U.S. GOVERNMENT PUBLISHING OFFICE

32–389 PDF WASHINGTON : 2018

PATIENT RELIEF FROM COLLAPSING HEALTH 

MARKETS 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

FEBRUARY 2, 2017 

Serial No. 115–4 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

COMMITTEE ON ENERGY AND COMMERCE 

GREG WALDEN, Oregon 

Chairman 

JOE BARTON, Texas 

Vice Chairman 

FRED UPTON, Michigan 

JOHN SHIMKUS, Illinois 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

TIM WALBERG, Michigan 

MIMI WALTERS, California 

RYAN A. COSTELLO, Pennsylvania 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJA ́ N, New Mexico 

PAUL TONKO, New York 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

RAUL RUIZ, California 

SCOTT H. PETERS, California 

DEBBIE DINGELL, Michigan 

SUBCOMMITTEE ON HEALTH

MICHAEL C. BURGESS, TEXAS

Chairman 

BRETT GUTHRIE, Kentucky 

Vice Chairman 

JOE BARTON, Texas 

FRED UPTON, Michigan 

JOHN SHIMKUS, Illinois 

TIM MURPHY, Pennsylvania 

MARSHA BLACKBURN, Tennessee 

CATHY MCMORRIS RODGERS, Washington 

LEONARD LANCE, New Jersey 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILLY LONG, Missouri 

LARRY BUCSHON, Indiana 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

GREG WALDEN, Oregon (ex officio) 

GENE GREEN, Texas 

Ranking Member 

ELIOT L. ENGEL, New York 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

BEN RAY LUJA ́ N, New Mexico 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

ANNA G. ESHOO, California 

DIANA DEGETTE, Colorado 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

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(III) 

C O N T E N T S 

Page 

Hon. Michael C. Burgess, a Representative in Congress from the State of 

Texas, opening statement .................................................................................... 2 

Prepared statement .......................................................................................... 3 

Hon. Gene Green, a Representative in Congress from the State of Texas, 

opening statement ................................................................................................ 4 

Hon. Greg Walden, a Representative in Congress from the State of Oregon, 

opening statement ................................................................................................ 6 

Prepared statement .......................................................................................... 7 

Hon. Susan W. Brooks, a Representative in Congress from the State of 

Indiana, prepared statement ............................................................................... 9 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 10 

Prepared statement .......................................................................................... 11 

Hon. Anna G. Eshoo, a Representative in Congress from the State of California, prepared statement .................................................................................. 108 

WITNESSES

Douglas Holtz-Eakin, Ph.D., President, American Action Forum ....................... 14 

Prepared statement .......................................................................................... 17 

Answers to submitted questions 1 ................................................................... 188 

J.P. Wieske, Deputy Commissioner, Wisconsin Office of the Commissioner 

of Insurance .......................................................................................................... 23 

Prepared statement .......................................................................................... 25 

J. Leonard Lichtenfeld, M.D., Deputy Chief Medical Officer, American Cancer 

Society ................................................................................................................... 39 

Prepared statement .......................................................................................... 40 

Answers to submitted questions ...................................................................... 190 

SUBMITTED MATERIAL

Discussion Draft, H.R. lll, the Preexisting Conditions Protection and Continuous Coverage Incentive Act of 2017, submitted by Mr. Burgess ............... 109 

Discussion Draft, H.R. lll, the State Age Rating Flexibility Act of 2017, 

submitted by Mr. Burgess ................................................................................... 116 

Discussion Draft, H.R. lll, the Plan Verification and Fairness Act of 

2017, submitted by Mr. Burgess ......................................................................... 118 

Discussion Draft, H.R. lll, the Health Coverage State Flexibility Act 

of 2017, submitted by Mr. Burgess ..................................................................... 123 

Article of January 30, 2017, ‘‘It Cost $2.5 Million to Keep My Child Alive,’’ 

by Virginia Sole-Smith, Slate, submitted by Ms. Schakowsky ......................... 125 

Letter of February 1, 2017, from Joyce A. Rogers, Senior Vice President, 

Government Affairs, AARP, to Mr. Burgess and Mr. Green, submitted by 

Mr. Butterfield ..................................................................................................... 128 

Chart, ‘‘Forecasters: Obamacare enrollment will hold steady,’’ by Sarah Kliff, 

Vox.com, January 24, 2017, submitted by Ms. DeGette ................................... 131 

Report of the Congressional Budget Office, ‘‘How Repealing Portions of the 

Affordable Care Act Would Affect Health Insurance Coverage and Premiums,’’ submitted by Ms. DeGette .................................................................... 133 

1Dr. Holtz-Eakin did not answer submitted questions for the record by the time of printing. 

Page

IV 

Report of the Henry J. Kaiser Family Foundation, ‘‘High-Risk Pools for Uninsurable Individuals,’’ July 2016, submitted by Mr. Luja ́n ................................ 137 

Statement of the Asian & Pacific Islander American Health Forum, February 

2, 2017, submitted by Mr. Green ........................................................................ 148 

Statement of the American Heart Association, February 2, 2017, submitted 

by Mr. Green ........................................................................................................ 152 

Letter of February 2, 2017, from Rob Restuccia, Executive Director, Community Catalyst, to Mr. Walden and Mr. Pallone, submitted by Mr. Green ........ 156 

Letter of February 2, 2017, from Debra L. Ness, President, National Partnership for Women & Families, to Mr. Walden and Mr. Pallone, submitted 

by Mr. Green ........................................................................................................ 158 

Statement of the National Women’s Law Center, February 2, 2017, submitted 

by Mr. Green ........................................................................................................ 160 

State of Wisconsin Report, ‘‘Fact Sheet on Mandated Benefits in Health 

Insurance Policies,’’ submitted by Mr. Tonko .................................................... 163 

Statement of Bill Flores, a Representative in Congress from the State of 

Texas, submitted by Mr. Burgess ....................................................................... 171 

Statement of the Blue Cross and Blue Shield Association, February 1, 2017, 

submitted by Mr. Burgess ................................................................................... 172 

Statement of the American Congress of Obstetricians and Gynecologists, February 2, 2017, submitted by Mr. Burgess .......................................................... 175 

Letter of January 2, 2017, from Richard I. Fiesta, Executive Director, Alliance 

for Retired Americans, to Mr. Burgess and Mr. Green, submitted by Mr. 

Burgess ................................................................................................................. 180 

Letter of February 2, 2017, from Mary Grealy, President, Healthcare Leadership Council, to Mr. Burgess, submitted by Mr. Burgess ................................. 182 

Statement of America’s Health Insurance Plans, February 2, 2017, submitted 

by Mr. Burgess ..................................................................................................... 184 

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PATIENT RELIEF FROM COLLAPSING HEALTH 

MARKETS 

THURSDAY, FEBRUARY 2, 2017 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON HEALTH, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The subcommittee met, pursuant to call, at 10:39 a.m., in Room 

2123, Rayburn House Office Building, Hon. Michael C. Burgess 

(chairman of the subcommittee) presiding. 

Members present: Representatives Burgess, Guthrie, Barton, 

Upton, Shimkus, Murphy, Blackburn, McMorris Rodgers, Lance, 

Griffith, Bilirakis, Long, Bucshon, Brooks, Mullin, Hudson, Collins, 

Carter, Walden (ex officio), Green, Engel, Schakowsky, Butterfield, 

Matsui, Castor, Sarbanes, Luja ́n, Schrader, Kennedy, Ca ́ rdenas, 

Eshoo, DeGette, McNerney, Tonko, and Pallone (ex officio). 

Staff present: Michael D. Bloomquist, Deputy Staff Director; 

Adam Buckalew, Professional Staff Member, Health; Karen Christian, General Counsel; Jordan Davis, Director of Policy and External Affairs; Paige Decker, Executive Assistant and Committee 

Clerk; Paul Edattel, Chief Counsel, Health; Blair Ellis, Press Secretary/Digital Coordinator; Adam Fromm, Director of Outreach and 

Coalitions; Caleb Graff, Professional Staff Member, Health; Jay 

Gulshen, Legislative Clerk, Health; Zach Hunter, Communications 

Director; Peter Kielty, Deputy General Counsel; Katie McKeough, 

Press Assistant; Carly McWilliams, Professional Staff Member, 

Health; James Paluskiewicz, Professional Staff Member, Health; 

Kristen Shatynski, Professional Staff Member, Health; Jennifer 

Sherman, Press Secretary; Josh Trent, Deputy Chief Counsel, 

Health; Hamlin Wade, Special Advisor for External Affairs; Luke 

Wallwork, Staff Assistant; Jeff Carroll, Minority Staff Director; Tiffany Guarascio, Minority Deputy Staff Director and Chief Health 

Advisor; Jessica Martinez, Minority Outreach and Member Services 

Coordinator; Dan Miller, Minority Staff Assistant; Samantha 

Satchell, Minority Policy Analyst; Matt Schumacher, Minority 

Press Assistant; Andrew Souvall, Minority Director of Communications, Member Services, and Outreach; and Arielle Woronoff, Minority Health Counsel. 

Mr. BURGESS. I want to thank our guests for being with us this 

morning. I thank everyone for their indulgence. The Subcommittee 

on Health will now come to order. I will recognize myself for 5 minutes. 

2 

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

We are all here to help Americans, all Americans, insured, uninsured and functionally uninsured. We want people to get access to 

quality affordable health care. Our system is plagued with problems that impose the highest burden on individuals and consumers 

who have fewer choices, sometimes burdensome mandates, costs 

that continue to spike and—Americans who remain uninsured. 

Leading up to the 2016 elections, promises were made to voters 

that the healthcare system would get back on track. We laid out 

a step-by-step plan to prioritize access to quality affordable health 

care not just insurance. The new administration has taken steps to 

reduce the regulatory burden, and this hearing marks another step 

in that journey to stabilize and rebuild our healthcare system. 

I will be the first to admit we do not agree on everything, but 

members of this subcommittee, both sides of the dais, have a strong 

track record of advancing bipartisan legislation. I am confident we 

can continue to advance bills through an open and through an inclusive process to protect and empower patients. 

In today’s hearing we will consider policies that bolster the 

health markets and reassure Americans that help is on the way. 

To start, we all agree that individuals should have the comfort of 

knowing that they will not be denied a health plan from an insurer 

based upon their health status. 

Chairman Walden has offered a bill that will maintain safeguards for patients with preexisting conditions following the repeal 

of the Affordable Care Act. In addition, Representative Brooks is 

working on a bill that will go beyond protections for preexisting 

conditions by creating incentives for continuous coverage. 

Currently, individuals moving from one job to another are protected from rate increases by existing law. Extending these protections to the individual market is a simple but important reform 

that will encourage Americans to enroll in coverage and to stay enrolled. Rather than forcing people to buy insurance that fails to 

meet their needs, this policy will reward people for making responsible decisions. 

Young, healthy adults have faced the highest rate hikes in premiums to account for the higher costs of covering older, less 

healthy individuals. Today we will discuss legislation offered by 

Representative Bucshon to modify age rating restrictions and bring 

younger, healthier individuals into the insurance market. 

Regulations have allowed individuals to keep coverage for a full 

3 months without paying premiums. Dozens of statutory and regulatory instances allow individuals to enroll in a plan through a special enrollment period. To stabilize the market, Representative Flores and Representative Blackburn have offered legislation intended 

to end manipulation of health insurance rules. 

I look forward to hearing from our witnesses on the merits of setting the grace period to 30 days for nonpayment of premiums and 

requiring verification of eligibility for those special enrollment periods. I think it is important to note that all of these bills, all of 

these bills would allow States the flexibility to modify the requirements. After all, States understand what their residents need better than Washington. 

3 

Good policy that will stand the test of time requires hard work. 

It requires compromise. It requires the scrutiny of the American 

people. As we learned with the Affordable Care Act, policy hastily 

built by folks behind closed doors results in devastating consequences. We are committed to large-scale reform. Real people are 

struggling as we speak, and we are not waiting to take action. 

These bills are an important example of the work we are doing 

right now, right now to advance Member-driven solutions that will 

improve health care for Americans. I am hopeful, hopeful that we 

can work together to reform our health system for the benefit of 

the American people. 

[The statement of Mr. Burgess follows:] 

PREPARED STATEMENT OF HON. MICHAEL C. BURGESS

We are here to help all Americans-insured, uninsured, and functionally uninsured-to get access to quality, affordable health care. Our healthcare system is 

plagued with problems that impose the highest burden on individuals-consumers 

have fewer choices and burdensome mandates, costs continue to spike, and as many 

as 30 million Americans remain uninsured. 

Leading up to the 2016 elections, we promised voters that we would get health 

care back on track. We laid out a step-by-step plan to prioritize access to quality 

affordable health care, not just insurance. The new administration has taken steps 

to reduce regulatory burden, and this hearing marks another step in our journey 

to stabilize and rebuild our healthcare system. 

While we do not agree on everything, members of this subcommittee have a 

strong track-record of advancing bipartisan legislation. I am confident that we can 

continue to advance bills through an open and inclusive process to protect and empower patients. 

In today’s hearing, we will consider policies to bolster our collapsing health markets and reassure Americans that help is on the way. To start, we all agree that 

individuals should have the comfort of knowing they will not be denied a plan from 

a health insurer based on their health status. Chairman Walden has offered a bill 

that will maintain safeguards for patients with preexisting conditions following repeal of the ACA. 

In addition, Representative Brooks is working on a bill that will go beyond protections for preexisting conditions by creating incentives for continuous coverage. 

Currently, individuals moving from one job to another are protected from rate increases by existing law. Extending these protections to the individual market is a 

simple but important reform that will encourage Americans to enroll in coverage 

and stay enrolled. Rather than forcing people to buy insurance that fails to meet 

their needs, this policy will reward people for making responsible decisions. 

Young, healthy adults have faced the highest rate hikes in premiums, to account 

for the higher costs of covering older, less healthy individuals. Today we will discuss 

legislation authored by Representative Bucshon to modify age rating restrictions 

and bring younger healthier individuals into the insurance market. 

Regulations have allowed individuals to keep coverage for three full months without paying premiums. Dozens of statutory and regulatory instances allow individuals to enroll in a plan through a special enrollment period. To stabilize the market, 

Representative Flores and Representative Blackburn have authored legislation intended to end gaming of health insurance rules. 

I look forward to hearing from our witnesses on the merits of setting the grace 

period to 30 days for nonpayment of premiums, and requiring verification of eligibility for special enrollment periods. I think it is important to note that all of these 

bills would allow States the flexibility to modify these requirements. After all, 

States understand what their residents want and need better than Washington. 

Good policy that will stand the test of time requires hard work, compromise, and 

the scrutiny of the American people. As we learned during the ACA, policy hastily 

crafted by Government bureaucrats behind closed doors results in devastating consequences. 

