that came forward with the Heritage Foundation in the late 1980s. It really is not a Democratic proposal; it is built on the private insurance system. 

Now, Washington does have an exchange. It is up and operating. 

It is enrolling—as Ranking Member McDermott pointed out, we 

have got 100,000 people enrolled, 175,000 people who are queued 

up right now to be enrolled. It is proceeding quite nicely. And for 

those reasons I said no to the opportunity to extend existing poliVerDate Sep 11 2014 08:50 Aug 15, 2016 Jkt 021102 PO 00000 Frm 00040 Fmt 6633 Sfmt 6602 I:\WAYS\WAYSPS\21102\21102.XXX 21102

dkrause on DSKHT7XVN1PROD with LOCATORS
37 

cies. It would have been very disruptive, as Mr. Carlson pointed 

out, to our market if we had allowed that to take place, because 

the Affordable Care Act is working in the State of Washington. 

You know, I know that we have had some problems. Whether we 

talk about the canceled policies, or whether we are talking about 

Web site’s operability, those are challenges, and those are good 

things to bring up. But it is also important to take a look at major 

programs historically, whether it is Social Security, whether it is 

Medicare, or whether it was the pharmaceutical benefit under the 

Medicare program. They have all had challenges as they started 

up, particularly when we look at the pharmaceutical program and 

some of the problems they had. I saw that because I was the insurance commissioner at the time. 

What I would like to urge people to do is to be patient. This is 

in the early stages of enrollment. Don’t just look right now and say, 

this issue right now is an impediment. And the headline of the day 

is not what we need to be doing. It is being patient and going forward. Focus on the benefits of the Affordable Care Act to consumers. If you can take the name of ‘‘Obama’’ out of ObamaCare 

and just focus on the benefits, you find the benefits are widely popular in virtually every district in the United States. 

Rome wasn’t built in a day. And I can tell you right now the 

problems with our current existing healthcare system didn’t occur 

in a day. We need to be patient, move forward, and focus on enrollment. It is—enrollment is only in its early stages at this point. 

States like mine need you. I would urge you to be a critic; that is 

fair, that is reasonable, it is expected, particularly from the party 

that did not advocate for the Affordable Care Act. But at the same 

time we need to solve problems, because going forward we are talking about people that are hurting. We need to make changes not 

just for these people, but also to address the challenges for the U.S. 

economy if we don’t make these changes. 

Thank you, Mr. Chairman. 

[The prepared statement of Mr. Kreidler follows:] 


dkrause on DSKHT7XVN1PROD with LOCATORS
38 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.024
39 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.025
40 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.026
41 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.027
42 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.028
43 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.029
44 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.030
45 

f 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.031
46 

Chairman BRADY. Thank you, Commissioner, Congressman, appreciate your testimony. 

One, congratulations on running a model exchange. Two things 

stand out. One is that you did testing, extensive testing, of your 

Web site and exchange before the deadline hit. I wish Washington 

would have followed your lead, because this has led—despite repeated assurances to this Committee and all of Congress, both parties, that was not done. 

And the second thing that stands out really drives my first question, which is the coverage gap. You are running as good as exchange as exists in America, yet so far have only signed up a fraction of those in Washington State who have received cancellation 

notices. We are all concerned about the potential coverage gap on 

January 1st as a result, again, of this defective rollout. 

So, Ms. Turner, let me start with you. How significant could that 

coverage gap be for families in America? How significant could it 

be that families show up on New Year’s Day in the hospital needing that lifesaving prescription and find that what they signed up 

for didn’t actually make it all the way through the process, they 

don’t have that coverage? How concerned should we be? 

Ms. TURNER. One hundred percent concerned. It is absolutely 

going to happen. When we have a deadline of December 23rd for 

people to enroll, and all of that paperwork has to be processed that 

people think that their coverage will start on January 1, I think 

it is just—it is impossible for everyone that signs up on—by December 23rd to get coverage and to have that work through the 

system. 

And in particular we see that the data that is coming from the 

Federal hub, from the Federal Web site, that the 480—843—the 

834 forms are inadequate and wrong. At least a third of it is inaccurate. 

So I think it is a huge, huge concern that people are doing their 

best to try to sign up for this coverage and are not going to be able 

to get through the Web site and be able to be signed up, and may, 

even worse, think they are and have it not be processed. 

Chairman BRADY. Thank you. 

Dr. Gottlieb, you, in your testimony, point out something I don’t 

think anyone has focused on, which is the payment gap, the part 

of the process where after you enroll—in your testimony, you say 

the system to ensure that our local healthcare providers are being 

reimbursed does not yet exist in the system. Could you talk a little 

more about—and why should we be concerned about that? 

Dr. GOTTLIEB. Well, the issue is whether or not people who 

think they have enrolled in a plan on the exchanges are actually 

enrolled in those plans. With the information—we know that the 

back end hasn’t been built yet, and we know that the subsidies 

that should flow to the insurers aren’t going to flow on the insurers 

appropriately or on time. And so the question becomes what do the 

insurance plans do if they don’t have someone either appropriately 

enrolled in their plan or that they have been paid for? And while 

I think they are going to be hard pressed not to honor the contract 

that they—or the, you know, purported contract they have with 

that consumer, I am hard pressed to believe that they are going to 


dkrause on DSKHT7XVN1PROD with LOCATORS
47 

allow money to flow to providers when they haven’t been paid on 

those policies. They are going to hold up those payments. 

It is not clear exactly what they are going to do, frankly. That 

is why we should be thinking about this and worried about this, 

because people are going to start to try to access care in January, 

and either the providers aren’t going to get paid on time, and they 

could very well drop out of these plans, or the contracts might not 

be honored at all. 

Now, I know the Administration made an announcement last 

night that they are going to effectively guarantee those payments. 

I don’t think that fully resolves this problem, because it doesn’t resolve the issue of what the insurers are going to do with the providers when they haven’t been paid yet, they haven’t either received the premiums, appropriate information to enroll the beneficiary, or haven’t received the subsidies. 

Chairman BRADY. So if Washington doesn’t pay its bills on time, 

the insurance company—they are going to be in a bind in paying 

those local doctor bills and hospitals as well. Is that—— 

Dr. GOTTLIEB. That is right. We have seen the insurance companies do this in the past. If they are not getting paid, it is a reasonable expectation that they are not going to let money flow out 

to pay bills. 

Chairman BRADY. I don’t think many of us are worried about 

the insurance companies. We are really worried about the process 

of does that local doctor—are they assured that they are actually 

going to see reimbursement. And I think that is the concern. 

Dr. GOTTLIEB. And if they don’t, they might not continue providing care. They might have to drop out of these contracts, and 

it is just going to further strain the access issue. 

Chairman BRADY. Let us talk about that. Let us talk sort of 

about the doc shock, which may be—after sticker shock may be our 

biggest challenge for our families, which is in your testimony, you 

pointed out that many of these plans are a very narrow network. 

And so the affordable ones—at least those with the lower prices. 

So a family may find they can’t see a doctor that they have seen, 

or they see multiple doctors, can’t see both a local hospital or provider, and may well be forced out of network. And in your testimony you make a case that when that occurs—not if it occurs, 

when that occurs—that patient will be maybe required to carry the 

entire cost of that treatment, and it won’t count toward their deductible, or out-of-pocket caps, or any of that. So, in effect, you are 

saying they almost are going to see a HMO experience with them 

paying extremely steep bills under these plans; is that correct? 

Dr. GOTTLIEB. Well, that is exactly right. I think—you know, 

conceptually, in the 1990s, when HMOs were first introduced, people rejected them. We had the Patients’ Bill of Rights introduced 

into Congress. And most consumers demonstrated that they prefer 

PPO-style plans, which afforded flexibility on providers, and they 

were willing to trade away some benefits and higher copays and 

deductibles for that flexibility. 