While we are committed to large-scale reform, real people are struggling as we 

speak and we are not waiting to take action. These bills are an important example 

of the work we are doing right now to advance Member-driven solutions that will 

improve health care for all Americans. I am hopeful that we can work together to 

reform our healthcare system for the benefit of the American people. 

4 

Mr. BURGESS. And I would now like to yield the remainder of my 

time to Dr. Larry Bucshon of Indiana. 

Mr. BUCSHON. Thank you, Mr. Chairman. Currently the Affordable Care Act requires that the most generous plan costs no more 

than three times the least generous plan according to age. As a 

consequence, younger healthier individuals have been priced out of 

the health insurance market, destabilizing risk pools and driving 

premiums higher for everyone. 

H.R. 708, the State Age Rating Flexibility Act of 2017 would set 

this ratio at 5:1 or also allow States to set their own age rating 

based on their unique patient population. For example, Indiana 

had no age rating prior to the ACA. This solution encourages more 

actuarially sound plans to enter the marketplace, providing more 

affordable options for younger, healthier individuals and bringing 

them back into the insurance market to more adequately balance 

the risk pools and drive down the premiums for almost everyone. 

I yield back. 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman, and the Chair recognizes the gentleman from Texas, 

Mr. Green, 5 minutes for the purpose of an opening statement, 

please. 

Mr. GREEN. Thank you, Mr. Chairman. Before I start, we have 

a member of our Energy and Commerce Committee but not a member of the subcommittee. I would like to ask to waive on Jerry 

McNerney, who will be here shortly, and I just wanted to give notice that—— 

Mr. BURGESS. Is the gentleman making a unanimous consent request? 

Mr. GREEN. Yes. 

Mr. BURGESS. Without objection, so ordered. 

Mr. GREEN. OK, and Congressman Paul Tonko, also unanimous 

consent. 

Mr. BURGESS. Again, without objection, so ordered. 

OPENING STATEMENT OF HON. GENE GREEN, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. GREEN. Thank you, Mr. Chairman. Thanks to the Affordable 

Care Act, 20 million previously uninsured Americans now have 

health coverage. For the first time ever, less than nine percent of 

Americans are uninsured with the uninsured rate currently at 8.6 

percent. Since the enactment of the ACA, for roughly 150,000 million Americans who have coverage through their employer, premium growth remains much lower than in the past and everyone 

benefits from consumer protections and provisions that improve 

and expand coverage. 

Unfortunately, my colleagues want to undo the progress we have 

made. There should be no repeal of healthcare reform without an 

immediate adequate replacement that achieves the same historical 

gains in coverage, ensures people with preexisting conditions aren’t 

blocked or priced out of the market, and that health plans cover a 

basic set of benefits and consumer protections. 

Repealing the Affordable Care Act in whole or in part without an 

adequate replacement in place would cause chaos and is downright 

irresponsible. It has been 7 years, and, despite claims to have a 

5 

better way, the bills we are considering today will only further sabotage the existing system and offer only unfinished, inadequate 

proposals that as written would leave Americans worse off and put 

insurance companies back in charge. 

It is truly fitting that today is Groundhog Day, except unlike Bill 

Murray it is not a comedy. For 7 years we have asked Republicans 

to work with us to strengthen the ACA and make health care more 

affordable and accessible, and for 7 years they told us they would 

not. This is real and not an abstract intellectual debate, and the 

discussion draft my colleagues have put forward today is just indefensible. 

Thirty million people would stand to lose their health insurance 

if the ACA is repealed. The emergency room should not be the 

point of entry for our healthcare system. It is bad for patients, 

budgets and the healthcare system as a whole. Repeal and replace 

is a slogan not a meaningful policy and would likely put us on a 

path to catastrophe. 

The gravity of the situation is hard to overstate. There are real 

people with real concerns who deserve more than a half written bill 

and inadequate talking points. Proceeding with repeal with halfbaked ideas for replacement is offensive and confusing and alarming. My colleagues across the aisle control the Congress and the 

White House. Millions of people are relying on them and looking 

to them for what they are going to do to protect them. We are well 

past talking points and the American people deserve answers. 

As always, I stand to work with my colleagues, with anyone, to 

amend and improve the Affordable Care Act. And thank you, Mr. 

Chairman. I yield the remaining balance of time to Congresswoman 

Schakowsky. 

Ms. SCHAKOWSKY. Thank you. It has been reported that some of 

our Republican colleagues have recently voiced important and specific concerns about repealing the ACA. And, for example, Congressman Tom McClintock of California, quote, said, ‘‘We had better be sure that we are prepared to live with the market being created ... that’s going to be called ‘Trumpcare.’ Republicans will own 

it lock, stock, and barrel.’’ And then Congressman Tom MAcArthur 

of New Jersey said, quote, ‘‘We’re telling those people that we’re 

not going to pull the rug out from under them, and if we do this 

too fast, we are, in fact, going to pull the rug out from under them.’’ 

Mr. Cassidy pointed out that their plan to tax employer-sponsored insurance will increase taxes on the middle class, and these 

serious concerns and unanswered questions show that Republicans 

are finally starting to realize what Democrats have known all 

along, that their plan to sabotage the ACA will leave millions of 

Americans without coverage, will reduce the quality of insurance, 

and will raise costs for everyone. 

And regardless of the rhetoric that we may hear today, we know 

that this half-written, half-baked bill put forth by Chairman Walden will allow insurance companies to charge people with preexisting conditions whatever they want and charge them whatever 

they want for their coverage. That is what the bill actually does. 

Now that Republicans have started to recognize the consequences 

of their plan to take away coverage from 30 million Americans, I 

hope that they will finally actually work with us to make health 

6 

care more affordable and more accessible. We are ready to sit 

down. We have been ready for 7, 8 years to do exactly that. Let’s 

do it. 

I do agree with the chairman of the subcommittee that we all 

agree that we want to provide quality, affordable health care. 

Those Republicans who have misgivings are right to have that. So 

let’s sit down and do it together instead of these continual proposals that will hurt all of our constituents. And I yield back to the 

gentleman from Texas. 

Mr. BURGESS. The gentlechair thanks the gentlelady. The 

gentlelady yields back. The Chair would like to recount the number 

of times it was rebuffed by the Obama administration on those 

very points, but I will reserve that until later. The Chair now recognizes the chairman of the full committee, Mr. Walden, 5 minutes 

for questions, please, for an opening statement, please. 

OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF OREGON 

Mr. WALDEN. Yes, thank you. Thank you, Mr. Chairman, I appreciate it and I appreciate the concerns of my colleagues. I would 

note from the record there have been multiple pieces of legislation 

since Obamacare was enacted that have received Democrat and Republican votes and actually signed by the President to repeal problems in Obamacare. Those became law. 

So to argue that nothing has ever been done to try and straighten it out is false. I think Democrats combined cast 4,775 votes to 

repeal, to reform, to change Obamacare, so check the facts. We are 

here today, we know on our side we are going to repeal Obamacare. 

It is not working. It has left a lot of wreckage around. We are here 

to clean it up. And in fact we are wide open to hearing from our 

colleagues on policy. That is what we are about. 

We know Obamacare has, what it has done to the healthcare system. It is why we are hard at work crafting reconciliation language 

to repeal it, and today we begin the important work of laying the 

foundation to rebuild America’s healthcare markets as we dismantle Obamacare. We have to save this individual healthcare insurance market. It is collapsing. And if you want to walk away and 

just let it collapse, a pox on your side. That is not what I am about. 

I have always been a problem solver. 

You will hear us in a minute talk about bipartisan legislation, go 

after those who try and corner certain markets, drive up costs— 

things like EpiPen. I am happy to work with you, but it has to be 

something that can move this forward and take care of people. 

There is no shortage of evidence that patients and families are 

hurting under the overwhelming weight of Obamacare. Patients in 

21 States have seen average premium increases of 25 percent or 

more this year. People in seven States will experience premium increases of 50 percent or more. That is not sustainable. 

In 2016 there were 225 counties across America that had just 

one insurance choice in the market, just one on the exchange. This 

year that number has climbed to a 1,022, 1,022 counties with just 

one insurer. That is a third of the entire number of counties in the 

country, a third. Five entire States now, patients there have just 

one choice. 

7 

And if you focus on what those plans are saying, they are evaluating right now whether they can even stay in these markets in the 

outlying years because of what is coming in existing law passed in 

a partisan manner by Democrats. Over five of the original 23 insurance co-ops remain in business, five of 23. They tried it, it didn’t 

work. Two of those failed co-ops are sadly in my own State of Oregon and we are pretty progressive about trying new things and a 

lot of it has worked. These did not. 

We have the responsibility to prevent a real train wreck for millions of Americans. Not only can we solve this problem but we 

must solve this problem. It is time to end the partisan rhetoric and 

actually come to the table and solve these problems and I commend 

my colleagues on both sides of the aisle who are willing to do that. 

The proposals before us today close enrollment gaps, protect taxpayers and give patients cost relief. The first three bills should 

come as no surprise. They were introduced last Congress and were 

the topic of two hearings in this subcommittee. The other proposal 

is equally important to all of us. We will ensure patients with preexisting conditions will always have access to coverage and care, 

period. 

To take this a step further, we have included a placeholder as 

all of you have sort of referenced in your testimony, and I appreciate your testimony. Everybody has a different view of this. We 

want to get it right. That is why there is placeholder language. Our 

Better Way agenda envisions a new patient protection in the individual market for helping patients keep health coverage. HIPAA, 

Medicare Part B, Medicare Part D can serve as guidance for the 

Congress as we consider how best to achieve the goals of protecting 

America’s sickest patients and maintaining market stability. We 

can do both without Obamacare’s unpopular individual mandate 

where all these carve-outs have occurred. 

We have got the best minds focused on helping us, including our 

witnesses today. We are going to get this right. We are going to 

take the time to get this right. That is why you see a placeholder 

language in the draft. And my colleague Susan Brooks is championing these efforts and I would actually like to yield her a few 

minutes for remarks at this time, and then I will conclude with one 

other announcement. 

[The statement of Mr. Walden follows:] 

PREPARED STATEMENT OF HON. GREG WALDEN

We all know the damage Obamacare has wrought on our healthcare system, 

which is why this committee is hard at work crafting reconciliation language to repeal it. But today, we begin the important work of laying the foundation to rebuild 

America’s healthcare markets as we dismantle Obamacare; especially, saving the individual market from total collapse-which is where it is headed absent our intervention. 

Look, there’s no shortage of evidence that patients and families are hurting under 

the overwhelming weight of Obamacare. 

• Patients in 21 States have seen average premium increases of 25 percent or 

more this year. 

• Folks in seven States will experience premium increases of 50 percent or more. 

• In 2016, 225 counties had one insurer. This year, there are 1,022 counties with 

just one insurer—that’s a third of the entire country. 

• Five entire States just have one insurer offering coverage on the exchange. 

• Only five of the original 23 health insurance co-ops remain in business. In my 

home State of Oregon, we had not one, but two co-ops fail! 

8 

We have the responsibility to prevent a real train wreck for millions of Americans. 

Not only can we solve this problem, but we must solve this problem. 

The proposals before us today close enrollment gaps, protect taxpayers, and give 

patients cost relief. The first three bills should come as no surprise—they were introduced last Congress, and were the topic of two hearings in this subcommittee. 

The other proposal is equally important to all of us. We will ensure patients with 

preexisting conditions will always have access to coverage and care. Period. 

To take this a step further, we’ve included a placeholder for a continuous coverage 

incentive. Our Better Way agenda envisions a new patient protection in the individual market for helping patients keep health coverage. HIPAA, Medicare Part B 

and Medicare Part D can serve as guidance for the Congress as we consider how 

to best achieve the goals of protecting America’s sickest patients and maintaining 

market stability. We can do both without Obamacare’s unpopular individual mandate. 

We’ve got the best minds focused on helping us, including our witnesses today. 

We are going to take time to get it right. That’s why you see placeholder language 

in the draft, today. My colleague, Susan Brooks is championing these efforts, and 

I’d like to yield to her for a few remarks. Mrs. Brooks. ... 

Thank you, Susan. 

While I know our focus today is on insurance reforms, we are also working in 

other areas of health care to bring relief to patients. Next week, we will take up 

legislation sponsored by Rep. Gus Bilirakis and Rep. Kurt Schrader that would 

incentivize generic drug development and increase competition in the market. And 

for those in industry who think it’s OK to corner a market, drive up prices and rip 

off consumers, know that your days are numbered. 

President Trump made it clear in the White House meeting I attended with him 

and Vice President Pence: He wants competition that will bring lower drug prices 

and that is precisely what this measure will accomplish. Patients are tired of waiting for relief. We are going to move forward in a bipartisan way to give them help. 

It’s an important step forward. And it needs to happen now. 

Specifically, the bill would require FDA to prioritize and expedite the review of 

generic applications for drug products that are currently in shortage or where there 

are few manufacturers on the market, if any. We all remember recent situations 

where bad actors jacked up the price of older, off-patent drugs because there was 

no competition. We want to make sure that doesn’t happen again. 

This bill would also increase transparency around the current generic backlog at 

FDA. While progress has been made, there are still an unacceptably high number 

of generic drug applications sitting at FDA that, if and when approved, could bring 

additional lower cost alternatives to patients. Whether it’s examples like daraprim 

or EpiPen, patients need solutions and this bipartisan bill gives us all a new tool 

to fight back on their behalf. 

Mrs. BROOKS. Thank you, Mr. Chairman. Yes, I agree. We all 

agree we have to save the individual market, yet we all know current law requires individuals to buy Government-dictated insurance. Instead, we propose giving people freedom from this mandate, it is only fair. Continuous coverage isn’t a new idea. It has 

been discussed by reputable public policy organizations like the 

economic and political freedom center at Hoover Institution, free 

enterprise-focused American Enterprise Institute and others. 

We don’t pretend that this is the only solution, but we are confident that continuous coverage provides promise. That is why it is 

part of our Better Way Plan, a fairness agenda for helping patients 

get relief. And today this placeholder provides the clearest signal 

yet that we are working with patients and healthcare groups to 

draft language that balances important health status protections 

with necessary risk mitigation tools. 

I look forward to the panelists’ expert feedback today on the 

value of how this idea might help patients get and keep health coverage, and with that I yield back. 

[The statement of Mrs. Brooks follows:] 

9 

PREPARED STATEMENT OF HON. SUSAN W. BROOKS

Thank you, Mr. Chairman. 

As we all know, current law requires individuals to buy Government-dictated insurance. Instead, we propose giving people freedom from this mandate—it’s only 

fair. 