I think what the Affordable Care Act really does is force us back 

into that old option, the HMO-style option, where you are trading 

away the flexibility in favor of this government-guaranteed benefit 

package and really not lower copays or deductibles. The copays and 


dkrause on DSKHT7XVN1PROD with LOCATORS
48 

deductibles are fashioned off of catastrophic plans here. So they are 

still quite, quite high. But it is a foregone conclusion that you won’t 

be able—if you have multiple doctors, it will be very hard to envision patients being able to keep their full complement of providers. 

Now, the fact is that it is very hard to get a handle on what 

these networks look like. We tried hard. And a lot of the networks 

aren’t even formed yet, which begs the question how these even— 

these plans even got through the review process at CMS. But that 

said, they are not even formed. So patients are enrolling in plans 

where they really don’t know what the full network is. 

We did a study. We put out an analysis on Anthem Blue Cross 

Blue Shield. And, frankly, we chose that plan because they are the 

most transparent. They provide their full network not only for the 

exchange-based plans, but also for their commercial market. Also, 

they are highly regarded. So we dealt with one of the better plans. 

And we picked the most populous county in each State to look at, 

and looked across six specialty areas, and the numbers were pretty 

grim. And I think that this represents the high watermark. This 

is probably the best you are going to see. When we looked at 

Molina Health, for example, a Medicaid plan, it looked far worse, 

but it was much harder to get data because the network information wasn’t available in all of the States. But this is going to 

present a lot of challenges to patients. 

Chairman BRADY. Could that doc shock also apply to medicines? 

You know, if you—you are a patient using either new or specialized 

medicines, could that formulary also be narrower in those plans so 

that you are faced with the same very high out-of-pocket costs that 

don’t apply to any of your deductibles or your caps? 

Dr. GOTTLIEB. Yeah. It absolutely does apply to medicines. It 

hasn’t been as acute of an issue so far, one, because people haven’t 

tried to tap the insurance, and, two, because a lot of the States 

benchmarked off State plans that had reasonably good formularies. 

But if the drug isn’t on your formulary, then you are going to have 

to pay out of pocket for it. And, again, the coinsurance applies. You 

could pay all of the money out of pocket. So you could be out a lot 

of money. 

Now, there is a way to appeal to CMS to try to get that overturned, to get the drug paid for, but most patients aren’t going to 

be able to go at risk if it is an expensive cancer drug, for instance. 

First of all, they are not going to be able to go out of pocket for 

the 3 or 4 months it might take to appeal. And even on a risk-adjusted basis, even if their doctor says, look, there is an 80-percent 

chance I will win the appeal, that 20-percent chance might be too 

much for them to take because the money would be so substantial 

that they would be forced to pay. So I think that this will be prohibitive. 

Where this is going to become a much more acute issue, first of 

all, some States that don’t have good model formularies, but also 

going forward, new drugs, it is going to be slow to see new drugs 

introduced into those formularies because of the process that is 

being put in place. So access is going to be inhibited for newer 

therapies as we go forward and as these formularies should adapt 

over time to new—to new treatments. 


dkrause on DSKHT7XVN1PROD with LOCATORS
49 

Chairman BRADY. Right. I think this is an important issue, it 

hasn’t been highlighted much, but it is a real concern for the families who don’t fit into the box, as Washington likes to do. 

You are right about the uncertainty back home. I met roundtable 

with our local hospitals. One of them—they don’t know which plans 

they are in. One of them has figured out that they are in 23 of 56 

plans in Texas. Two of the other hospitals had no clue what they 

are included in. The doctors talked about really the return of the 

HMOs. One of them sort of jokingly called this ‘‘HMObamaCare’’ 

because of those narrower networks and the concern that those 

out-of-network costs will be so high. 

Let me ask, you know, aside from the sticker shock and potential 

doc shock our family could face, the testimony today, we saw, really 

lays out next year as sort of an aftershock to where we are right 

now, because of the enrollment problems, because of the mix of 

those who are enrolling that are—families may well face much 

higher premiums next year and end the mandate their local businesses offer. 

Mr. Carlson, can you address that for a moment? 

Mr. CARLSON. Well, I mean, I think it has been, you know, 

clear in some of the statements the actuarial community has made 

that there are a lot of forces that are changing premium rates. Obviously, I speak of this prior to any consideration of the premium 

subsidies. But, you know, most of the changes in the benefit requirements and most of the change—you know, you have the insurer piece and those other factors that are driving up the premium rates. Then when you look at the gender rating and other 

market reforms, again, specific populations that are targeted there 

create a premium rate increase for that particular population; for 

example, younger individuals. So, you know, that is a concern to 

individuals buying insurance on the exchange. 

Now, another concern, and I talked about it in my testimony, you 

know, we need to get our premium rates filed by sometime at the 

end of spring or toward the end of spring, but then we are going 

to have very little information to work with. So, if our enrollment 

is not enough to provide any valid data, again, we are going to be 

kind of, I don’t want to say guessing, but having to make some 

pretty significant assumptions about what premiums are going to 

be in 2015, which makes our job a little more difficult. And if the 

risk pool is not a broad and balanced risk pool, which is going to 

put upward pressure on the premium rates for 2015 as we try to 

work with the data we do have. 

Chairman BRADY. And I think this point: One, to be fair, we 

need to allow the White House to finish their push to see what that 

enrollment mix will be. But I think the point we have heard today 

in a number of the testimonies is that if the younger don’t sign up 

and the healthier don’t sign up, in significant amounts, and if the 

White House misses the $7 million goal significantly, it could well 

lead, depending on that mix, to higher rates in 2015. 

Well, thank you all very much for your testimony. 

Dr. McDermott. 

Mr. MCDERMOTT. Thank you, Mr. Chairman. 

As I listen to this testimony, there are two countries. There are 

those States where they put up a State exchange, and then there 


dkrause on DSKHT7XVN1PROD with LOCATORS
50 

are all the rest that sat back on their hands and said, let the Federal Government do it so we can throw rocks at them later because 

it isn’t working. 

Mr. Kreidler, I would like you to talk about how you got bipartisan support to put together and begin a long time ago. Nothing 

that we have heard testified here today is unknown. It has been 

known for 3 years. So you knew in 19—or 2005 that you were going 

to have—or 2009 you would have certain problems, and you started 

working on them, the narrow networks and all the rest. I would 

like to hear how you went through the process of putting together 

an exchange that works. 

Mr. KREIDLER. Thank you, Congressman McDermott. 

Let me say that, you know, I sit as a board member of the 

Health Benefit Exchange in the State of Washington, and as such 

I can tell you right now that the makeup of the board looks like 

a rainbow coalition, so to speak, of political views. We don’t always 

agree on the best course of action, but we always have from—our 

primary focus and interest is making sure that it works, that people have access to health care, that it has affordable. 

And from the standpoint of looking at the networks that are out 

there right now, that has been a job for our office, and inside the 

exchange, obviously, one part of the change that we are seeing 

right now are narrower networks. And as a part of that right now, 

we are taking very seriously to make sure that if there is a problem from the standpoint of making sure that there is an essential 

benefit, and it is not in part of the network, that they will be treated as in network and from the standpoint of the patient and the 

consumer. So that they wind up getting the benefit of the doubt 

when they do have those exclusive types of benefit, whether it is 

cancer treatment, or whether it is hemophilia, or whatever it might 

be, we make sure that they are going to still be—if the promise has 

been made in the policy, we are going to make sure the insurance 

company lives up to that promise. 

So we are working to endeavor to make sure that that happens 

so that as we go forward, we see health carriers that are playing 

a much more active role now in plan management, something that 

all of us thought was really important going forward to see that 

that happened, and we are starting to see it right now. We want 

to make sure that it is not something that disadvantages the consumer. And from the standpoint of services that can be bought 

competitively in the market, that are comparable quality and outcomes, that is desirable if it offers a better price and reasonable access. 

Access is what we—we are concerned about. We want to make 

sure that policy performs and offers the access that has been guaranteed in that policy, and we are going to work together to make 

sure that happens, whether it is through the exchange, or whether 

it is outside of the exchange. Because the—all of the plans in the 

individual market and the small-group market have to meet the 

same standards, whether they are in the exchange or outside of the 

change. And we have got a lot of plans out there, a lot of carriers, 

and we offer some real opportunity for consumers. 

Mr. MCDERMOTT. Dr. Gottlieb talked about the fact that doctors might not get paid, or that somehow payments would be held 


dkrause on DSKHT7XVN1PROD with LOCATORS
51 

back by insurance companies. Have you ever had a complaint to 

your office from a physician’s office that the insurance company 

wasn’t paying their bills? 

Mr. KREIDLER. We have had—Congressman McDermott, we 

have had lots of complaints about that over the years, well before 

the Affordable Care Act. 

Mr. MCDERMOTT. Really? Before ObamaCare? 

Mr. KREIDLER. Oh, way before ObamaCare. 

Mr. MCDERMOTT. Oh. 

Mr. KREIDLER. And that has always been an issue. And when 

we hear those complaints, and it is a fully regulated plan that we 

have authority over, we contact that company right away, and we 

make sure that they are living up to their promises that they are 

paying on those claims. If there is a problem out there, we are 

going to go after that carrier to make sure that they are complying. 

And, quite frankly, we have received a remarkable amount of goodfaith work with the health insurance carriers in the State of Washington when we bring it to attention. Everybody makes mistakes. 

They can make mistakes as well as anybody else, and when they 

do, they are quick to make the correction of that. 

So I don’t look forward to them holding back. Now, again, we are 

talking about a State-driven exchange. We didn’t cede the power to 

the Federal Government. We said we wanted to make sure our 

plan worked to the benefit of Washington consumers, that it wound 

up being styled to what we are used to in the State of Washington, 

so we took control of it. We did not defer to the Federal Government. So it made a big difference. 

Mr. MCDERMOTT. Could I just ask you to talk a little bit about 

the change? In my understanding, insurance regulation has always 

been done at the State level. Federal Government has never put its 

hand into it before. Now we are putting our hand into it sort of— 

I don’t know exactly how it feels or what it looks like. Tell me— 

I mean, some States clearly have insurance commissioners that 

aren’t doing their job, but the clear—the question I have is what 

is it like to have us start telling you what to do? 

Mr. KREIDLER. Well, to some degree we have already had some 

of that because of ERISA and HIPAA and some of the other standards that were out there well before ObamaCare. 

We had some guidance from the Federal Government. When it 

came to regulation, you are absolutely right, Congressman 

McDermott, that we have been for the fully insured market the 

ones that have been in charge of this, so that we have been driving 

it at State level. So that hasn’t—that is something that we are 

used to. 

As we look at the Federal involvement right now, it is one that 

provides some bottom-line guidance so that there aren’t low-ballers 

out there, that consumers are protected; they get the services they 

want. 

Chairman BRADY. Thank you, Commissioner. 

Mr. Johnson. 

Mr. JOHNSON. Thank you, Mr. Chairman. 

Dr. Gottlieb, you mentioned in your testimony it has been reported that the focus has been to fix the Web site registration process, but that means insurance—insurers are still getting faulty reVerDate Sep 11 2014 08:50 Aug 15, 2016 Jkt 021102 PO 00000 Frm 00055 Fmt 6633 Sfmt 6602 I:\WAYS\WAYSPS\21102\21102.XXX 21102

dkrause on DSKHT7XVN1PROD with LOCATORS
52 

ports on individuals who believe they have signed up for coverage, 

but aren’t actually enrolled. 

Yesterday the Texas Health and Human Services Commissioner 

sent a letter to Secretary Sebelius stating he has serious questions 

about the validity of the data we have received from CMS. While 

electronic account transfers have been delayed, CMS has provided 

States with spreadsheets of individuals the marketplace determined would be Medicaid or CHIP eligible as of January 2014. Our 

review of the spreadsheets for Texas found individuals with addresses from other States, including as far away as New York; 

fields that were left blank; and people who are already receiving 

Medicaid or CHIP. 

Given all the problems and mistakes that are still ongoing, how 

can the Federal Government force people to buy a product they 

don’t want? And businesses have been given a year reprieve from 

this onerous law. Shouldn’t individuals be treated fairly and be 

given a delay from this complicated mess as well? 

Dr. GOTTLIEB. Well, I am one who believes that at some point 

the Administration will announce that they are not going to enforce 

the individual mandate, and they will just wait perhaps until after 

the enrollment deadline. I find it hard to believe that they are 

going to enforce the penalty on people in a situation where it is, 

you know, nearly impossible in certain situations to sign up, and 

certainly difficult. 

So, yes, I don’t think there should be an individual mandate. We 

should also keep in mind that since the data being transmitted to 

the plans is wrong, most of that—a lot of that revolves around determination of eligibility for the subsidies. So it is fair to assume 

that some of those subsidy calculations are wrong. And it is also 

fair to assume that you are more likely to enroll in a plan if the 

subsidy calculation is wrong in your favor than against you. And 

so there is going to be a percentage of people, and it could be potentially high, who were told they were eligible for subsidies and enrolled on the basis of that assumption where their subsidy calculations were wrong. 

It is unclear how that is going to be handled, whether that 

money is going to be clawed back, or there is going to be some kind 

of grace given for this year since the mistake is on the part of the 

Web site and the Federal Government. But I think it is fair to assume that—and who knows how big the number is—that there is 

a certain percentage of people who enrolled who have wrong calculations. 

Mr. JOHNSON. Well, maybe we need a delay to figure it all out. 

Ms. Turner, I want to do just a simple comparison. Let us compare what we know about 2014 to what will happen in 2015. One, 

will premiums be higher or lower in 2015 than 2014? 

Ms. TURNER. I think we have heard that that greatly depends 

upon all the young, healthy people signing up for coverage and getting the 7 million enrolled. That looks increasingly unlikely. And 

I think if we start to see enrollments decline, you get—the exchanges become basically high-risk pools instead of the broader 

plan that you are going to see premiums only go up, and I think 

that is going to significantly impact enrollment in 2015. 


dkrause on DSKHT7XVN1PROD with LOCATORS
53 

Mr. JOHNSON. Yeah. Well, will individuals have more or fewer 

choices of doctors? 

Ms. TURNER. And as Dr. Gottlieb has shown in his new study, 

across the—the one plan that he was able to get good data on, that 

we see that the—the choice of physicians is dramatically reduced, 

and the limited networks are really a result of trying to have so 

many benefits in the plan. But providers and especially hospitals 

are very limited. 

Mr. JOHNSON. In your opinion, will more or fewer insurers participate in the exchanges? 

Ms. TURNER. If I were an insurance company, I would be looking very carefully at this and thinking, if you didn’t get in one of 

these exchanges, you are thinking, I am so glad. And I think they 

are going to go about it very carefully. 

Mr. JOHNSON. Walk softly and carry a big stick. 

Will insurers expand or decrease the number of counties where 

they offer plans? 

Ms. TURNER. We are starting to see much more not only limitations in the number of physicians and hospitals, but also geographic limitations in what the plans are offering. So I think you 

are going to continue to see more limits, fewer benefits, and ultimately higher costs. 

Mr. JOHNSON. Wow. Well, will the individual mandate be more 

or less popular as we go downstream? 

Ms. TURNER. There was a recent study just this week showing 

that the more that people knew about the law, the more unpopular 

it was. And I think a number of people don’t understand the—the 

individual mandate. It is not being promoted by the Administration, and it is—the penalties are significant, and people feel it is 

of an affront to their freedom. 

Mr. JOHNSON. You bet. 

And will more or fewer employees—employers offer coverage for 

their employees. 

Ms. TURNER. If you are a big company, and you are looking at 

the possibility of paying a $2,000 fine per employee instead of 

$11,000 for employee health insurance, they are likely to have to 

drop coverage. 

Mr. JOHNSON. Thank you, ma’am. Thank you. 

Chairman BRADY. Thank you. 

Mr. Thompson. 

Mr. THOMPSON. Thank you, Mr. Chairman. 

Ms. Turner, you mentioned that some folks are going to be hit 

with more expensive and less attractive policies. What is a less attractive policy? 