Continuous coverage isn’t a new idea. It’s been discussed by reputable public policy organizations like the economic and political freedom-centered Hoover Institution and the free enterprise-focused American Enterprise Institute. This coverage incentive has also been contemplated in publications by Rand Corporation, Urban Institute, and others. 

We don’t pretend that this is the only solution. But we’re confident that continuous coverage provides promise. This is why it’s part of our Better Way plan—our 

fairness agenda for helping patients get relief. And today, this placeholder provides 

the clearest signal yet that we’re working with patients and healthcare groups to 

draft language that balances important health status protections with necessary 

risk mitigation tools. 

I look forward to the panelists’ expert feedback on the value of how this idea may 

help patients get—and keep—health coverage. 

Mr. WALDEN. Mr. Chairman, if I could just conclude. While I 

know our focus today is on insurance reforms, we are also working 

in other areas of health care to bring relief to patients. Next week 

we will take up legislation sponsored by Representatives Bilirakis 

and Schrader, bipartisan bill that would incentivize generic drug 

development and increased competition in the market. 

And for those in the industry who think it is OK to corner a market and drive up prices and rip off consumers, know that your days 

are numbered. President Trump made it clear in the White House 

meeting I attended with him and Vice President Pence, he wants 

competition that will bring lower drug prices and that is precisely 

what this measure will help accomplish. 

Patients are tired of waiting for relief. We are going to move forward in a bipartisan way to give them help. It is an important first 

step. It needs to happen now. Specifically, the bill would require 

FDA to prioritize and expedite the review of generic applications 

for drug products that are currently in shortage or where there are 

few manufacturers on the market. 

We all remember recent situations where bad actors jacked up 

the price of older, off-patent drugs because there was no competition. We want to make sure that does not happen again. This bill 

would also increase transparency around the current generic backlog at FDA, and while progress has been made there are still an 

unacceptably high number of generic drug applications sitting at 

the Food and Drug Administration that if and when approved could 

bring additional lower cost alternatives to patients. 

Whether it is examples like Daraprim or EpiPen, patients need 

solutions. I believe this bipartisan bill gives us a new tool to fight 

back on their behalf. I thank you for the indulgence of the committee and I yield back the balance of my time. 

Mr. BURGESS. The Chair thanks the gentleman. The Chair recognizes the gentleman from New Jersey, Mr. Pallone, 5 minutes for 

an opening statement, please. 

10 

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. Thank you, Mr. Chairman. I am trying not to blow 

up here today because I like Chairman Walden, he is a nice guy. 

I like the gentlewoman from Indiana, she is a lovely woman. But 

I just, the statements that are coming out from the two of you 

about what you think you are doing versus what is really happening here are very disturbing to me. 

No one has a problem with making improvements to the ACA, 

but you are not seeking to make improvements. You are seeking 

to repeal it without saying how you are going to replace it. And, 

you know, you can do a little, you know, if you really wanted to 

make some changes and do some things without repealing it, you 

know, we would be fine to work together, but there is no suggestion 

of that. And the idea that this is collapsing of its own weight is 

simply not true. 

The reason that the ACA is going to have problems here is because you and the President are purposely, in my opinion, making 

it collapse because of the policies that you are espousing. You 

know, the best example of that was when the White House last 

week announced that they weren’t going to do anymore promotion. 

They were going to pull the ads, so that people wouldn’t even be 

able to sign up or wouldn’t even know what they were signing up 

for. 

So, you know, don’t suggest to me that somehow this is going to 

collapse because of the bill, because of the ACA. It is going to collapse because of purposeful Republican policies. And, you know, the 

gentleman from Indiana mentioned the individual mandate. You 

know that without the individual mandate that the younger and 

healthier people are not going to sign up, and then the insurance 

pool becomes broken and then the insurance companies pull out 

and gradually the ACA collapses, again if you eliminate the individual mandate. 

So I just have to say, you know, Republicans have been rooting 

for the demise of the Affordable Care Act for 7 years, actively trying to sabotage the law. They have done this under the guise of 

having a better way, but today it is clear that this was never the 

case. Now that the time has come for them to actually show the 

public this better way they are in complete disarray and today it 

is clear that Republicans have no plan to replace the ACA. Every 

day their timeline changes and all they have successfully done so 

far is create chaos and uncertainty among patients and insurance 

companies. Chaos here with the ACA, chaos with immigration, 

chaos with foreign policy, the list goes on from this badly motivated 

person, in my opinion, who is in the White House. 

The bills we are discussing today are supposedly the first pieces 

of the Republicans’ elusive plan, so essentially, after a 7-year 

smear campaign on the ACA, they intend to move forward three 

bills from last Congress that help insurance companies instead of 

people. 

And another bill, the only so-called replacement, is literally halfwritten. You know, I had to laugh—again I love you, Dr. Burgess, 

but I had to laugh when you said that the ACA was hastily built 

11 

upon. I mean, the chairman’s bill literally runs off the page. I 

mean, I took it this morning and I started to read it, and then I 

got to ‘‘Title II 09 Continuous Coverage,’’ it says, ‘‘incentive 

[placeholder].’’ Talk about hastily built, what is this, half-built? I 

mean, I just, I don’t even know where to begin. 

[The statement of Mr. Pallone follows:] 

PREPARED STATEMENT OF HON. FRANK PALLONE, JR. 

Since 1965, the Medicaid program has been an invaluable resource to poor families, pregnant women, children, seniors, and now, thanks to the Affordable Care Act, 

low-income working adults. It is also the program that individuals with disabilities 

depend on to maintain independence in the community. 

In 2016, over 97 million Americans depended on Medicaid at some point during 

the year. Together, Medicaid and CHIP cover 1 in 3 children in this country, and 

nearly half of all births. It is undeniable that Medicaid coverage pays us back as 

a society tenfold—that’s why improving and strengthening Medicaid for generations 

to come continues to be one of my primary goals. 

Last Congress, this committee worked together on targeted policies that genuinely 

strengthened and improved the Medicaid program for beneficiaries. Unfortunately, 

the bills before us today do not share these priorities. In fact, one piece of legislation 

continues the Trump administration’s assault against our legal permanent resident 

population and naturalized citizens. 

The Republican strategy to strengthen Medicaid is to remove or exclude certain 

people from the program and then apply those resources to another person. This is 

a meaningless approach to resource management. There is no evidence to suggest 

that some beneficiaries take away resources from others, or that excluding some 

beneficiaries will benefit others. 

In today’s hearing we will discuss three bills that are based on this very falsehood, bills that target specific beneficiaries for exclusion. Bills that ultimately 

incentivize and reward those States that choose to operate waiting lists for Home 

and Community Based Services. 

In order to truly strengthen the Medicaid program, we should expand coverage, 

protect against fraud, and implement advanced delivery system reform. The Affordable Care Act did just that. Thanks to the Affordable Care Act, 31 States and the 

District of Columbia have adopted expansion and dramatically lowered the uninsured rate. All 50 States are testing innovative models of care, and Medicaid eligibility and data collection systems have been modernized. 

Medicaid has always been under attack by Republicans, but the threat to this program and to its beneficiaries is more dangerous than ever before. Republican policies to cap or turn the program into a block grant would result in the rug being 

pulled out from under millions of children, elderly, individuals with disabilities and 

low-income working adults. These policies are nothing but bad for our providers and 

our State economies. In fact, one analysis by the Kaiser Family Foundation found 

that block granting Medicaid would lead States to drop between 14.3 million and 

20.5 million people from Medicaid, an enrollment decline of 25 to 35 percent, and 

would lead States to cut provider reimbursements by more than 30 percent. 

Republicans keep saying that they have a plan—and that Americans will not lose 

their health coverage. It’s clear today, that the Republicans only game plan right 

now is to sabotage health coverage for tens of millions of Americans. 

I yield back. 

Mr. PALLONE. I am going to stop, because I have to give some 

time to Congressman Kennedy and then, if there is also time, to 

Representative Castor, so I will yield to the gentleman from Massachusetts initially. 

Mr. KENNEDY. Thank you, and I thank the ranking member. I 

want to thank Chairman Burgess and Ranking Member Green for 

their leadership as we confront one of the most contentious debates 

this body will address in the coming year. All of us in the subcommittee can agree that there is room for improvement in our 

healthcare system from premium deductibles that should be lower, 

12 

insurance options in rural and underserved areas that must be increased. 

But there are also areas where the law is working well. In Massachusetts we have a 2.8 percent unemployment rate and a 2.8 percent uninsured rate. On this side of the dais we are happy to have 

the debate about fixing the Affordable Care Act, but repealing the 

ACA without a replacement, and the four half measures today before us are not a replacement, will only exacerbate those problems. 

More than that it will erode the very minor progress that we have 

made to reform our mental healthcare system in this very room 

last year with 21st Century Cures. 

For the roughly 43 million Americans suffering from mental illness, parity laws that currently guarantee coverage will crumble. 

For the 30 percent of patients with a mental health issue that is 

covered by the Medicaid expansion treatment will no longer be 

within reach. For constituents in all of our districts, red or blue, 

rural and urban, preventive screenings for behavioral health that 

can save lives will be unaffordable and inaccessible. Simply put, no 

matter where you live if you have coverage or you are uninsured, 

you are on an uncertain path that will lead to seismic, tragic shifts 

in our behavioral healthcare system. Today is an opportunity for all 

of our colleagues to commit to changing course. I yield back. 

Mr. PALLONE. Mr. Chairman, Mr. Walden had like an extra 

minute and a half, and I would like Ms. Castor to have a minute 

if possible. I would ask unanimous consent. 

Mr. BURGESS. Are you asking a unanimous consent request? So 

ordered. 

Ms. CASTOR. Well, thank you very much. Members, the fear 

across America is widespread about the Republican plan to withdraw this lifeline that is the Affordable Care Act. I wanted to tell 

you about a woman who approached me recently back in Tampa. 

Sixty-year-old Kathy Palmer is a single parent with a student in 

high school. She is doing everything right. She is working part-time 

at a small company. She is working towards her bachelor’s degree 

in accounting. She is paying her fair share in taxes. 

She took personal responsibility—because her company is so 

small and doesn’t provide health insurance—she took personal responsibility and went shopping out on healthcare.gov, and in our 

very robust market, far from collapsing in the Tampa Bay area, 

where we have 61 plans to choose from, she chose a plan and she 

has been paying her premiums. 

And thank goodness for that, because in December she wound up 

in the hospital with what she thought was a heart attack. When 

she got out of the hospital that bill for all the care she received was 

$70,000. Without the Affordable Care Act, she would be bankrupt. 

Her future and probably her child’s future would have been very 

bleak. 

So I ask my Republican colleagues to listen to our constituents 

all across this country. Before you go and do the damage of repealing the Affordable Care Act, understand what it will mean for the 

families that we represent and their economic futures. I yield back. 

Mr. BURGESS. Does the gentleman from New Jersey yield back? 

Mr. PALLONE. Yes, Mr. Chairman. 

13 

Mr. BURGESS. The Chair thanks the gentleman. The gentleman 

yields back. We now conclude with Member opening statements. 

The Chair would remind Members that, pursuant to committee 

rules, all Members’ opening statements will be made part of the 

record. We want to thank our witnesses for being here today, for 

taking time to testify before the subcommittee. Each witness will 

have the opportunity to give an opening statement followed by 

questions from our Members. 

We are pleased today to welcome Dr. Doug Holtz-Eakin, no 

stranger to this committee room, president of the American Action 

Forum; Mr. J.P. Wieske, deputy commissioner for insurance for the 

State of Wisconsin; and Dr. Leonard Lichtenfeld, deputy chief medical officer for the American Cancer Society. 

We appreciate each of you being here today. We will begin our 

panel with Dr. Holtz-Eakin, and you are recognized 5 minutes for 

the purpose of an opening statement. 

Mr. KENNEDY. Mr. Chairman, just before we begin the statements, I would like to raise a parliamentary inquiry. 

Mr. BURGESS. The gentleman from Massachusetts, for what purpose does the gentleman from Massachusetts seek recognition? 

Mr. KENNEDY. Mr. Chairman, I ask a parliamentary inquiry to 

try to understand from you, sir, given some of the hearing—— 

Mr. BURGESS. The gentleman will state his parliamentary inquiry. 

Mr. KENNEDY. I would like assurance, Mr. Chairman, given what 

we have learned in the past several days about coordination between various House staffers and the administration and transition 

team and the signing of nondisclosure agreements—— 

Mr. BURGESS. The gentleman—— 

Mr. KENNEDY. Would like to understand if such agreements—— 

Mr. BURGESS. The gentleman has actually not stated a parliamentary inquiry, but I do want to accommodate your request. 

We are here of course to take testimony on bills before the committee. I think that can proceed, and I will defer to the chairman 

of the full committee for a discussion with you on your parliamentary inquiry. 

The gentleman, Dr. Holtz-Eakin, is recognized for 5 minutes for 

an opening statement, please. 

Mr. KENNEDY. So Mr. Chairman, when—I appreciate your deference to the full committee chairman as to what is going to happen next. What, just so I understand given as you did indicate the 

challenge of hastily built—— 

Mr. BURGESS. The gentleman did not state a parliamentary inquiry. 

Mr. KENNEDY. And so my question about—— 

Mr. PALLONE. He didn’t finish his sentence. 

Mr. KENNEDY [continuing]. The existence of nondisclosure agreements is unanswered, so it is unanswered. 

Mr. BURGESS. The gentleman, Mr. Holtz-Eakin, is recognized 5 

minutes for the purpose of summarizing your opening statement. 

Mr. GRIFFITH. Mr. Chairman. Mr. Chairman, parliamentary inquiry. 

Mr. BURGESS. For what purpose does the gentleman from Virginia seek recognition? 

14 

Mr. GRIFFITH. Mr. Chairman, I inquire that if a Member asks a 

question that is not a parliamentary inquiry, is it not improper for 

the chairman to answer? 

Mr. BURGESS. Yes. 

Mr. GRIFFITH. So then you would actually be out of order if you 

attempted to answer Mr. Kennedy’s question. Am I not correct? 

Mr. BURGESS. Yes. 

Mr. GRIFFITH. I yield. 

Mr. PALLONE. Mr. Chairman. 

Mr. BURGESS. For what purpose does the gentleman from New 

Jersey seek—— 

Mr. PALLONE. I just, I am not sure I understood what you were 

saying. You are saying you are going to get back to us about—I understand you are saying it is not a parliamentary inquiry, but did 

you say you are going to get back to Mr. Kennedy and respond to 

his question, or that Chairman Walden would? Is that what you 

said? 

Mr. BURGESS. Well, the parliamentary inquiry was not about the 

proceeding with today’s hearing on taking testimony from witnesses on the bill in front of us. I do respect the gentleman from 

Massachusetts a great deal, as he knows, and I do want to see his 

question answered for him, and I will seek the proper forum with 

the chairman of the full committee for him to do so. 