Ms. TURNER. As Dr. Gottlieb described, the limit—more limited 

network, the hospitals—— 

Mr. THOMPSON. The which? 

Ms. TURNER. More limited networks and the fewer number of 

doctors that are providing. There were a number of people that are 

saying even when they get on the exchange, they find to have to 

make a choice between the hospital that they have been going to 

or the doctor that they have been seeing. So the limitations on networks and the—I think they are also going to be very surprised at 


dkrause on DSKHT7XVN1PROD with LOCATORS
54 

the high deductibles in many of these policies. The most affordable 

plans have deductibles of 3- and 4,000—— 

Mr. THOMPSON. So you weren’t talking about what is covered; 

you weren’t talking about preventive care, mental health, drug and 

alcohol addiction, all of the—all of the—the fact that they can’t 

drop you for a preexisting condition. That is not what you were 

talking about as less attractive. 

Ms. TURNER. I am talking about the consumer’s actual experience in accessing that care. 

Mr. THOMPSON. And tell me, you just responded to Mr. Johnson’s question about whether or not insurance companies would 

want to get on the exchange. Why wouldn’t an insurance company 

want to get—have access to that marketplace? 

Ms. TURNER. I think initially they felt that this would not only 

be something that they should do as insurance companies, insure 

people, but also that this was going to be a large new pool of potentially healthy people that they could get on their—on their plan. 

But they are finding now that the—the Web site is so difficult to 

get on and has been, that only—— 

Mr. THOMPSON. Which—you mean the one in the 36 States 

that have tried to—— 

Ms. TURNER. Well, no one has been able to sign up on the Oregon exchange either. A number of others are still having trouble. 

You—Vermont, Oregon, others. 

But just the risk pool that they are now seeing of people who are 

going to get on exchanges. As I said, I think that the exchanges 

could very well become high-risk pools, and the policies are not 

priced for that. 

Mr. THOMPSON. So the effort to discourage young people from 

signing up is having an effect as to whether or not people will— 

insurance companies will get on the exchange? 

Ms. TURNER. Well, the law itself really discourages young people by charging them more. 

Mr. THOMPSON. Thank you. 

Dr. Kreidler, thank you for being here and for your testimony. 

I was impressed with what I heard you say and what I have been 

able to read in regard to what Washington is doing. And I am from 

California, a State has had similar success. We have—we were 

out—California was, I think, the first State to go after setting up 

its exchange and to get everything in place so this would work. 

We have had over 80,000 people sign up already. Twenty-five 

percent of those who have signed up are young people between the 

age of 18 and 34, and I think that is important to note, and we 

are getting about 10,000 applications a day. So it is working pretty 

well in California. And when I talked to the insurance folks—one 

was in my office today—they think it is going to be only improving 

as time goes on. It sounds like you are having similar success in 

Washington. 

I would like to ask you about the authority that your office carries in the State of Washington. Are you able to negotiate prices 

for the policies that are on your exchange, or is that done in another arm of the government? 

Mr. KREIDLER. No, it is done through the Office of the Insurance Commissioner. 


dkrause on DSKHT7XVN1PROD with LOCATORS
55 

Mr. THOMPSON. And so you regulate rates. What other regulatory authority do you have? If an insurance company—if there is 

a complaint about the cost of a policy, do you investigate that? And 

do you have some authority to regulate that? 

Mr. KREIDLER. Congressman Thompson, absolutely. We rely 

very heavily on getting consumer complaints about insurance companies’ behavior in the market, so you can do the targeted examinations of those companies to correct where we see deficiencies, 

such things as making sure that if you have a policy that says we 

are going to cover certain specialties, we are going to make sure 

that they live up to those promises. 

The rates, when they are filed with us, they have to be shown 

that they are not excessive. If they are, we talk to the insurance 

company and are going to be reluctant to approve any rates that 

are going to prove otherwise. 

So, yes, we look at it very closely. 

Mr. THOMPSON. And you have used that authority; you have 

exercised that authority in the past? 

Mr. KREIDLER. Use it very extensively. 

Mr. THOMPSON. And how does that work? Does it work to the 

consumer’s benefit? 

Mr. KREIDLER. Absolutely. The companies have learned that 

we play a strong ball game in the State of Washington. They come 

in with much better rates just to start with. We didn’t have the 

major issues around medical loss ratios, MLRs, as has been talked 

about. 

Mr. THOMPSON. Do you have third-party interveners in your 

State laws? So can a third party intervene and request a review 

on your behalf? 

Mr. KREIDLER. Not in the State of Washington do we have 

third parties. I am the person who is the third party protecting 

consumers. 

Mr. THOMPSON. Thank you. 

Chairman BRADY. Thank you, Commissioner. 

Mr. Nunes. 

Mr. NUNES. Thank you, Mr. Chairman. 

Dr. Gottlieb, if you could, walk me through the process. Let’s assume that I was able to log on to the Web site and it worked, and 

so in the last couple of weeks I have signed up. Do I receive an 

ObamaCare card in the mail? Or, like, what do I have for proof of 

insurance? 

That is what people really want. They want to carry a card 

around so that when they walk into the doctor’s office January 1st, 

they show them their card. So what am I receiving? 

Mr. GOTTLIEB. Well, there are not many people who we can 

ask. But presumably you are going to receive notification from the 

insurance company, just like you would in the individual market. 

And so I am sure there are some people who were able to get on 

early who have already received that notification, but a lot of people haven’t. 

Mr. NUNES. But I am supposed to get a card, right? 

Mr. GOTTLIEB. Yes. 

Mr. NUNES. Most Americans carry a card. 

Mr. GOTTLIEB. Yes. 


dkrause on DSKHT7XVN1PROD with LOCATORS
56 

Mr. NUNES. So do they have the cards yet? 

Ms. TURNER. I think that is going to have to come from the insurance companies. 

Mr. GOTTLIEB. Yeah, it will come from the insurance companies. But have they mailed them out yet? 

Mr. KREIDLER. I don’t know if they have mailed them out yet 

or not. 

Mr. GOTTLIEB. I haven’t heard of anyone, yeah. 

Mr. KREIDLER. Obviously, it would be a card that wouldn’t be 

valid until the 1st of January. 

Mr. GOTTLIEB. But you would want it by now, right? 

Mr. NUNES. So let’s assume that I do get this card before January 1st, I walk into the doctor’s office, and I show them my card. 

Is that doctor going—do all the doctors have to accept my 

ObamaCare card? 

Mr. GOTTLIEB. No. I mean, you bring up a critical issue, which 

is it is very hard for a consumer right now, depending on the plan 

they are in, to find out what the network looks like. A lot of these 

plans haven’t even made network information available to people 

who have enrolled. 

I think the only way certain consumers are going to find out 

what their network is, is to enroll in a plan, try to test it in January, and if they find out it is not good for them or their doctor 

doesn’t take it, they can disenroll and enroll in a new plan before 

March. And I suspect you will see consumers doing that. 

This information isn’t available. We looked hard for it. 

Mr. NUNES. So it is likely that I am going to walk into a doctor’s office—Americans will walk into their doctor that they have 

went to for years and doctors are going to reject the insurance? 

Mr. GOTTLIEB. It is possible. I mean, presumably, you would 

hope that most Americans would check if their GP is going to be 

taking the new policy. But, certainly, you won’t be able to do that 

with your full complement of providers. 

Mr. NUNES. But how are they going to check if they haven’t received the card yet? 

Mr. GOTTLIEB. Call up the doctor’s office, and hopefully the 

doctor knows if he is enrolled in the network. 

I mean, this is not easy; you are right. And, again, these plans 

are not, even to people after they have enrolled, making available 

the full network information yet. In a lot of cases, they don’t have 

the networks yet. They haven’t fully formed them. They are still 

putting them together. 

Mr. NUNES. Sounds like a lot of people aren’t going to have insurance coverage come January 1st. 

Mr. GOTTLIEB. Yep. 

Mr. NUNES. Do you agree with that, Ms. Turner? 