Mr. PALLONE. So you will get back to us to respond to his question. 

Mr. BURGESS. We will seek the appropriate forum. 

The gentleman, Dr. Holtz-Eakin is recognized. 

Mr. BUTTERFIELD. Mr. Chairman. Mr. Chairman. 

Mr. BURGESS. For what purpose does the gentleman from North 

Carolina seek recognition? 

Mr. BUTTERFIELD. I have a unanimous consent request. 

Mr. BURGESS. The gentleman will state his unanimous consent 

request. 

Mr. BUTTERFIELD. I would ask unanimous consent that the gentleman from Massachusetts be allowed to restate his parliamentary 

inquiry because I did not hear it. He was interrupted in the middle 

of the sentence. 

Mr. GRIFFITH. I object. 

Mr. BURGESS. Objection is heard. 

The Chair yields 5 minutes to Dr. Holtz-Eakin for the purpose 

of summarizing your opening statement. 

STATEMENTS OF DOUGLAS HOLTZ-EAKIN, PH.D., PRESIDENT, 

AMERICAN ACTION FORUM; J.P. WIESKE, DEPUTY COMMISSIONER, WISCONSIN OFFICE OF THE COMMISSIONER OF INSURANCE; AND J. LEONARD LICHTENFELD, M.D., DEPUTY 

CHIEF MEDICAL OFFICER, AMERICAN CANCER SOCIETY 

STATEMENT OF DOUGLAS HOLTZ-EAKIN 

Dr. HOLTZ-EAKIN. Thank you. Mr. Chairman, Ranking Member 

Green, members of the committee, I appreciate the chance to be 

here today to discuss these proposals to stabilize the ACA individual market. I am going to make three simple points. Point number one is that doing nothing is not an option. Under current law 

15 

the trend in the individual market is quite bad in terms of premiums rising, insurers exiting and coverage ultimately declining. 

Second is that the proposals under consideration, reforms to 

grace periods, special enrollment periods, the age rating bands and 

continuous coverage provisions are all sensible policy that I would 

hope would garner bipartisan support. And then third that if indeed these measures were enacted there would still be much work 

left to do; that that would not be enough to stabilize them. Let me 

elaborate on each and then I look forward to your questions. 

Under current law the exchanges are headed in the wrong direction. In 2017, the benchmark Silver Plans rose at an average rate 

of 27 percent coming on the heels of ten percent rises in 2016, so 

the insurance is becoming increasingly expensive. As was noted by 

Mr. Walden, in five States and in one-third of U.S. counties there 

is only one insurer that is a choice for those participating in this 

market. 

Seventeen of 23 co-ops have failed and the insurance that is out 

there is not really equivalent to affordable care. Eighty-four percent of participants require taxpayer assistance to purchase these 

policies and when they do they face family deductibles that are 

about average $7,400 in the Silver Plans, average $12,300 in the 

Bronze Plans, which means in many cases they are never getting 

to the point where the insurance is paying anything even after they 

have purchased it. My expectation is that if current law were unchanged and things were left on autopilot we would see exchange 

enrollments decline, decline substantially perhaps as low as eight 

million or so by 2020. 

Clearly something needs to be done. In each case these measures 

would tend to improve the risk pools, lower the premiums and thus 

attract people in and stabilize the markets in that fashion. Grace 

periods in the Affordable Care Act are 90 days. In all but two 

States, grace periods off the exchanges would be 30 or 31 days. 

So the playing field is not level in the individual market between 

off-exchange and on-exchange products. These long grace periods 

raise the prospect of an individual paying for 9 months and actually consuming a full year’s worth of healthcare coverage. That 

leads to obvious problems for insurers and the costs have to be 

shifted. 

In some cases they will be shifted to the taxpayer and in some 

cases they will be shifted to other customers in the form of higher 

premiums and thus exacerbating the upward pressure on premiums. And in some cases insurers will be obligated to pay only 

1 month of those costs and 2 months will be shifted to providers 

who will no longer want to participate in providing care to the people who need it in these markets. Moving the grace periods to 

match those off the exchange would be a very sensible way to take 

those pressures off. 

For the special enrollment periods the ACA has 30 conditions in 

which individuals can enroll. By comparison, Medicare has seven 

and HIPAA provides for three. These special enrollment periods 

are a way for high cost patients, and all the evidence which is in 

my testimony suggests they are higher cost than the other enrollees, to enter into the market. Again insurers have to jack up premiums in anticipation of this and the result is that a large number, 

16 

perhaps as many as a third of the participants in the individual 

market, have entered using this mechanism. Tightening them up 

would be a sensible way to stabilize the market and take pressure 

off premiums. 

The age ratings are 3:1. This relatively raises the cost of insurance for the young and healthy that is a group that has under-enrolled in the ACA exchanges. Getting them in is a key part of stabilizing it. Moving to 5:1 would match the data that is the ratio in 

costs and be a sensible thing for the committee to consider. 

And then lastly is the proposal for continuous coverage. Here I 

think it is simply the case that the individual mandate is not working as envisioned. There are about six and half million people in 

2015 who simply paid the penalty. There are another 12.7 who are 

simply exempt. The continuous coverage provision would be a way 

to encourage the young to enter the market at the age of 26, buy 

coverage, remain covered, and because they remain covered they 

can never be medically underwritten and charged a special premium because of a preexisting condition. It is a way to stabilize the 

pools and to ensure that they do not continue to deteriorate. 

So I thank the committee for the chance to be hear today. I think 

these are sensible ideas which would be good steps towards stabilizing the individual markets, and I look forward to answering your 

questions. 

[The statement of Dr. Holtz-Eakin follows:] 

17 


Patient Relief from Collapsing Health Markets 

U.S. House of Representatives 

Energy and Commerce Committee 

Subcommittee on Health 

Douglas Holtz-Eakin, President' 

American Action Forum 

February 2, 2017 

'The views expressed here are my own and not those of the American Action Forum. I thank 

Juliana Darrow, Tara O'Neill Hayes, and Christopher Holt for their assistance. 
18 


Chairman Burgess, Ranking Member Green, and members of the Subcommittee, thank you 

for the opportunity to testify today regarding ways in which policymakers may provide 

relief to participants in the Affordable Care Act's (ACA) collapsing health insurance 

markets. 

The individual market is in dire need of improvement. Exchange enrollment is low, 

premiums are rising and insurers are leaving the market. However, actions can be taken to 

stabilize and even improve the individual marketplace until a replacement plan is fully 

implemented. There are several simple changes that, if enacted, will provide relief to both 

consumers and insurers. As I have previously testified, these common-sense improvements 

to the current law should have bipartisan support. 

In this testimony, I hope to convey three main points: 

1. Given current law, doing nothing is not an option. The ACA is in a downward spiral. 

Prices will continue to rise and insurers will continue to leave unless significant changes 

are made. 

2. These reforms are good policy regardless of the performance of the markets or the 

political climate. They should receive bipartisan support. 

3. While these changes will certainly help, they will not be enough to produce a vibrant 

individual market. More will need be done to stabilize the market until a replacement plan 

can be fully implemented. 

Let me consider the reforms in turn. 

Grace Periods 

Under the Affordable Care Act (ACA), customers buying subsidized insurance coverage on 

the Exchanges are given a 90-day grace period during which insurers must continue 

offering coverage even if premiums are not paid. This means that consumers on the 

Exchange can receive coverage for twelve months while only paying for nine. Individuals 

can easily take advantage of this provision by not paying premiums but continuing to use 

care. Insurers are not allowed to cancel coverage even if the individual continues using 

medical care for 90 days. 1 This creates an uneven playing field for both insurers and tax 

payers because grace periods are often much shorter in the individual market off the 

Exchange. As of 2012, all but two states had grace period requirements of30 or 31 days for 

plans offered in the individual market.2 

Additionally, nonpayment does not prevent future insurance coverage. Health insurance 

companies cannot refuse enrollees that have had plans cancelled due to failure to make 

previous payments, or use premiums paid for new coverage to cover outstanding debt.3 A 

McKinsey study found that 21 percent of Exchange plan enrollees in 2015 stopped paying 

for coverage at some point during the year. In 2016, half of those individuals ( 49 percent) 

repurchased the same plan they had stopped paying for the year before; two thirds (67 
19 


percent) of those same individuals had also stopped paying for coverage at some point 

during the 2014 plan year.4 

Insurance companies are financially responsible for claims incurred only during the first 

month of missed premium payments, meaning that doctors are at risk of not being paid for 

care consumed at their offices for the last 60 days of a grace period. Plans on the Exchange 

have 34 percent fewer providers than commercial plans offered off the Exchange. 5 The risk 

of not being paid for up to two months may be contributing to this phenomenon. 

When setting yearly premiums, insurers, and providers both must take the potential of 

nonpayment into account and therefore raise prices for everyone. These increased 

premiums are also passed on to the taxpayers who are responsible for subsidizing the cost 

of 84 percent of individuals purchasing insurance through the Exchange.6 Aligning grace 

periods on and off the Exchange will level the playing field among consumers, and reducing 

the 90-day grace period could significantly diminish the risk oflosses for insurers and 

providers. This would help stabilize the insurance market and decrease costs for all 

consumers and taxpayers. 

Special Enrollment Periods 

The ACA has allowed for over 30 circumstances in which an individual may enroll in an 

Exchange plan through a Special Enrollment Period (SEP). 7 Medicare allows just seven of 

these instances, while the Health Insurance Portability and Accountability Act {HIPAA) 

requires three.8 Many individuals shopping for coverage on the Exchange take advantage of 

the ability to sign up for coverage throughout a plan year. Analysis by America's Health 

Insurance Plans (AHIP) shows that in the first two years of market place enrollment, up to 

one third of enrollees gained coverage through special enrollment periods.9 Between 

February and june of 2015 nearly 950,000 people signed up for coverage through SEPs on 

healthcare.gov.10 The abundance of qualifying circumstances and the lack of a robust SEP 

eligibility verification process undermines the business model that insurers rely on and 

destabilizes the market. Too much SEP flexibility can cause individuals to wait until they 

are sick to enroll in coverage; this would be like waiting for your house to catch fire before 

buying homeowners insurance. 

Multiple large insurers have tabulated statistics and expressed concerns about the misuse 

of SEPs. Individuals enrolling through SEPs had health care costs 24 percent higher than 

individuals who enrolled during open enrollment in the first three months of coverage in 

2014. 11 Data from Covered California shows that cost differences between customers who 

enroll through SEPs were 15 percent to 50 percent higher than those who enrolled during 

open enrollment in the four largest state plans.12 UnitedHealth reports that more than 20 

percent of its marketplace customers did not sign up during open enrollment and that 

those customers use 20 percent more health care.13 Blue Cross Blue Shield Association 

calculates that exchange customers using SEPs are 55 percent more expensive than the 

enrollees who are covered through open enrollment.14 
20 


Individuals who enroll in coverage during SEPs are also more likely to drop coverage. 

Anthem reports that enrollees who use SEPs are more than twice as likely to drop coverage 

after a short period of time. Aetna reports that SEP enrollees stay on a plan for less than 

four months, on average, while enrollees who sign up during open enrollment maintain 

coverage for an average of eight to nine months. 15 

Instituting a formal process requiring documentation for eligibility verification will help to 

reduce the number of individuals taking advantage of the current enrollment system. 

Requiring eligibility to be verified prior to coverage becoming effective would reduce the 

number of fraudulent claims. To protect individuals who are eligible and in need of urgent 

care, coverage could be made retroactive to the day of application, once eligibility was 

confirmed. Congress should also be informed of the number of individuals who attempt to 

enroll during an SEP but are unable to do so. Information on whether enrollment was not 

permitted because the individual did not submit necessary documentation or because the 

documentation was invalid should also be provided. This will allow policymakers to make 

more informed decisions on needed policy changes. 

Age Rating Bands 

The ACA only allows for a 3:1 difference in premiums between the youngest and oldest 

individuals in an insurance pool. However, average health care expenses for a 64 year old 

are 4.8 times greater than that of a 21 year old.16 Because this 3:1 rating does not reflect 

the actual difference in health care costs between the young and the elderly, it artificially 

inflates premiums for younger and healthier individuals forcing them to further subsidize 

coverage of older and typically sicker individuals. 

These high premiums have caused low enrollment of young adults on the Exchange. In 

2016, 3.5 million young adults (18-34) enrolled in Exchange plans. This represented only 

28 percent of enrollees even though this age group was anticipated to make up around 40 

percent of the enrollee population.17 According to US Census data, the uninsured rate for 

those aged 19-34 is 4.6 percent higher than the uninsured rate for those aged 35-64. 18 

Increased enrollment among young adults would contribute to market stability by infusing 

the risk pool with more low-risk individuals. Adjusting the age rating limit to allow 

premiums to reflect the pre-ACA average cost difference of 5:1 would reduce premiums 

and remove some of the financial disincentive preventing younger people from purchasing 

insurance. This is a standard provision across ACA replacement plans, because better 

aligning premiums with costs is the only way to allow insurance to work without excessive 

regulations. 

Continuous Coverage 

Continuous coverage provisions are a standard feature of many ACA replacement plans. 

This type of policy serves as an alternative to the individual mandate. In addition to the 

intrusion on individual liberty, the individual mandate has proved to be less effective than 

expected. Many individuals, particularly the younger, healthier individuals just discussed, 
21 


choose to forego insurance, and pay the associated penalty instead of purchasing coverage 

they do not want or need. Preliminary Internal Revenue Service reports state that 6.5 

million people paid the penalty for not having coverage in 2015. An additional12.7 million 

people were exempted from the mandate.19 Based on calculations made from 

Congressional Budget Office projections, MF estimates that 2.7 million people were 

expected to pay the penalty in 2015.20 This large difference in reality compared to 

projections suggests that the individual mandate is a flawed and ineffective mechanism for 

ensuring insurance coverage for Americans. 

The continuous coverage model, on the other hand, incentivizes individuals to purchase 

coverage without taxing those who choose to go without. Under such a policy, any 

individual who remains continuously covered would be permanently protected against 

medical underwriting in which insurers set premiums based on one's health status. This 

incentivizes both healthy and unhealthy individuals to enroll and maintain coverage. 

People with pre-existing conditions who were already insured would simply have to 

maintain coverage to benefit from these protections. Everyone who is currently uninsured, 

whether having a pre-existing condition or not, would be provided a one-time open 

enrollment period to gain coverage so they, too, could receive the benefit. This protection 

would especially incentivize young individuals to buy insurance because they would be 

guaranteed relatively low premiums throughout their lifetime. Again, bringing these 

individuals into the market would greatly stabilize the insurance risk pool, which would 

allow insurers to compete for these new market entrants by providing policies with lower 

premiums and greater benefits. Continuous coverage requirements would also incentivize 

insurers to invest in preventive and wellness services that will keep their consumers 

healthy and their costs down as they age. 