Ms. TURNER. [Nonverbal response.] 

Mr. NUNES. Mr. Carlson, do you agree that a lot of people are 

not going to have insurance coverage that think they are entitled 

to it or were dropped off of their employer’s plan? 

Mr. CARLSON. Well, I think the critical issue is, with the extension of the enrollment, people are going to wait longer to get the 

coverage than they would have otherwise. 

Mr. NUNES. Now—— 


dkrause on DSKHT7XVN1PROD with LOCATORS
57 

Mr. MCDERMOTT. Would the gentleman yield? 

Mr. NUNES. Mr. Kreidler, now, in Washington, everything is 

great; everybody has got their cards? 

Mr. KREIDLER. Congressman, they do not have their cards, but 

what they do have—and that will, of course, be through a private 

insurance company. But people are going to wind up going to any 

doctor; what they have an interest in is knowing whether they are 

in-network or not. 

And Dr. Gottlieb identifies, one of the challenges we have is making it easier for people to find out if their provider, the one that 

they rely on the most, which is often going to be a family practice 

provider, that that provider is in-network or not. And that information isn’t as readily available right now, either through the Federal 

exchanges or, for that matter, even in the State of Washington, but 

we are working to correct that. 

One of the things we encourage people to do—— 

Mr. NUNES. But you have 3 weeks left. 

Mr. KREIDLER. Well, it means calling the insurance company. 

If you have gone through the enrollment process and you have 

identified your insurance company, let’s say it is a Blue Cross or 

a Blue Shield plan or whatever it is, you give them a call and say, 

hey, is my provider in-network for this particular plan, and they 

are going to communicate. If they contact the exchange, they are 

going to have information too, probably not as readily available as 

calling the insurer themselves, but people can find out. 

It is just a little bit more challenging right now. It is one of the 

glitches in the system that we are going to work out and make it 

a much more consumer-friendly—— 

Mr. NUNES. So if I have a Washington State utopian Obama 

card, does that allow me to get into any doctor in Washington 

State, or are there going to be some that are going to reject the 

card? 

Mr. KREIDLER. Well, if you have an Obama card, you probably 

wouldn’t get into any doctor’s office, because they will all be private 

insurance companies. But if you come in with a private insurance 

company’s card, you can go anyplace you want to, but if it is out 

of network, you are going to expose yourself to considerably more 

cost to you as an individual. 

It is important to make sure that when you go in, that you are 

going to maximize your benefits. And one of the ways you do that 

is to find out if you are in-network, and that is where you have the 

protections. 

Mr. NUNES. Thank you. 

I yield back. 

Chairman BRADY. Thank you. 

Mr. Pascrell. 

Mr. PASCRELL. Thanks, Mr. Chairman. 

Mr. Chairman, I just have to begin by taking exception to something that you said earlier to my good friend. You said that there 

was no plan B to correct the myriad of problems—you didn’t use 

the word ‘‘myriad’’; that is my word—that exists with the ACA. 

And our panelists have defined some of those problems very nicely, 

and I think some of them are undeniable. Some of them need to 

be addressed beyond the rollout of the plan. We all know that. 


dkrause on DSKHT7XVN1PROD with LOCATORS
58 

But it took us 6, 7 years to respond to Plan D back in 2005 to 

make sure people who were paying premiums were getting some 

benefit. Remember? Between $2,200, $2,300, and $5,200, those people paid premiums, right, Mr. Carlson, Ms. Turner? They paid premiums and got no benefits. Remember that? Oh, it took us 6, 7 

years. 

Ms. TURNER. There was a coverage gap. 

Mr. PASCRELL. Mr. Chairman, here is what you said. You said 

that there was no plan B from the Obama Administration to correct these problems. I think some are legitimate concerns, and we 

should all have them. 

But, Mr. Chairman, you have no plan. In fact, if you watched the 

last 2 weeks, I see many of my good friends on the other side of 

the aisle scrambling to put a flawed erector set of disjointed proposals together, many of which have already been rejected. So we 

are still waiting to see your plan A. 

I don’t want to minimize these problems, as I said. I voted for 

the Affordable Care Act. I am proud of it. I want the law to succeed. 

And, remember, we came together after 2005, and we worked together across the aisle even though many of the folks on the Democratic side voted against it. And the reason why I think it succeeded over years is that we worked together. 

You don’t want to hear that. You don’t want to hear that we 

worked together. We had the choice—we had the choice to turn our 

backs, go back to our districts, and tell seniors this was all baloney. 

We chose not to do that, Mr. Chairman. We chose to use the legislation to help educate the people as to what the benefits were from 

Plan D reform. That is what we chose to do. You chose not to do 

that. 

In fact, we have example after example—and I am glad our good 

friend from Washington is here today. The fact is that since October the 1st, there have been improvements made to the Web site. 

Some States have shown, like Mr. Kreidler’s home State of Washington, once these technical problems are corrected, it doesn’t mean 

the other problems go away, but it is a smoother sail to the object. 

Everyone wants the law to succeed. Or do they? My friends on 

the other side, while they may feign concern now, have been actively working to make healthcare reform fail. And you can’t deny 

that, Mr. Chairman. You just can’t deny that. You want to deprive 

millions of Americans of health insurance. And I don’t think you 

care any less than I do about those millions of people, but let’s be 

straight about the whole situation. 

Our Governor in our great State of New Jersey, the Ranking 

Leading Member now in the polls that he is going to be the next 

President of the United States, he accepted the Medicaid money 

from the Federal Government. He got it half-right. 

But I used to be a teacher, and in my classes you didn’t get a 

passing grade for doing the bare minimum. The Governor refused 

to set up a State marketplace—we need to look at every one of 

these States—and has left millions of Federal dollars in outreach 

and education funding unspent. 

If you remember, in the ACA, $3.6 billion in Federal money for 

grants. New York State, which has a similar population in terms 


dkrause on DSKHT7XVN1PROD with LOCATORS
59 

of the target here as New Jersey, New York State received $369 

million. Imagine a Governor turning that down to inform and educate the people in his State on something as dramatic as Social Security and Medicare, to at least inform the folks—at least inform 

the folks what they should be doing and what their options are. It 

would seem to me to be fair. 

I ask you, Mr. Chairman, as a leader within your party and on 

this great Committee, come over, help us make it right—— 

Chairman BRADY. All time has expired. 

Mr. PASCRELL [continuing]. Or give us your plan A. 

Chairman BRADY. I think the witnesses got off easy on that 

question. 

Mr. PASCRELL. Yeah, I didn’t get to them. 

Chairman BRADY. Mr. Gerlach is recognized. 

Mr. PASCRELL. Are we going to have a double round? Can we 

come around again, Mr. Brady? 

Mr. GERLACH. Thank you, Mr. Chairman. 

Dr. Gottlieb, in your testimony, on page 8, under the conclusion 

section, you state that, ‘‘for every consumer that is made better off 

under this scheme, there will be other consumers that are harmed.’’ 

And then you go on to state that ‘‘these people who will make 

out worse under ObamaCare—the ObamaCare losers—seem to be 

getting shorter shrift in political discussions’’ that are going on 

here. ‘‘Many of these families are solidly middle-class, and many 

struggle financially.’’ 

Can you expand on that a bit more? Who will be the ObamaCare 

losers under the current scenario of the existing law? 

And is there any way to calculate, for every one person that ends 

up with an insurance policy that he or she did not have before, how 

many are actually getting worse policies relative to what they want 

as a citizen, as a consumer, relative to what they have to pay in 

a premium each month and what the deductible is going to be and 

whether the policy provides coverage they don’t even want or need? 

How many of the folks out there are going to end up being losers 

because they are going to be worse off compared to every one person that will have a better situation? 

Mr. GOTTLIEB. Well, all great questions. It is really hard to 

quantify. It depends on the State you are in, certainly. But you can 

make an assumption that many of the people who are losing their 

coverage and are going to be forced into the exchanges are being 

disadvantaged in some way. Certainly, they made a conscious decision to purchase a certain style of plan in the individual market. 