Conclusion 

Substantial reform is imperative to ensure a successful health insurance market, but in the 

meantime, enacting legislation that resolves at least some of the problems in the short term 

is essential. The changes discussed here today, while necessary, will not fix everything. 

Additional financial resources will also be needed to both keep insurers in the individual 

market and the millions of individuals relying upon them for coverage. 
22 


Notes 

1 https://www.healthcare.gov/apply·and·enroll/health-insurance-grace-period/ 

2 State Laws Requiring Grace Periods for Premium Payments. Rep. Washington, D.C: America's Health Insurance Plans, 2012. Print. 

3 https://www.healthcare.gov/app!y-and-enroH/health-insurance-grace-period/ 

4http://healthcare.mckinsey.com/sltes/default/files/McK%202016%200EP%20Consumer%20SurveV0..6201nfographic vF.pdf 

s http://avalere.com/expertlse/managed-care/inslghts/exchange-plans-indude-34-percent-fewer-providers-than-the-average-for-comm 

6 https://www.cms.gov/Newsroom/MediaRe!easeDatabase/Fact-sheets/2016-FacHheets·items/2016-1D-19.html 

1 https://ahip.org/wp-content/uploads/2016/03/AHIP~BCBSA~SEP~Analysis·Febl6.pdf 

8 https://www.americanactionforum.org/testimony/common~sense·solutions·improve-affordable-care-act-s!mple-changes-can-go-!ongway/# edn3 

9 https://ahlp.org/wp-content/up!oads/2016/03/AHIP-BCBSA-SEP-Analysis-Febl6.pdf 

10 https://www.nytimes.com/2016/01/10/us/polttig{insurers-say-costs·are-c!imbing-as-more-enro!!-past-hea!th-act-deadline.html? r=l 

11 https://ahip.org/wp-content/uploads/2016/03/AHIP-BCBSA-SEP-Analysis-Feb16.pdf 

12 http://board.coveredca.com/meetings/2016/2-18/PPT-Covered%20Californla%20SEP%20Pollcy.pdf 

13 https://www.nvtimes.com/2016/01/10/us/polltics/insurers~say-costs-are-clfmbing-as-more-enrgU-past-health~act-deadline.html? r-1 

14 http://www.politico.com/storv/2016/01/gaming-obamacare-insurance-health-care-217598 

15 https:/lwww.nvtlmes.com/2016/01/10/us/politics/insurers-say-costs-are-cllmbing-as-more-enroU-past·health-act-deadline.html? r=l 

16 https://www.americanactionforum.org/insight/age-bands-affordable-care-act/ 17 https:/laspe.hhs.gov/sites/default/ftles/pdf/187866/Finalenrollment2016.pdf 

111 http://www2.census.gov/programs-survevs/demo/tables/p60/257/table2.pdf 

19 https://www.irs.gov/pub/newsroom/commissionertetteracafilingseason.pdf 

20 AAF projection is based on the total amount of expected revenue from payment of penalties in 2015 divided by 2 percent of the national 

median-income that year, as the penalty in 2015 was either $325 or 2 percent of income, whichever was greater. Thus, this is a low estimate of 

the number of individuals who were expected to pay the penalty in 2015. 
23 

Mr. BURGESS. The Chair thanks the gentleman. Mr. Wieske, you 

are recognized 5 minutes to summarize your opening statement, 

please. 

STATEMENT OF J.P. WIESKE 

Mr. WIESKE. Thank you, Chairman, and thank you, Ranking 

Member. I appreciate the time and the effort in discussing this important issue. As you know, as a regulator in the State of Wisconsin we have been on the front lines of having to deal with the 

issues surrounding the implementation of Obamacare. It has been 

frustrating to hear consistently that the folks don’t seem to understand that States have an important role here and that States do 

have existing laws in place that have protected their consumers. 

I would like to just kind of flash back before the ACA and talk 

a little bit about the Wisconsin insurance market before the ACA, 

what happened with the ACA, and what we hope to see in the future. In short, prior to the ACA Wisconsin had an excellent uninsured rating and we continue to do so in Wisconsin. We could rate 

consistently in the top six for the least number of uninsured. We 

still rank in the top six for the number of uninsured in the last report. 

Wisconsin covered its folks who were vulnerable and were not eligible for the private market through a high-risk pool. And I know 

there has been a lot of talk about high-risk pools across the country. Wisconsin’s high-risk pool works, worked while it existed. In 

fact, I got a call 2 weeks ago from a legislator who had constituents 

asking him to reinstate the Wisconsin high-risk pool because the 

coverage they had under Obamacare was inferior to what they had 

under the high-risk pool. 

They had numerous plan options. The coverage was obviously expensive. There is no question about that. Although if you see the 

numbers in my testimony with the Federal subsidy those rates 

went down considerably. And I think one of the most important 

features that Wisconsinites had in that high-risk pool was they 

could go to any doctor in the State. There is not a single plan in 

our exchange where you can go to any doctor in the State and get 

coverage without having really significant deductibles and having 

out-of-network costs. 

It was funded on assessments on the insurers as well as mandatory discounts for the providers, and the coverage, consumers had 

huge number of options inside that plan. And typically, I think 

what is interesting about the high-risk pools is that they stayed on 

those high-risk pools for about 3 to 4 years and once they were 

there they moved into other group coverage later, so it was a great 

gap coverage. 

I will also note that we had relatively low premiums in Wisconsin compared to, and you can see in my testimony that the rates 

went up considerably. They went up much more on the young folks 

than they went up on the older folks because of the age band and 

that has caused an abandonment by and large of the market, individual market, by a lot of the folks in the younger age bands unless 

they have medical conditions. 

It has been very expensive for coverage. The fortunate thing in 

Wisconsin is we haven’t seen the high increases. We had 16 perVerDate Mar 15 2010 10:31 Nov 08, 2018 Jkt 037690 PO 00000 Frm 00027 Fmt 6633 Sfmt 6633 I:\115THCONGRESS\115X4PATIENTRELIEFASKOK101718\115X4PATIENTRELIEFWORK
24 

cent increases this last year. We still have 15 insurers in the State 

doing business. We still have a co-op doing business and that is in 

part because we recognize that our job as a regulator is to minimize the consumer disruption. However, I think one of the big 

issues going forward is if we don’t look at the transition coverage 

and if we don’t make changes going forward we are expecting to 

see the small group market start to implode and that is going to 

put folks, more folks in the individual market which is 

unaffordable And that will impact taxes. That will impact everything across the board. 

So we have serious concerns about not reforming the individual 

market impacting the small group market, not repealing 

Obamacare and ending up killing the small group market as well, 

which is on its way. About 80 percent of folks in the small group 

market are still in transition plans, so that is important to understand. 

Going forward I think it is important to understand that States 

have a number of laws on the books. We have preexisting condition 

laws in Wisconsin. We have mental health parity laws. We had the 

coverage to age 27, in fact, not 26, in the State prior to Obamacare 

passing. We did a number of consumer protections and we take 

consumer protections seriously in the State, and we do a lot of 

work and we deal with consumers directly, and we deal with insurers directly and we have discussions with insurers directly. We 

have done this for years. We have been regulating the health insurance market since the 1940s. 

And I will stop and indicate that we are ready to be here and 

help and be part of the solution as State regulators and that not 

all of these solutions need to be federally centric. Thank you. 

[The statement of Mr. Wieske follows:] 

25 


Testimony of 

Deputy Commissioner J.P. Wieske, on behalf of the 

Wisconsin Office of the Commissioner of Insurance 

Before the 

Subcommittee on Health 

U.S. House Committee on Energy and Commerce 

Regarding: 

Patient Relief from Collapsing Health Markets 

February 2, 2017 

2125 Rayburn House Office Building 
26 


EXECUTIVE SUMMARY 

The state experience with the Affordable Care Act (ACA) or Obamacare has been mixed. States 

like Wisconsin had a well-functioning market prior to the passage of the ACA. Our individual 

and small group markets were competitive allowing consumers numerous choices including coops, HMO's, not-for-profit plans as well as traditional health insurance options. 

For consumers who could not meet the underwriting requirements of private coverage, the state 

had a high-risk pool which provided relatively affordable health insurance coverage while 

offering a choice of plan designs, and provided subsidies for those with family incomes up to 

$34,000. 

The ACA has changed the Wisconsin health insurance market. Consumers have fewer choices. 

Rates have increased significantly. A number of our insurers have seen a significant loss in 

capital. Insurers have left the individual market and those that remain have reduced service areas 

and plan offerings. To make changes to their coverage, consumers must now work with the 

federal government and not with the insurer from whom they wish to purchase coverage. In the 

long run, the ACA market is not sustainable. 

It is our belief health insurance should be primarily regulated at the state level and states should 

have the ability to determine what is best for their market. What works in Wisconsin may not be 

the best solution for California or New York. A return to the states does not mean an unregulated 

health insurance market. Indeed, the ACA includes many standards that were first implemented 

at the state level. 

2 
27 


TESTIMONY 

Good morning Chairman Burgess, Ranking Member Green, and distinguished members of the 

Subcommittee on Health. My name is J.P. Wieske and I am the Deputy Commissioner of 

Insurance for the Wisconsin Office of the Commissioner oflnsurance (OCI). I have been with 

OCJ since October of2011. As part of my duties, I have been involved with a number of health 

insurance issues including serving on Wisconsin's high-risk pool board, working with our state 

legislature, and assisting with operationalizing the Affordable Care Act (ACA). In addition, I 

have been actively involved with the National Association oflnsurance Commissioners (NAIC) 

serving as chair of the Regulatory Framework Task Force, Network Adequacy Subgroup, and a 

group discussing pharmacy benefits. 

Thank you for the opportunity to testifY on the state of Wisconsin's health insurance market. 

While the Wisconsin market has been healthier than most, the ACA has caused significant harm. 

Before describing the current state of the market, it is important to understand what it looked like 

prior to the passage of the ACA. 

As a regulator, Wisconsin has been traditionally known as a state with tough but consistent rules. 

We were one of the first states with a number of market and consumer protections that eventually 

became models for the NAIC and were subsequently included as part of the ACA. These 

included independent external review, standardized applications, coverage for adult dependents, 

coverage for certain health care services associated with cancer clinical trials, guaranteed 

renewability in the individual and small group markets, and a robust review of insurer market 

conduct. Our financial review of companies has been led by highly experienced staff. In short, 

3 
28 


we ensured, and continue to ensure, that insurers in the health insurance market deal with 

consumers fairly and maintain the financial means to pay consumer claims. 

Pre-ACA, the Wisconsin market was certainly not the least expensive in the country; however, 

we typically landed in the lowest third of states. While the medical care provided in Wisconsin is 

high quality, it is not inexpensive. The medical costs in our market are relatively higher than 

other states. In fact, a U.S. Government Accountability Office (GAO) report released in the early 

2000s named eight Wisconsin cities among the 10 most expensive medical areas in the country. 

However, our competitive health insurance market ensured Wisconsin consumers paid relatively 

low rates despite the relatively high medical costs. 

Wisconsin consumers in both the individual and small group markets had a large number of 

insurers and plans to choose from. They could choose from large national companies or small 

regional insurers, a managed care plan with a narrow network or a plan with limited managed 

care and a broad network, or a for-profit company or not-for-profit company. In some areas of 

the state, consumers could choose to participate in one of Wisconsin's two pre-ACA co-ops. 

Wisconsin also had a number of other important consumer protections. Wisconsin- in fact all 

states- included guaranteed renewability requirements in their laws. Many of these laws predated the 1997 HIPAA law, and required insurers to continue to cover all individuals and groups 

at the option of the insured- regardless of their health status. It meant consumer coverage could 

not be cancelled as a result of a health condition. The small group market included guaranteed 

issue, pre-existing condition credit, and rate limits. The individual market included pre-existing 

4 
29 


condition limits, and guaranteed issue requirements for HIPAA-eligible individuals. In some 

states, it was true that individuals could be declined for private coverage due to their health 

status, but in most cases these individuals were provided with alternative coverage. 

For consumers that could not qualify for private coverage, Wisconsin had a high-risk pool called 

the Wisconsin Health Insurance Risk-Sharing Plan (HIRSP) Authority. HIRSP provided 

comprehensive coverage to consumers with the ability to choose any medical provider practicing 

in Wisconsin. It was funded by premiums from consumers, assessments on insurers, and 

contributions from medical providers. Consumers could choose from a variety of plan options, 

and for the most impoverished consumers, further subsidies were made available. The cost of 

coverage closely mirrored the cost of private coverage in the state. 

Many other issues were dealt with at the state level. Some states limited the permissible age 

bands (while not as narrowly as the age bands in the ACA which proposed a 3 to I ratio), though 

few, if any, needed to prescribe a specific curve as required by current federal rules. In the preACA market, the age curve varied from insurer to insurer, allowing consumers some advantage 

in shopping for coverage. There was very little need to create an artificial process for a special 

enrollment period especially when consumers could purchase coverage throughout the year. 

Rules were established by law or regulation and insurers were required to follow those rules or 

face significant regulatory penalties. Ultimately, all issues were dealt with more efficiently by 

not inserting an additional layer of bureaucracy through a government entity -like the federal 

exchange- interfering in the relationship between an insurer and its customer. It is ludicrous that 

a consumer should need to receive the "OK" from any federal bureaucracy to add their spouse or 

5 
30 


newborn child to their policy. This delay adds to the frustration of consumers with the ACA, as 

their insurers are forced to send their requests to the federal exchange for approval. It is the 

proper role of government to set rules, and to ensure insurers are complying not to add an 

expensive and inefficient bureaucracy. 

Overall, pre-ACA, Wisconsin had a well-functioning health insurance market that protected 

consumers, guaranteed access to affordable health insurance for the most vulnerable, and had 

significant state authority to enforce our laws. 

The ACA made a number of changes to the rules governing health insurance markets across the 

country. These "one-size-fits-all" changes have impacted rates, consumer choice, and the ability 

for a free market to operate. A one-size-fits-all approach does not work in health insurance 

policy. The ACA forced the nation to spend years and billions of taxpayer dollars trying to 

centralize health care coverage at the federal level. Federal bureaucrats dictated complex rules 

and inconsistent "sub-regulatory guidance" to state insurance commissioners, and left us in a 

difficult position to balance mounting mandates with consumer protections. Ultimately, our job 

is to serve the citizens of Wisconsin and not the federal government. 

While we did not agree with the market destabilizing approach of the ACA, when the Supreme 

Court affirmed its legality, Wisconsin operationalized the law. Wisconsin has fared better than 

most states, thanks in part to our decisions to minimize consumer harm and our efforts to protect 

a competitive health insurance market. Still, Wisconsin consumers have suffered under the ACA. 