They are being forced into the exchange and buying a plan that 

they didn’t necessarily want. 

Now, for many of those folks, they are going to encounter higher 

costs. In certain States, they might see comparable costs or lower 

costs, but those are the exceptions. Those happen to be States that 

had a lot of insurance regulation previously, and now, you know, 

the sort of exchange environment is comparable to what they were 

experiencing. But most people are going to see higher costs and 

have to pay for benefits that they didn’t necessarily make a decision that they wanted. 

We have done some, you know, rough math at the American Enterprise Institute, and, generally speaking—and this is a sort of a 


dkrause on DSKHT7XVN1PROD with LOCATORS
60 

crude statement, blanket statement—if you are above 250 percent 

of the Federal poverty level, chances are you are going to be paying 

more in the exchange, even with the benefit of the subsidies. The 

subsidies won’t be rich enough to offset the higher costs. 

Mr. GERLACH. And how much is 250 percent of Federal poverty? About how much is that in income? Mr. GOTTLIEB. $30,000 for an individual, $60,000 a year in annual income for a family of four. 

So anyone above that level, there is a high probability that they 

are going to be in a more difficult financial situation, notwithstanding the fact that some people might argue, well, they are getting more benefits. But they are getting benefits they didn’t necessarily want. 

You know, this goes right up through the continuum. So you think about, for example, a family of four earning $95,000 a year 

forced off their employer-provided coverage into the exchange, that 

family is now using after-tax dollars to buy a policy in the exchange. If they buy a silver plan in the exchange, they might be 

looking at a situation where they are spending almost 25 percent 

of their after-tax income on health care. Now, clearly, they are not 

going to be able to do that. But that is a lot of hardship. 

And I think, you know, we are worried about the people at the 

lower income bands, but we shouldn’t give short shrift to the people 

who are middle-income, higher-middle-income, who are also being 

badly hurt here. 

Mr. GERLACH. Mr. Carlson, with your actuarial background, 

what is your thought on that question? Who are the ObamaCare 

losers in all of this process? 

Mr. CARLSON. Well, I think if you look at the—from a premium 

rate perspective, and that is kind of the way I look at it, you have 

made market reforms that have kind of changed how the private 

insurance, healthcare insurance, is being funded. 

Basically, with the essential benefits, you have required that all 

policies cover maternity and all policies cover prescription drugs. 

So, you know, if an individual doesn’t need those benefits, they are 

still going to share in the cost of that. You know, from an actuarial 

perspective, that is a policy decision: How do we want to spread the 

cost of health care across individuals who purchase health care? 

You know, tell me how you want to do it, and the actuary will price 

it. 

But, you know, to the extent there are individuals who don’t 

need those benefits, they are going to be paying for something that, 

you know, is spreading the cost to somebody who doesn’t need it 

beyond what they would actually use for benefits. 

Mr. GERLACH. Congressman Kreidler, if you look at it from the 

perspective that we are going to have losers in this entire system 

once it is implemented, and then you look at the fact that the enactment has 21 new taxes in it that will raise over a trillion dollars 

over 10 years and take that out of the private-sector economy, you 

will have a whole new governmental regulatory regime that will 

impact physicians and other healthcare providers, and at the end 

of all that, according to the Congressional Budget Office, you will 

still have about 30 million uninsured people in the United States, 

which is around the same figure we started this discussion with 


dkrause on DSKHT7XVN1PROD with LOCATORS
61 

back in 2008 and 2009, how can any rational person support the 

Affordable Care Act? 

Mr. KREIDLER. What I am seeing with the current insurers 

right now, I am not seeing the kind of rate problems that are being 

described here. In the King County metropolitan area, or King 

County, the most populated county in the State of Washington, we 

went through one of the major carriers there. They had 31 plans. 

We found that all 31 plans would have wound up—only 1 of the 

31 plans would have actually wound up costing more. 

I think if you ever tried to identify some people that would perhaps see the price shock that comes along, it would be somebody 

that is relatively healthy, that doesn’t care about having prescription drug coverage, doesn’t care about pharmaceutical coverage or 

maternity coverage and things of that nature. But, you know—— 

Chairman BRADY. Commissioner, I apologize. All time has expired by a long way. 

Mr. GERLACH. Thank you. 

Chairman BRADY. So Dr. Price. 

Mr. PRICE. Thank you, Mr. Chairman. And I want to thank you 

for holding this hearing. 

The President and the Administration apparently came out yesterday and said they were going to come out every single day for 

the next 3 weeks with a new benefit of the Affordable Care Act. 

And so having this hearing is incredibly important because the 

American people know that there is not a new benefit to this law 

every single day. 

And yet he said something yesterday that he says virtually every 

single time he stands up, and that is that there are no other ideas. 

‘‘If somebody has got a better idea, then come talk to me.’’ 

Well, Mr. President, we have had a better idea for over three 

Congresses. H.R. 2300 is the bill that gets patients covered, solves 

the insurance challenges, saves hundreds of billions of dollars, and 

doesn’t raise taxes by a dime, and doesn’t put Washington in 

charge of health care. 

So, Mr. President, here we are. We have a better idea. So give 

me a call. We have asked, haven’t heard a word. So my phone 

number in the office, 225–4510, Mr. President. Thank you. Thank 

you. 

The problem is the President’s plan now, as we heard yesterday, 

is to go on offense and blame the Republicans. Well, there is a 

great plan. If this was pension care or worker’s comp or even unemployment insurance, maybe that sounds, politically, like what 

ought to be done at the White House, but, Mr. Chairman, this is 

people’s lives. 

I spent over 20 years taking care of patients. People hurt when 

they can’t get medical care. People’s health care is compromised 

when they can’t get medical care. People lose lives when they can’t 

get medical care. This is serious stuff. 

And so it is not just distressing, to quote my friend from Washington State, it is cavalier and arrogant to have the Administration 

do this. It is cruel and irresponsible to have the Administration 

move in this direction. 


dkrause on DSKHT7XVN1PROD with LOCATORS
62 

We talk in Washington-speak here a lot, and so I want to drill 

down a little bit, if I may, with some of you on the panel. We have 

talked about ‘‘coverage gap.’’ What does that mean? 

Dr. Gottlieb, what does ‘‘coverage gap’’ mean? 

Mr. GOTTLIEB. Quite simply, people might not be covered, they 

might not have insurance. 

Mr. PRICE. They don’t have insurance, they don’t have insurance. They had it before, they don’t have it now. That is a coverage 

gap. That means you can’t see a doctor, you can’t go to a hospital 

and have the procedure or the service covered. 

What about ‘‘back end’’? We have heard, ‘‘The back end hasn’t 

been completed.’’ Sounds like a medical term. 

But, Dr. Gottlieb, what is ‘‘back end’’? What does that mean? 

Mr. GOTTLIEB. Well, that would be my jargon again. That is a 

reference to the systems to allow payments to the insurance companies and to the providers. So the front end, people can enroll, but 

then all the stuff that should happen after that hasn’t been built 

out yet. 

Mr. PRICE. So it means doctors and hospitals and other providers aren’t yet—there is no mechanism to pay them yet for the 

services they provide? 

This ties in to a committee hearing in another committee a couple weeks ago that 40 percent of the Web site wasn’t completed, 

that they haven’t even done it, haven’t even done it. 

That is the back end. So, folks at home listening, what that 

means is your doctor won’t get paid. If your doctor doesn’t get paid, 

you know what happens. He or she can’t see you. 

‘‘Network information.’’ Mr. Kreidler used ‘‘network information,’’ 

‘‘We didn’t have the network information complete.’’ 

Ms. Turner, what is ‘‘network information’’? 

Ms. TURNER. Well, one would assume that that is the networks 

of doctors and hospitals that people would be able to see if they 

were to sign up for various health plans. 

Mr. PRICE. So we are asking the American people to make a decision about the most important thing in their lives, their health 

care for themselves and for their family, and we don’t even have 

the information available to them to allow them to make a responsible decision. You talk about cruel and irresponsible. 