6 
31 


In Wisconsin's individual market alone, we have seen: premiums double, plan designs dictated 

by federal bureaucrats to meet political goals rather than meet consumer needs, and loss of 

competition in the health insurance market. The unprecedented federal encroachment over a 

consumer's freedom to make decisions such as individual mandate and more recently the auto recnrollment process, which allows federal government to choose a health care plan for individuals 

if they do not choose one for themselves, sent the message that citizens cannot be trusted to take 

care of themselves. Government should never substitute its judgement for the judgement of its 

citizens. 

Healthcare is inherently personal and local. Someone from Rhinelander, Wisconsin should not 

have their health care choices dictated to them from somebody in Washington. What may work 

for Wisconsin may not work for New York and California. In the insurance market, it is not our 

job to design health plans and dictate to insurers the products they must offer. For the consumer, 

it is not our job to force individuals to spend their money on a product the federal government 

deemed appropriate as a condition of receiving a federal subsidy. Our job in government is to 

pursue solutions that remove barriers and set appropriate parameters to allow the private health 

insurance market the ability to offer affordable products designed to address a variety of 

consumer needs, based on individual circumstances. Vulnerable consumers need protections 

available from the law, but they also need to access a functioning health insurance market. 

I want to particularly note that repeal does not mean an unregulated health insurance market. It 

means a return of control back to the states to allow for a health insurance market that is 

responsive to consumer needs. It means states can design solutions to protect the vulnerable. 

7 
32 


Centralizing authority in the federal government and in exchanges has not made the markets 

better and has not improved the consumer experience as evidenced by state insurance markets 

near collapse, the loss of capital in health insurance markets, and a number of insurers looking to 

exit the individual market. 

ACA Impact on Wisconsin Health Insurance Rates 

With the enactment of the ACA came guaranteed issue, new rate bands that increased costs for 

the young and healthy, additional coverage mandates, and the elimination ofHIRSP, 

Wisconsin's high-risk pool. Wisconsin insurers were quickly faced with an uncertain influx of 

individuals with serious health conditions; 20,000 alone from HIRSP. They were also faced with 

vague regulations from the federal Department of Health and Human Services (HHS) that 

changed constantly and were not communicated consistently from HHS. The special enrollment 

period definitions were initially vague, and HHS choose not to apply the rules uniformly i.e., 

consumers using certain "magic words" received an SEP regardless of circumstances while 

others were rejected despite their status. In short, insurers wanting to continue to participate in 

the Wisconsin health insurance market ultimately had no choice but to increase rates. The net 

result was that Wisconsin consumers paid more for coverage, including those individuals who 

previously received coverage through HIRSP. 

To offset the increased risk insurers would take on under the ACA, HHS issued regulations 

creating risk adjustment, reinsurance, and risk corridor programs, i.e., the "three Rs." Each of 

these programs was to have either state components or to be managed entirely by the states. 

However, in one oftheir first acts of ignoring state concerns, HHS changed course and modified 

8 
33 


regulations to allow the federal government to take over the "three Rs" from states. 

Unfortunately for Wisconsin consumers, this change would negatively impact them as insurers 

struggled to plan for and capture their estimated risk and receive their fair share offunding from 

these programs. HHS continues to struggle to manage these programs in a way that fairly 

compensates insurers taking on a significant portion of the risk. 

Rising health care costs and adjusting to the fundamental market changes the ACA imposed both 

continue to drive up the cost of health insurance. These pressures are further exacerbated by 

uncertainty related to the risk pool, federal funding, and federal regulations that constantly 

change without significant notice. Insurers are operating in a turbulent environment and many 

are struggling to remain profitable and offer affordable coverage that meets consumer needs. 

Detailed Impact ofthe ACA on Wisconsin Health Insurance Rates 

In an effort to prepare consumers for the coming market, OCI issued a press release in 2013 to 

highlight the expected increases. The chart used in the release is below: 

Percent Increase From Pre to Post 2014, Average Per Area 

63 45.48 58.12 22.54 70.04 32.01 26.07 9.72 37.29 

9 
34 


The chart shows increases varied from a low of almost I 0 percent for a 63-year-old in Kenosha 

to almost 89 percent for a 21-year-old in La Crosse. For purposes of comparison, we used a 

$2,000 deductible plan pre- and post-ACA. Male and female rates were averaged pre-ACA. In 

many cases, the post-ACA plan had a higher deductible but we attempted to match the plan 

design as close as possible. When multiple plans were available, the rates were averaged. Below 

are the premium tables used to develop the percentages: 

21 

40 

50 

63 

Family 

21 

40 

50 

63 

Family 

252.07 

376.72 

563.70 

716.57 

355.04 

496.16 

820.09 

1,062.90 

257.02 

358.56 

556.99 

753.46 

381.28 

532.83 

880.69 

1,141.44 

Pre 1/112014 

240.85 

364.56 

579.86 

682.23 

Post 1/1/2014 

319.67 

446.74 

738.39 

957.00 

172.38 

266.39 

408.21 

466.62 

397.52 

555.53 

918.21 

1,190.08 

193.78 

282.66 

449.88 

546.25 

336.06 

469.65 

764.96 

1,001.22 

Pre-ACA, Wisconsin was able to offer a guaranteed access environment that kept private market 

coverage affordable with many insurers and plan options to choose from. Pooling the high-risk 

individuals together and managing their needs separately was a huge factor in the state's success 

in offering a competitive insurance market that was able to respond to consumer needs; both 

10 
35 


those in the private market and those in the high-risk pool. HIRSP rates were comparable to 

private market rates, with many plan options that offered deductibles ranging from $1,000 to 

$7,500, and a broad network that allowed members to choose from any medical provider in 

Wisconsin. With the implementation of the ACA, the impact on our HIRSP members-our most 

vulnerable citizens-was more pronounced. Their coverage was replaced with more expensive 

coverage, limited plan design options, and limited access to their choice of providers. 

Listed in the table below are the 2013 HlRSP rates without subsidies applied. Individuals with 

household incomes between $0 and $34,000 were eligible for both deductible discounts (not on 

the HSA-eligible plans) and premium discounts (between 15 percent- 43 percent, depending on 

income). The premiums reflected under HIRSP Federal were possible as a result of federal 

dollars sent to states as a means to transition from a pre- to post-ACA marketplace. They are 

included to demonstrate the impact federal high-risk pool block grant assistance may have on 

offering rates to high-risk pool members that are comparable to similar plan options in the 

private marketplace. 

50 535.00 474.50 310.00 

63 775.00 689.50 445.00 

' 2500 Refers to the deductible level. For more information on HlRSP visit: 

https://docs.legis.wisconsin.gov/misc/lfb/informational papers/january 2013/0053 health insurance risk sharing 

plan informational paper 53.pdf 

II 
36 


Since 2014, the market rates have continued to increase annually. The years 2015 and 2016 saw 

relatively moderate average increases of almost 3.8 percent and 8.3 percent, respectively, though 

many consumers received much higher or lower increases depending on their particular plan. 

The increase on the federal exchange in 2017 averages roughly 16 percent with a high of37 

percent and a decrease of more than 10 percent. Wisconsin's increases are likely more moderate 

than what is seen in other states due to the highly competitive nature of our market. It takes 17 

insurers to comprise an 80 percent share of the individual health insurance market. That said, the 

challenges imposed by the ACA have led to individual market exits which reduce consumer 

choice; and if continued as a trend for future years, threaten the ability of our market to prevent 

rates from reaching levels seen in other states. Wisconsin's competitive market is a saving grace 

for consumers as a means for holding down what would be even higher increases. Insurers in our 

state are fighting an uphill battle to adhere to ACA regulations and still remain viable enough to 

offer competitive products. 

The Impact of Special Enrollment Periods 

Wisconsin serves as chair of the NAIC Health Care Reform Alternatives Working Group and 

after hearing about numerous problems, we asked for feedback. What we found was extremely 

problematic. Consumers faced significant uncertainty in applying for a Special Enrollment 

Period (SEP). We were told it took weeks for consumers to get proper permission from the 

federal exchange, if they received permission at all. In other cases, the industry highlighted 

consumers were provided coverage without any documentation or proof of eligibility for an SEP. 

The rules were vague, and the exchange staff, at the time, was not properly trained. Insurers 

highlighted loss ratios exceeding 150 percent on their SEP business. Even more problematic, it 

12 
37 


was clear many consumers were using the process to receive costly medical care and then 

immediately dropping coverage. HHS acknowledged the issues and has promised to seek more 

documentation, though at this point it appears HHS will only review 50 percent of cases. 

Consumer Choice and Interfering with a Free Market Model 

So far, for plan year 2017, Wisconsin has had several insurers exit the individual market 

completely, leave the federal exchange, or reduce the number of counties they are willing to 

serve. As a result, there were over 3 7,000 individuals enrolled in a plan offered by an insurer that 

will not be available to them in 2017. These numbers may pale in comparison to other states, but 

for affected consumers the issue is serious. The HHS solution was to "auto re-enroll" these 

individuals into a new plan with a new insurer. While federal regulations indicate this can only 

occur if permitted under state law, HHS was unwilling to change course in light of several states, 

including Wisconsin, indicating the auto re-enrollment process violates several state laws. 

Wisconsin was required to issue new bulletins and requirements on insurers, and hold public 

sessions to inform the public of the problematic issue. 

Auto re-enrollment is impacting consumer choice at the market level as well. HHS is cherry 

picking which insurers will get additional business. This is interfering with a free market which 

has successfully offered affordable choice meeting consumer demand. HHS added lives to 

insurers who, in some cases, were given a leg up in growing their business and for others 

unanticipated additional lives may result in financial harm. When insurers were made aware two 

months out from the open enrollment period that several thousand lives are now anticipated in 

13 
38 


being auto-enrolled with them, they are faced with significant rating and operational 

considerations. 

A Look Ahead; Impact of Transitional Plans 

It is important to remember the volume of consumers covered under transitional plans in the 

individual and small group markets. In Wisconsin, as of December 31,2015, there were 203,587 

covered lives under transitional plans. In 2018, when these plans are no longer available, 

consumers, in particular employers, will experience rate increases as they are forced to purchase 

coverage meeting all ACA requirements. 

Conclusion 

In conclusion, Wisconsin had a strong health insurance market offering products responding to 

consumer needs prior to the ACA. Since the passage of the ACA, insurers struggle to continue to 

stay viable and offer affordable coverage to Wisconsin consumers. Rates continue to increase 

and an insurer's ability to predict risk from year to year remains difficult in light of an unstable 

federal regulatory environment where the rules keep changing without attention to the diverse 

insurance markets that exist across the country. Each state is unique. Forcing health insurance 

markets into a standardized set of federal regulations adds an unnecessary layer of complexity 

that stifles both an insurer's and state regulator's ability to be innovative and have the flexibility 

necessary to meet consumer needs. 

14 
39 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman. Dr. Lichtenfeld, you are recognized 5 minutes to summarize your opening statement, please. 

STATEMENT OF J. LEONARD LICHTENFELD 

Dr. LICHTENFELD. Thank you, Mr. Chairman and Ranking Member Green, and members of the subcommittee. My name is Len 

Lichtenfeld. I am Deputy Chief Medical Officer for the American 

Cancer Society and I appreciate having the opportunity to be with 

you today. 

I am also pleased to be here on behalf of the nearly two million 

patients and people who will be diagnosed with cancer this year 

and the over 15 million cancer survivors that are living today as 

a result of successful treatment. These Americans who are your 

constituents, for them access to comprehensive, affordable health 

insurance coverage truly is a matter of life and death. 

Mr. Chairman, we appreciate your stated support for retaining 

two very important patient protections enacted as part of the ACA, 

the preex provision that bans discrimination against people based 

on their health condition; and secondly, guaranteed issue of coverage. And we look forward to working with you on the language 

in the legislation to make sure these provisions work to do just 

that. Providing patient access to coverage is obviously meaningful, 

but only insofar as the coverage itself is affordable and provides 

enough benefits to be meaningful for someone with cancer. And 

that is certainly the lens through which we view these particular 

pieces of proposed legislation. 

Prior to 2010 the insurance coverage was defined as just about 

anything marketed and sold by the industry and often contained 

exclusions, and hidden clauses resulted in denial of claims for all 

sorts of medically needed services. Current law requires that insurance provide major health coverage. When people buy insurance, 

especially when they are required to do so either by mandate or 

continuous coverage requirements, it is important to remember 

that insurance must cover a defined set of benefits to cover those 

individuals when they do become ill. 

My written statement goes into greater detail, but in the limited 

time I have with you today I want to focus on why cancer patients 

need access to health insurance and how we can improve the system to address their needs. Research shows that individuals who 

lack health insurance coverage are less likely to get screened for 

cancer, more likely to have their cancer diagnosed at a later stage 

when the chance of survival diminishes and the treatments are certainly much more complicated. I know from my days as a practicing oncologist that it is very difficult to tell someone they have 

cancer; it is even more difficult to guide them through what is 

hopefully successful treatment. What is worse than that is being 

told by a patient they can’t afford the treatment because they lack 

health insurance coverage or because their health insurance 

doesn’t provide coverage for the oncology and cancer related services necessary for their journey. 

Individuals with cancer including cancer survivors know how important it is to maintain health coverage. And unfortunately, before 

the patient protections provided under the ACA many were unable 

40 

to obtain health insurance coverage because of the cancer diagnosis 

constituting a preexisting condition and others faced lifetime or annual limits on their coverage while others were still only able to 

purchase a health insurance coverage with limited benefits that 

provide inadequate reimbursement when they needed it most. 

Individuals with cancer want and need continuous access to comprehensive health insurance coverage. Unfortunately, the realities 

of life sometimes interfere with this goal. We have made great 

strides in cancer treatments over the years, but unfortunately 

many treatments still result in unimaginable fatigue and other 

symptoms that can be very debilitating such that the individual is 

unable to work. 

Research suggests that between 40 and 65 percent of cancer patients stop working while receiving cancer treatment with absence 

from work that ranges from 45 days to 6 months depending on the 

treatment, and sometimes these folks lose their jobs and their affordable employer-sponsored coverage. 

Imagine a diagnosis with cancer and undergoing treatments that 

make work impossible, repeated absences result in a loss of your 

livelihood, you have no income, yet you had a terrible disease and 

you need to get coverage for that illness. Cancer treatments have 

left you physically unable to even look for a new job. This is not 

only a hypothetical it is very real, and everyone in this room knows 

patients with cancer who have gone through such experience. 