Ms. Turner, another question was asked of you about young people being discouraged to sign up, and you weren’t allowed to continue your answer. I think you started, ‘‘The law discourages,’’ and 

then you were cut off. Would you expand on why the law discourages young people? 

Ms. TURNER. I think this is such an important issue, and it 

shows that the law needed to be thought through better because 

young people were the very people that the exchanges need to attract to the plan, because they are being told they have to pay a 

higher actuarial price for their health insurance in order to be able 

to have older people pay less. 

So you need to have them in, but they are figuring this out, first 

of all. If they are young and healthy, they are not going to spend 

3 or 4 days, a week, trying to get through a Web site for insurance 

when they find that they are going to have to pay more for it than 

their actuarial rates. 


dkrause on DSKHT7XVN1PROD with LOCATORS
63 

Mr. PRICE. So a huge financial disincentive—— 

Ms. TURNER. Yes. 

Mr. PRICE [continuing]. For young, healthy people to sign up. 

And that is in the law. Republicans didn’t make that up. 

Ms. TURNER. Right. 

Mr. PRICE. That is in the law. 

So, Mr. President, we have a better idea, H.R. 2300. I look forward to your call. 

Thank you. 

Chairman BRADY. Thank you. 

Mr. Smith is recognized. 

Mr. SMITH. Thank you, Mr. Chairman. 

And thank you to our witnesses today. 

I know that as we deal with what has been noted by many as 

a very serious issue, I hope that we can bring about a system that 

is patient-centered, where the government doesn’t stand in the way 

of patients and their care. And some patients find care in different 

ways or at different levels, but the patients, I hope, would be in 

charge. 

And so I am very concerned on the very topic that was just mentioned, about the need actuarially for younger, healthier folks to 

sign up who were not previously signing up, to spread that risk, 

and yet there are indications that these younger folks are not signing up. 

Commissioner Kreidler, could you disagree with that? Is that not 

the case? 

Mr. KREIDLER. Congressman, I would agree right now that we 

are not attracting as many of the young and the healthy that really 

need to be a part of the Affordable Care Act because insurance only 

works if you have good risk and bad risk. And if they have good 

risk, you need to balance it out. That is the only way insurance 

works. 

Mr. SMITH. And do you think that those targets are being met? 

Mr. KREIDLER. The targets currently are not being met. And 

one of the challenges that make it more difficult is all of the controversy around the Affordable Care Act. Such things as cancelled 

policies and the like only wind up offering more distraction. And 

we need to make sure that people are incentivized, realize they 

have an obligation for personal responsibility, and do the signup for 

health insurance so they don’t have to have their rates paid for, effectively, by other people who are insured. 

Mr. SMITH. Mr. Carlson, if these folks aren’t signing up, ultimately, what is at risk? 

Mr. CARLSON. Well, I think what is at risk is the future of that 

risk pool. The premiums that were set for 2014 assumed a certain 

mix of younger and older individuals. If that mix is not met, you 

have an issue that the insurance company is not going to be collecting enough premiums relative to the claims they expected. And 

that also is going to drive their pricing for 2015. 

So, you know, unless they can see that the risk pool will change 

to be a more balanced risk pool, they have to build in to their pricing the assumption that they are not going to be able to enroll 

those younger individuals and are going to have to increase their 

premiums to reflect that difference. 


dkrause on DSKHT7XVN1PROD with LOCATORS
64 

Mr. SMITH. Are there any numbers that you could maybe point 

to in terms of what expectations—I mean, it is probably difficult to 

do, but any rule of thumb? 

Mr. CARLSON. You know, I think at this point it is way too 

early to make any judgment. I think it is certainly a positive number and not a negative number; I will put it that way. 

Mr. SMITH. Okay. 

Well, I just have such extreme concern that if young people 

weren’t signing up before and they will be faced with a higher premium yet because of all of the new mandates and the government, 

and the heavy hand of government, I would add, intervening, that 

will result in a higher premium, I can’t imagine that human beings 

would be more anxious to sign up for that, even with some of the 

penalties in place. 

Commissioner Kreidler, do you see any objection there? 

Mr. KREIDLER. You know, one is that there is the opportunity 

up to the age of 26 of staying on your parents’ policy. The other 

is that there are catastrophic plans up to the age of 30 that are 

much more affordable that are possible for younger and healthier 

individuals to sign up for. 

So there are some options out there to help bend that cost curve 

down for the individual—cost curve from the standpoint of how 

much it costs them. 

But nobody is immune from bad luck. A good friend wound up 

with her son having a skiing accident in Utah and wound up costing her something like $20,000 because of a broken leg, and he 

didn’t have health insurance. Well, mom went out there to pay for 

it. Now, it is going to be easier for her to make sure that he has 

reasonable coverage than it has been in the past. 

But, yes, it means exhibiting personal responsibility so that we 

work to avoid the fact that, if you wind up with bad luck, you don’t 

have to cost-shift to other people. 

Mr. SMITH. Okay. Thank you. 

I will yield back. 

Chairman BRADY. Thank you. 

Mrs. Black. 

Mrs. BLACK. Thank you, Mr. Chairman. 

I want to go to the topic of security. 

And so, Ms. Turner, this question is going to be for you. We are 

learning that HHS never built security into the Web site. As a matter of fact, there was a top security expert yesterday on CNBC that 

stated, and I quote, ‘‘Putting your information on there is definitely 

a risk,’’ and he was talking about the Web site. 

As a matter of fact, there was a piece on there that actually said, 

and I paraphrase, that there was no expectation of security of your 

information. It has since been removed from the Web site. I don’t 

know that we can be confident now that something has changed 

since the removal of that. 

But is it fair to force people to use this Web site, the individual 

mandate that forces people to buy insurance that maybe they don’t 

want and to expose them to the fear of having their most personal 

information hacked? Do you think that would be a concern? 

Ms. TURNER. That is a huge issue, and it is yet another deterrent for people to go on to the Web site. I am not an IT expert, 


dkrause on DSKHT7XVN1PROD with LOCATORS
65 

but I certainly have read—a number of them have said that, even 

with this last push, this last row of fixes, that they did nothing to 

improve the security of the information that people are required to 

put on this Web site. 

This is a huge amount of personal information that people are 

required to disclose in order to see what subsidies are available, et 

cetera, as well as ultimately credit card information, bank account 

information. And if hackers can so easily get at a system, it is yet 

another deterrent from people enrolling in this coverage. I think 

that needs to be—that has to be a priority. 

Mrs. BLACK. Thank you. And I would say, given the many problems that have already been identified, that this may be another 

one that would indicate there is a reason for a delay in the individual mandate, as there was for an employer delay. 

Mr. Kreidler, I just want to go to you because you have built a 

Web site. And what did you do to ensure that there was security 

information on your Web site? 

Mr. KREIDLER. We had a number of protocols that were required of us. One, even receiving the Federal grant was there an 

obligation to be able to demonstrate that this information would be 

treated confidentially. And going forward, we had an obligation to 

make sure that the system operated. 

But, you know, all Web sites—I mean, we have certainly seen it 

with some of the major Web sites in this country where there have 

been compromises that have taken place, private Web sites that 

have had problems with personal information. I think it is an ongoing obligation and a challenge in the new era of Web sites and the 

kind of information that can be accessed, is to build in as much security as possible. 

Mrs. BLACK. So you say that, in order to receive the government 

grant to build the Web site, you had to ensure that you would use, 

I would say, probably standards that are accepted within the industry to ensure that, such as the end-to-end testing. Did you do 

end-to-end testing on your Web site? 

Mr. KREIDLER. We did do testing. I wish we would have done 

more testing, just from the consumer perspective more than the 

privacy issue. 

But part of this is, even though we have our Web site at the 

State of Washington level, you have the Federal hub that you also 

interact with, which goes to a lot of the more critical personal information that you are describing, whether it is IRS information for 

eligibility or whatever. So it is a complex system, and confidentiality is something that we take very seriously. 

Mrs. BLACK. Well, and thank you for that. And I would say, 

given the fact that the Federal Government required you to use industry standards to ensure that you did end-to-end testing and to 

ensure the folks that are using your Web site, that they could be 

confident in putting that material in, that at least you did all you 

could to protect them, that is certainly a disappointment, that the 

Federal level did not follow those same standards. Because we 

know that they did not do end-to-end testing. And so this is a big 

concern. 

With the little bit of time that I have left, verification, income 

verification, has been something that I have been very concerned 


dkrause on DSKHT7XVN1PROD with LOCATORS
66 

about. Because the two planks of the ACA was that if someone did 

not have employer-sponsored insurance, they could apply, and 

when they applied, we would have to verify income to be sure that 

their income was at a level where they were eligible for these tax 

credits. 

We learned yesterday that the Inspector General for the Tax Administration—and I quote: ‘‘The IRS’s existing fraud-detection system may not be capable of identifying the ACA’s refund fraud or 

schemes prior to the issuance of tax return funds.’’ So now we have 

another situation that was not set up or being followed, where we 

don’t know how much fraud is going to take place here. 

So thank you very much, Mr. Chairman. 

Chairman BRADY. Thank you. 

Mr. Reichert is recognized. 

Mr. REICHERT. Thank you, Mr. Chairman. Thank you for allowing me to be a part of this hearing and pose some questions. 

And I would feel a little bit guilty, Mr. Kreidler, if I didn’t attend—I am not on the healthcare Subcommittee. I now am on 

Human Resources and Trade. But I think, as a fellow Washingtonian, I wanted to be here, along with Jim McDermott and yourself. So thank you for coming. 

Thank all of you for your testimony. 

And I know you are proud of the product, and I know you put 

a lot of hard work into the Washington State exchange system, but 

I just want to be here to bring a little bit of reality to it. And I 

think you have touched on some of those things, but I want to 

highlight some of the issues that we have had. 

You know, my good friend from New Jersey has said, look, you 

know, we are looking for this to work. And what we want, though, 

really, is quality health care, affordable health care. We want access, and we want the freedom to choose. And I think that, in the 

ObamaCare plan, which we oppose because it hasn’t lived up to 

any of those promises, in our opinion—that is why we are working 

to correct this. Because these are the things we should all be—it 

is not just about making the law work. These are the things that 

we should be after, right, for our constituents. 

So I know you are proud of your work and proud of the fact that 

over 176,000 people have enrolled in the Washington exchange program. But out of those 176,000, 158,000 of those are Medicaid enrollees; only 18,000 are individual enrollees. 

And isn’t it true that if that number doesn’t go up by 2015, that 

the health insurance providers will have to increase their premiums for the losses that they are going to incur if they don’t get 

those individual enrollments up? 

Mr. KREIDLER. It is an ongoing concern because we obviously 

want to get as many people enrolled through qualified health plans 

through the exchange, people who will be eligible for subsidies and 

some that are not eligible for subsidies also signing up for plans. 

Mr. REICHERT. But isn’t it true, though, sir, that premiums will 

probably go up if those numbers don’t rise? 

Mr. KREIDLER. You know, as Mr. Carlson has pointed out—— 

Mr. REICHERT. Is that a ‘‘yes’’? 


dkrause on DSKHT7XVN1PROD with LOCATORS
67 

Mr. KREIDLER. As an actuary, the answer is it is too early to 

say. Because you are only going to have about a quarter of a year 

in order to make those determinations. 

Mr. REICHERT. Okay. 

Mr. KREIDLER. There are a lot of other pressures that apply, 

such as market share and competition, that are going to drive insurance companies that help to hold down the rates. 

Mr. REICHERT. I agree that there is some time yet, but it looks 

like, from the information that we have been able to gather, the 

premiums will go up if those enrollments don’t go up. 

The other issue is the 8,000 people who had a subsidy issue. 

They enrolled in programs, discovered that their subsidies were incorrectly calculated. I think you are trying to address that problem. 

But once they have discovered that their subsidies are less than 

what they supposed in the first place, now their premiums go up, 

and they have insurance plans that they didn’t want or it doesn’t 

provide the service that they need. I think that is a huge issue. 

Eight thousand people—you talked a little bit earlier about 

glitches. Glitches mean people to me. That is 8,000 people that are 

in a glitch. That needs to be fixed. Two hundred and ninety thousand people in Washington State received notices that their insurance plans were cancelled—290,000 people—in this glitch. 

The President said, after he made these promises, you can keep 

your healthcare plan, which was really not totally truthful, finally 

came out and said, you can keep your healthcare plan. The House 

of Representatives here in the United States Congress passed a law 

that said you can keep your healthcare plan. Harry Reid did not 

bring that bill to the Senate floor. 

You decided, sir, to separate yourself from the President on that 

request and decided not to allow those 290,000 people to keep their 

health insurance. Did you speak to any of those health insurance 

carriers to see whether or not they could continue their coverage 

before you made that decision for those 290,000? 

Mr. KREIDLER. The answer to that, Congressman, is, no, I did 

not. 

Mr. REICHERT. Why not? 

Mr. KREIDLER. I regulate. I regulate the—— 

Mr. REICHERT. Why did you not contact those insurance companies? 

Mr. KREIDLER. We had a statement from the American Health 

Insurance Plans, AHIP, that was very clear that they were distressed by it. 

The irony of it is they were distressed about what the President 

proposed, but they privately would have said that the Upton measure that passed here—— 

Mr. REICHERT. Well, before my time runs out—— 

Mr. KREIDLER [continuing]. Would have been much more—— 

Mr. REICHERT. Before my time runs out, Mr. Kreidler, I want 

to make a couple more points. 

Soon to hit will be the employer mandate—the employer small 

businesses association plans, they are going to get their notices for 

cancellations. I know that some already have. 

The other thing that really bothers me is this narrowing network 

issue that you spoke of earlier in your testimony. Look, we have 


dkrause on DSKHT7XVN1PROD with LOCATORS
68 

plans, and only one insurance company covers Cancer Alliance, 

Children’s Hospital, University of Washington’s Hospital—— 

Chairman BRADY. All time has expired. 

Mr. REICHERT. Thank you, Mr. Chairman. 

Chairman BRADY. No, thank you, Mr. Reichert. 

First, let me recognize Dr. McDermott for a unanimous-consent 

request. 

Mr. MCDERMOTT. Mr. Chairman, thank you. 

I ask unanimous consent that we enter into the record a letter 

from the Association of Washington Healthcare Plans dated December 2nd, 2013. 

It responds directly to what Mr. Reichert is saying. It says: Accordingly, if the Administration of Congress chooses to make additional policy changes in the ACA, we ask that you advocate for allowing States with a functioning State-based exchange like Washington to continue with implementation as currently required 

under ACA. 

Chairman BRADY. Right. The time—— 

Mr. MCDERMOTT. The insurers in Washington State ask him 

not to make the change. 

Chairman BRADY. Thank you. 

Without objection. 

[The information submitted by the Honorable Jim McDermott 

follows:] 


dkrause on DSKHT7XVN1PROD with LOCATORS
69 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.032
70 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.033
71 

f 


dkrause on DSKHT7XVN1PROD with LOCATORS21102A.034
72 

Chairman BRADY. One, I would like to thank our witnesses for 

their testimony today. 

There are a lot of concerns about this law. A lot of families and 

patients and local doctors have concerns. We are going to continue. 

I think your testimony was insightful, your answers were thoughtful, we think, I think, very helpful in this whole discussion. We will 

continue to do oversight, vigorous oversight, over this law for Republicans and Democrats to be able to make sure we know what 

that impact is. 

As a reminder, any Member who wishes to submit a question for 

the record will have 14 days to do so. So if any questions come your 

way, I would ask that the witnesses respond in a timely manner, 

as I know you will. 

With that, this Subcommittee is adjourned. 

[Whereupon, at 11:44 a.m., the Subcommittee was adjourned.] 

Æ 


dkrause on DSKHT7XVN1PROD with LOCATORS