So as you contemplate changes to the healthcare market, we 

urge you to give great consideration to how the various policies 

under consideration intersect and how an individual with cancer 

would be impacted. We are not saying the current market is perfect, more needs to be done to ensure affordability, but affordability 

cannot be judged on premium alone. We need to also consider outof-pocket costs and the value of the benefits provided. Catastrophic 

plans will have lower premiums, but few cancer patients will be 

able to afford the deductibles, co-pays and other out-of-pocket costs 

associated with oncology treatment. 

In closing, I appreciate the opportunity to share our views from 

the American Cancer Society on how the healthcare system needs 

to ensure that individuals with cancer have access to the products 

and services necessary for their treatment, and I am glad to answer any questions from the committee. Thank you very much. 

[The statement of Dr. Lichtenfeld follows:] 

41 


American Cancer Society 

Cancer Action Network 

555 ll'h Street, NW 

Suite 300 

Washington, DC 20004 

202.661.5700 

www.acscan.org 

Statement of J. Leonard Lichtenfeld, M.D. 

Deputy Chief Medical Officer 

American Cancer Society 

"Patient Relief from Collapsing Health Markets" 

United States House of Representatives 

Committee on Energy and Commerce 

Subcommittee on Health 

February 2, 2017 
42 


Chairman Michael Burgess, Ranking Member Green, and other members of the Subcommittee: 

1 am Dr. Len Lichtenfeld, Deputy Chief Medical Office for the American Cancer Society. On 

behalf of the Society, thank you for the opportunity to testify today. ACS is a nationwide, 

community-based voluntary health organization dedicated to eliminating cancer as a major 

health problem by preventing the disease, saving lives, and diminishing suffering through 

research, education, advocacy, and service. The Society, operating through its national office 

and 11 geographic divisions throughout the United States throughout the United States, is the 

largest voluntary health organization in the United States. 

In the United States there are more than 1.6 million Americans who will be diagnosed with 

cancer this year. 1 An additionallS.S million Americans living today have a history of cancer.2 

For these Americans- many of your own constituents access to affordable health insurance is 

a matter of life or death. Research from the American Cancer Society has shown that uninsured 

Americans are less likely to get screened for cancer and thus are more likely to have their 

cancer diagnosed at an advanced stage when survival is less likely and the cost of care more 

expensive.3 

Yet for many years, a cancer diagnosis made it nearly impossible to get or keep insurance. 

Before the Affordable Care Act was passed into law, millions of cancer patients found 

themselves unable to purchase insurance because of their pre-existing condition. Even those 

who were able to obtain coverage often found that annual or lifetime limits severely curtailed 

their coverage leaving them vulnerable to enormous costs. Some people even found their 

insurance policies rescinded after being diagnosed with cancer. 

One such example is that of Kathleen Watson, a now 61-year-old woman living in Lake City, 

Florida. Kathleen sought to purchase insurance on the individual market, but was denied 

because of a pre-existing diagnosis of leukocytosis, a condition of too many white blood cells 

that is often a sign of leukemia, but in and of itself is not a cancer diagnosis. She was denied 

coverage by several insurance carriers outright and as a result she could not afford treatment 

and delayed necessary medical care. 

1 American Cancer Society, Cancer Facts & Figures 2017, available at 

https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-andfigures/2017 I cancer -facts-and-figu res-2017 .pdf. 

'l>l 

3 E Ward et al, "Association of Insurance with Cancer Care Utilization and Outcomes, CA: A Cancer Journal for 

Clinicians 58: 1 (Jan./Feb. 2008 ), http://www .cancer .org/ca ncer /news/report -links-health-insurance-status-withcancer-care. 

2 
43 


Kathleen continued applying for coverage, and in 2008 a plan in the individual market finally 

accepted her application. In 2009, after having enrolled in the plan, Kathleen was diagnosed 

with chronic non-Hodgkin's lymphoma. However, as she began treatment the plan denied all 

her claims- the plan even denied the claim for testing her bone marrow to confirm her 

diagnosis. Later the Florida insurance commissioner determined the plan was not credible and 

Kathleen's insurance was cancelled. Kathleen says about this time, "The stress was 

overbearing. I couldn't sleep- always worried, didn't know what the next step would be. When 

everything is yanked out from underneath you, you don't know where to turn. !lost my 401k, 

savings, everything." She was left with $250,000 in medical debt and no health insurance 

coverage. This medical debt continues to affect her credit today. 

In the intervening years Kathleen-unable to get insurance on the individual market because of 

her pre-existing condition -was able to find work and get employer-sponsored coverage and 

cancer care. I am happy to report that she is now cancer-free. 

However, four months ago Kathleen suffered a non-workplace injury that has left her unable to 

work and on short-term disability. Her inability to work means her employer coverage expired 

at the end of the December. Keenly aware of the need for health insurance with her history 

and health complications, Kathleen enrolled before the deadline in an individual plan through 

the state exchange. Fortunately, her disability income allows her to make just enough to 

qualify for subsidies in the exchange instead of falling into Florida's Medicaid expansion 

coverage gap. Her new exchange plan includes all of her doctors and financial assistance that 

makes accessing her recommended cancer follow-up and other necessary health care 

affordable. 

She's gone from being uninsured and uninsurable in 2004, with a delayed diagnosis, and heaps 

of medical debt to finally being able to purchase a quality individual plan that is affordable in 

2016. 

Kathleen's story is just one example of the significant strides we have made in the quest to 

prevent cancer and central to this success is ensuring that all Americans can access and 

maintain affordable health insurance coverage. As Congress considers legislation to change the 

current health insurance market we urge you to consider how the policies will impact a person 

with cancer or other serious illness. Further, we believe any changes should be grounded in the 

following principles for ensuring that cancer patients have access to the care they need for their 

cancer treatment. 

Protecting Patients- For cancer patients and survivors, getting and keeping insurance is 

paramount. The following patient protections contained in current law should be 

retained: prohibition on pre-existing condition exclusions; prohibition on annual and 

3 
44 


lifetime limits; maximum out-of-pocket limits; and prohibition on insurance policy 

rescissions. 

Comprehensive Coverage -Insurance should cover the major health needs of cancer 

patients and survivors, including hospitalization, specialty cancer care, physician 

services, prescription drugs, rehabilitative care, and mental health services. Streamlined 

"basic" policies that do not include explicitly defined comprehensive benefits put cancer 

patients and survivors at risk of inadequate treatment, and could jeopardize access to 

necessary preventive care, treatment and follow-up care. 

Affordable Coverage- Affordable premiums and cost-sharing (including deductibles, 

copays and coinsurance) should be retained to ensure that persons with cancer and 

survivors can buy and maintain insurance coverage. 

Equitable Coverage- Changes to the insurance market should guarantee that people at 

all income levels have access to an affordable and consistent standard of coverage in 

every state. While 31 states and the District of Columbia have chosen to expand their 

Medicaid programs following the 2012 Supreme Court decision,4 unfortunately lowincome individuals in 19 states lack access to comprehensive and affordable coverage 

options because their state decided not to expand their Medicaid program. 

Preventive Care- A substantial number of all cancer deaths can be prevented and the 

substantial cost of the treatment of advanced disease could be reduced through the use 

of existing evidence-based prevention and early detection strategies.5 Research shows 

that required cost-sharing- including copays, coinsurance and deductibles- can be a 

significant barrier for patients who need preventive services.6•

7 This is especially true 

for lower-income patients and patients on a fixed income, for whom these payments 

can represent a significant percentage of their income. Individuals need access to 

evidence-based preventive services. 

We appreciate the invitation to testify today on four bills before the committee, which appear 

to work together to address concerns expressed by the insurance industry about the viability of 

the individual and small group markets. While we recognize the importance of strengthening 

the markets in order to keep the system working, we are concerned about how these bills, one 

4 National Federation of Independent Business (NFI B) vs. Sebelius, 567 U.S._ (2012), 183 L. Ed. 2d 450, 132 S.Ct. 

2556. 

5 American Cancer Society. Cancer Prevention & Early Detection Facts & Figures 2015-2016. 

Atlanta: American Cancer Society; 2015. 6 The Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, liaisons, and Staff. 

(2008). A Clinical Practice Guideline for Treating Tobacco Use and Dependence: 2008 Update: A U.S. Public Health 

Service Report. American Journal of Preventive Medicine, 35(2), 158-176. 

http:f/doi.org/10.1016/i.amepre.2008.04.009 

7 Han X, Robin Yabroff K, Guy GP, Zheng Z, Jemal A. Has recommended preventive service use increased after 

elimination of cost-sharing as part of the Affordable Care Act in the United States? Prev Med. 2015 Sep;78:85·91. 

dol: 10.1016/j.ypmed.2015.07.012. 

4 
45 


of which is not completely written yet, might impact care and access to adequate and 

affordable coverage for individuals with cancer. 

As the Subcommittee considers legislation to change health care markets, we want to share 

with you our thoughts on how some of the proposals currently under consideration would 

affect people with cancer and cancer survivors. 

Continuous Coverage 

Under current law, non-grandfathered health plans in the individual market are prohibited from 

taking into account an individual's pre-existing condition or health status when issuing health 

insurance coverage. The Kaiser Family Foundation estimates that 27 percent of adult Americans 

under the age of 65 have a pre-existing condition.8 Prior to January 1, 2014, health insurance 

issuers were permitted to refuse to cover an individual who had a pre-existing condition; could 

provide coverage but limit and/or refuse to cover care associated with the individual's preexisting condition; or, could charge the individual a higher premium based on her pre-existing 

condition (thus making insurance unaffordable). A survey conducted before these exclusions 

were prohibited found that 36 percent of those who tried to purchase health insurance directly 

from an insurance company in the individual insurance market were turned down, were 

charged more, or had a specific health problem excluded from their coverage.9 

In its current, admittedly incomplete draft, it appears that the continuous coverage legislation 

before the committee would exempt individuals from pre-existing condition exclusions only if 

they maintain continuous coverage (defined as having a gap in coverage of less than 63 days). 

Individuals who fail to maintain continuous coverage could be subject to medical underwriting. 

As currently discussed, this provision could actually restore the discriminatory practice of preexisting condition exclusions insofar as individuals with pre-existing conditions could be charged 

higher premiums. 

As the Subcommittee moves forward with the legislation, we would welcome the opportunity 

to work with you to ensure policy changes do not impact a patient's uninterrupted access to 

health insurance coverage and necessary treatment. However, a one-size-fits-all approach that 

imposes penalties for any interruption in coverage fails to recognize the many legitimate 

reasons that patients have coverage gaps. For instance, many people may experience a gap in 

coverage when they lose their job and their employee coverage. Research suggests that 

8 Claxton G, Cox C, Damico A, Levitt L, Pollitz K. Pre-existing Conditions and Medical Underwriting in the Individual 

Insurance Market Prior to the ACA. Kaiser Family Foundation. December 2016, available at 

http:/lfiles.kff.org/attachment/lssue-Brief-Pre-existing-Conditions-and-Medicai-Underwriting-in-the-lndividuallnsurance-Market-Prior-to-the-ACA. 

9 Doty MM, Collins SR, Nicholson JL et al. Failure to Protect: Why the Individual insurance Market is not o Viable 

Option for Most US Families. The Commonwealth Fund, July 2009. 

5 
46 


between 40 and 85 percent of cancer patients stop working while receiving cancer treatment, 

with absences from work ranging from 45 days to 6 months depending on the treatment.10 

Gaps in coverage also occur as a result of a divorce or death of a spouse when one spouse is no 

longer covered on the other's health plan. Moving from one state to another may result in a 

gap in coverage. All of these examples- and many others- are common reasons why a person 

may have an unexpected gap in coverage. Penalties imposed on people in these situations may 

adversely impact access to care, interrupt life-saving treatment and make insurance 

unaffordable when they attempt to regain coverage. 

Gaps in coverage are detrimental to individuals in active cancer treatment who need regular 

access to care and services. When that access is disrupted, the effectiveness of the treatment 

could be jeopardized and the individual's chance of survival could be significantly reduced. 

Evidence-based protocols for chemotherapy and other cancer treatments often require 

treatment delivery on a prescribed timeline. Interruptions to this timeline because of coverage 

gaps can be detrimental. A gap in coverage can also cause a fatal delay in initiation of a 

treatment protocol. Recent research shows that delays in the initiation of chemotherapy for 

breast cancer patients resulted in adverse health outcomes. 11 

Allowing health insurers to charge higher premiums to those with pre-existing conditions who 

experience a gap in coverage of more than 63 days is overly broad and would unfairly penalize 

those who lose their coverage unexpectedly. Individuals with cancer may lose their job 

because their cancer and/or cancer treatment makes them unable to work. This also includes 

cancer survivors who are more likely to report being unable to work because of their health or 

having employment disability, including more missed work days or additional days spent in bed 

due to poor health.12 

Enacting a policy that penalizes individuals for losing their health insurance coverageparticularly at a time when they have also lost their employment- imposes an undue cost 

burden on individuals. Moreover, once an individual with a history of cancer is no longer 

10 Scott Ramsey, et al, "Washington State Cancer Patients Found to be at Greater Risk for Bankruptcy then People 

Without a Cancer Diagnosis," Health Affairs, 32, no. 6, (2013): 1143-1152. 11 Chavez-MacGregor M, Clarke CA, Lichtensztajn DY, Giordano SH. Delayed Initiation of Adjuvant Chemotherapy 

Among Patients With Breast Cancer. lAMA Oncol. 2016;2(3):322-329. doi:l0.1001/jamaoncol.2015.3856. 

12 Yabroff KR, Dowling EC, Guy GP, et al. Financial Hardship Associated With Cancer in the United States: Findings 

From a Population-Based Sample of Adult Cancer Survivors. Journal of Clinical Oncology. 2016;34(3):259-267. 

doi:l0.1200/JC0.2015.62.0468; GP Guy Jr, DU Ekwueme, KR Yabroff, eta I: Economic burden of cancer survivorship 

among adults in the United States J Clin Oncol 31:3749-3757,2013; EA Finkelstein, FK Tangka, JG Trogdon, etal: 

The personal financial burden of cancer for the working-aged population Am J Manag Care 15:801-806,2009; KR 

Yabroff, WF Lawrence, S Clauser, eta!: Burden of illness in cancer survivors: Findings from a population-based 

national sample J Natl Cancer lnst 96:1322-1330,2004. 

6 
47 


protected from the pre-existing condition exclusion policy, it remains unlikely that he/she will 

be able to purchase health insurance coverage at all. 

Special Enrollment Periods 

Special enrollment periods (SEPs) allow individuals with qualifying life changes -like divorce, 

marriage, birth, a permanent move, or loss of employer-sponsored health insurance- to enroll 

in a plan that best meets their needs. These SEPs are vital for individuals with cancer who may 

often experience a job loss (and subsequent loss of employer-sponsored health insurance) if 

their cancer and/or cancer treatment makes them unable to work. In addition, some 

individuals with cancer may have to move to a different location in order to be closer to family 

members who can provide necessary caregiving and/or to be closer to specialized treatment 

facilities to treat their specific form of cancer. 

The legislation under consideration by the Subcommittee would require an individual seeking 

to enroll in health insurance coverage through an SEP to submit evidence of eligibility for the 

SEP before being permitted to enroll. We are concerned that the result of this seemingly minor 

change in policy could be cancer patients failing to access health coverage and treatment in a 

timely way. 

Restricting SEPs and requiring enrollees to document their eligibility prior to coverage will lead 

to gaps in coverage, which can be detrimental to an individual who needs access to cancer 

treatment immediately. If the Subcommittee were to consider such legislation, the policy 

should provide a review process by which an individual could obtain expedited coverage when 

medically necessary. 

We also note that it may be challenging for individuals to obtain the required documentation 

necessary to qualify for an SEP. For example, employers are not required to automatically 

provide former employees with documentation of loss of minimum essential coverage (MEC). 

This makes documentation for qualification under a loss of MEC difficult- particularly if the 

individual's loss of employment was not a planned event, such as retirement. 

According to the Urban Institute, fewer than 15 percent of eligible people elect to use an SEP to 

enroll in a health plan.B While an industry-funded report indicates that individuals who enroll 

in health plans through an SEP have higher health care costs compared to individuals who 

enroll during an open enrollment period, the report does not provide data on why they are 

13 Buettgens M, DamS, Recht H, "More than 10 Million Uninsured Could Obtain Marketplace Coverage through 

Special Enrollment Periods," Washington: Robert Wood Johnson Found. & Urban Institute, Nov. 2015 available at 

http://www.urban.org/sites/default/files/alfresco/publication-pdfs/2000522-More-than-10-Million-UninsuredCould-Obtain-Marketplace-Coverage-through-Speciai-Enrollment-Periods.pdf. 

7 
48 


seeking enrollment during an SEP. 14 The individual may be a cancer patient seeking enrollment 

following the loss of employment due to illness. This SEP-qualifying individual will generate 

new costs, but it does not mean he is intentionally abusing the SEP system. 

In addition, we are concerned that under the proposed legislation, the individual may not enroll 

in a health plan via an SEP until the Exchange verifies that the individual is qualified. But there 

is no requirement for the Exchange to act. For example, if the individual with a prior cancer 

diagnosis submits documentation for SEP eligibility within 63 days of losing creditable coverage, 

but the Exchange fails to act in a timely manner, the individual may not be able to enroll in a 

health plan within the 63-day time period. Thus lacking "continuous coverage," the pre-existing 

condition exclusion provision would be triggered, allowing the health insurer to medically 

underwrite the policy. Absent additional legislative clarity, health insurers could use the 

combination of the SEP and restrictive continuous coverage provisions as a back-door way of 

denying coverage to potentially high-cost individuals. We strongly urge Congress to ensure that 

such highly discriminatory actions would not be permitted. 

We share the Subcommittee's concern about policies that could result in individuals "gaming" 

the SEP system. But people in cancer treatment or those who have a pre-existing cancer 

condition have no incentive to drop coverage. Many lose coverage when they lose their job 

because they are sick. Policy changes should not inadvertently prevent persons with cancer 

from having access to coverage. We are committed to working with the Subcommittee to 

advance this goal. 

Age Rating 

Under current law, health insurance issuers in the individual market are prohibited from 

charging older adults more than three times the premium charged to younger adults for the 

same coverage (e.g., 3:1 age rating). The legislation under consideration by the Subcommittee 

would relax these requirements and permit health insurance issuers to charge older adults five 

times that charged to younger individuals (e.g., a 5:1 age rating). The legislation also would 

allow states to impose a different ratio- either a higher or a lower ratio. 

While cancer can be diagnosed at any age, the incidence of cancer increases with age. 

According to the American Cancer Society, 85 percent of all cancers in the United States are 

diagnosed in people 50 years of age and older.15 Thus, increasing the age rating bands would 

mean that older individuals (those more at risk of developing cancer) would face significantly 

higher health care premiums or be priced out of the market completely. This problem would 

14 Carlson C, Giesa K, "Special Enrollment Periods and the Non-Group, ACA-Compliance Market," Washington: 

Oliver Wyman, Feb 2016, available at https://www.ahip.org/Wyman-SEP-Enrollment/. 15 American Cancer Society, Cancer Facts & Figures 2017. 

8 
49 


be exacerbated in states that choose to go beyond the 5:1 age rating provided in the 

legislation. Prior to the enactment of the ACA's age rating band restrictions, older adults 

faced significant problems accessing health insurance coverage, in large part because of age 

rating restrictions {compounded by the ability of issuers to use health status when setting 

premiums). 16 

Research suggests that relaxing the age rating bands would result in a slight reduction in 

premiums changed to younger cohorts relative to the significant increase in premiums 

charged to older cohorts. One study estimated that increasing the age bands to 5:1 would 

result in premiums for a 64-year-old to increase from $8,500 to $10,600 per year (a $2,100 

increase), while premiums for a 21-year-old would decrease from $2,800 to $2,100 (a 

reduction of only $700). 17 In addition, the policy would actually result in higher federal 

expenditures of an estimated $9.3 billion due to the advance premium tax credits. 18 

Grace Periods 

Under current law, individuals who have failed to pay premiums have a three-month "grace 

period" in which to repay overdue premiums before the issuer is permitted to terminate the 

individual's health insurance coverage. This policy is designed to ensure that individuals who 

are temporarily unable to afford a few monthly premium payments are permitted the 

opportunity to catch up before their plan terminates coverage. If an individual fails to pay her 

premium outside this grace period, coverage is terminated retroactive to the end of the first 

month of the grace period and the individual is responsible for the entire cost of any medical 

expenses incurred in the second and third months of the grace period. 

The legislation under consideration by the Subcommittee would retain the three-month grace 

period for plan years beginning before January 1, 2018, but would eliminate this patient 

protection for subsequent plan years. States would have the authority to set the appropriate 

grace period. If a state chooses not to do so, the default period would be one month. 

We are concerned that limiting the grace period would pose an undue burden on individuals 

who experience sudden or unexpected personal financial changes- such as coping with having 

to pay large deductibles and out-of-pocket costs associated with a serious disease like cancer. 

The out-of-pocket costs of a newly diagnosed cancer patient can be beyond the means of many 

Americans. When an individual is diagnosed and initially undergoes cancer treatment she 

usually incurs a significant portion in out-of-pocket costs between the deductible, and frequent 

16• Gerry Smolka, Leigh Purvis, and Carols Figueiredo, "Health Care Reform: What's at Stake for 50- to 64-YearOids," AARP Public Policy Institute, Insight on the Issues #124, March 2009. 17 C. Eibner and E. Saltzman, "Charing Order Adults Higher Premiums Could Cost Taxpayers," The Commonwealth 

Fund Slog. Sept. 15, 2015. 

"Jsh 

9 
50 


copayments and coinsurance associated with services and/or medications. Nearly half of all 

American adults report being unable to cover an emergency expense costing $400 without 

having to borrow or sell something to do so. 19 Yet many standard plans offer deductibles of 

$2,500 or more. Individuals often need additional time in order to try to obtain funds to cover 

these unexpected medical costs. Enacting legislation that would reduce the grace period would 

curtail the ability of individuals to retain their health insurance coverage at a time when they 

need it most (e.g., while they are undergoing treatment for a serious disease or illness). 

Moreover, we are deeply concerned that the legislation fails to provide a minimum protectiona state could conceivably limit the grace period to only a few days. While we would expect few 

states to take such draconian action, we nevertheless urge the Subcommittee to consider 

providing a federal floor of patient protections. 

Finally, we urge the Subcommittee to consider how this provision will be impacted if the other 

legislative proposals discussed above were implemented. For example, if an individual failed to 

pay her health insurance premiums for more than 30 days and her coverage was terminated, 

she would be uninsured and thus potentially face medical underwriting if she lacked coverage 

for a period of time provided under the legislation. 

Conclusion 

Thank you for the opportunity to testify before you today. As the Subcommittee considers 

changes to the health insurance market, we urge you to give serious consideration as to how 

these four bills would interact with each other in restricting patient access to adequate and 

affordable insurance coverage, particularly if there is a break in continuous coverage. 

As you continue consideration of legislation to strengthen the market, we hope that you will 

consider how this will work for people with cancer. We look forward to working with you to 

ensure stability in the market and a health care system that meets the needs of individuals with 

cancer. 

19 Board of Governors of the Federal Reserve, Report on the Economic Well-Being of U.S. Households in 2015. May 

2016, available at https://www.federalreserve.gov/2015-report-economic-well-being-us-households-201605.pdf. 

10 
51 


Summary of Testimony of J. Leonard Lichtenfeld, MD, 

Deputy Chief Medical Office, American Cancer Society 

In the United States there are more than 1.6 million Americans who will be diagnosed with 

cancer this year. An additional15.5 million Americans living today have a history of cancer. For 

these Americans access to affordable health insurance that covers their condition is a matter of 

survival. Research from the American Cancer Society has shown that uninsured Americans are 

less likely to get screened for cancer, are more likely to have their cancer diagnosed at an 

advanced stage, have worse outcomes and more expensive care. 

As Congress considers legislation to change the current health insurance market we urge you to 

consider how the policies will impact a person with cancer or other serious illness. Any 

legislation should ensure existing patient protections (e.g., ban on pre-existing condition 

exclusions; prohibition on annual and lifetime limits; maximum out-of-pocket limits; and 

prohibition on insurance policy rescissions}; and provide comprehensive, affordable, and 

equitable health insurance coverage (including coverage of preventive services}. 

While we recognize the importance of strengthening the markets in order to keep the system 

working, we are concerned about how these bills might impact care and access to adequate 

and affordable coverage for individuals with cancer. 

Continuous Coverage: ACS strongly supports the current law which prohibits health issuers 

from taking into account an individual's pre-existing condition or health status when issuing 

health insurance coverage. We are concerned that the legislation under consideration could 

allow issuers to medically underwrite policies for individuals who fail to maintain continuous 

coverage. As the Subcommittee moves forward with the legislation, we would welcome the 

opportunity to work with you to ensure policy changes do not impact a patient's uninterrupted 

access to health insurance coverage and necessary treatment. It is important to understand 

that if a patient loses coverage due to any number of unforeseeable life events, such as loss of 

employment or a move to accommodate treatment, that patient could be virtually uninsurable 

thereafter. 

Special Enrollment Periods (SEPs): SEPs are vital for individuals with cancer who may 

experience a job loss (and loss of employer-sponsored health insurance) if their cancer and/or 

cancer treatment makes them unable to work. Restricting SEPs and requiring enrollees to 

document their eligibility prior to coverage could lead to loss of continuous coverage. 

Age Rating: The purpose of insurance is to cover people when they become sick. Increasing 

the age rating bands would mean that older individuals (those more at risk of developing 

cancer) would face significantly higher health care premiums, and could be priced out of the 

market completely. 

Grace Periods: We are concerned that a severe limitation of the grace period for paying 

premiums would pose an undue burden on individuals who experience sudden or unexpected 

personal financial changes- such as coping with having to pay large deductibles and out-ofpocket costs associated with a serious disease like cancer. Enacting legislation that would 

reduce the grace period would curtail the ability of individuals to retain their health insurance 

coverage at a time when they need it most (e.g., while they are undergoing treatment for a 

serious disease or illness). 
52 

Mr. BURGESS. And the Chair thanks the gentleman. The Chair 

thanks all of our witnesses for being here today and for your testimony. We will move into the question portion of the hearing. The 

Chair does note that he was delayed in arriving at the hearing, so 

in compensation for that I am going to defer my questions to the 

end and recognize the gentleman from Texas, Mr. Barton, for questions. 

Mr. BARTON. It is rare that I am speechless, Mr. Chairman, but 

I am tempted to defer also because I had to go to a private meeting 

and missed—I was going to read my briefing book. I guess I am— 

but if you are recognizing me, I am going to try to go through it. 

I am tempted, but since you are Diet Coke man and not a Diet 

Dr. Pepper man I am a little skeptical. 

I do want to, first of all, commend the chairman for holding the 

hearing and commend our witnesses. I am going to ask a general 

question about the overall effectiveness or necessity of maintaining 

some sort of a health exchange option as we move away from the 

Affordable Care Act. Could each of you gentlemen comment on 

whether as we move to replace the Affordable Care Act we should 

give States the option to have something similar to a health exchange and also if we should have a national exchange in addition 

to that. 

Dr. HOLTZ-EAKIN. I certainly think there is good reason to give 

the States such an option. I have always thought that the most important thing would be to have healthy competition in the individual market. Exchanges can provide the consumer information 

necessary to make that competition work better, and the place 

where I have reservations is only when the exchange becomes a 

means for excessive regulation. 

But the exchange, per se, is a marketplace where consumers can 

get information and purchase policies that they like. It is a very 

valuable concept. 

Mr. BARTON. OK. 

Mr. WIESKE. I think the concept of the exchange, it is good way 

to deliver subsidies but it is a three percent cost on top of the insurance. That is roughly what they are charging back the insurers 

for coverage to the exchange, and this is a website. I am not so 

sure three percent is the, I mean that may reflect the actual cost, 

so I think there is a value proposition there. I think prior to the 

ACA there were a number of websites that provided coverage as 

well. 

And again, depending on what the purpose of the exchange is, I 

think he is right, that it has become a means to add to the regulatory burden on insurers and consumers, so I am not so sure of 

the value in part because of the cost, but I don’t think, you know, 

I think there is, there may some reason for it. 

Dr. LICHTENFELD. Mr. Barton, I appreciate your question. But 

speaking on behalf of the American Cancer Society, our major concern is that consumers have the opportunity to get affordable coverage that is going to meet their needs at their time of need, and 

the mechanism by which the committee decides going forward to 

achieve that must provide the information that people need to 

make that decision in a reasonable way. 

53 

There obviously are folks here who are involved in the insurance 

community much more directly than I am or that we are, but it is 

a matter of information, affordability, and access, and that adequate coverages are available and that the consumer be aware of 

those options as they go forward with their insurance. 

Mr. BARTON. Mr., is it ‘‘Wee-ski’’ or—— 

Mr. WIESKE. Wieske, yes, sir. 

Mr. BARTON. Wieske, not ‘‘wise guy,’’ just Wieske. Your State has 

a high-risk pool, and another thing that we want to try to do as 

we move away from the ACA is guarantee that people with preexisting conditions get adequate access to insurance. The full committee chairman has put out kind of a placeholder bill dealing with 

high-risk pools. How would you envision based on your State’s experience that working absent all the bells and whistles and mandates that we have currently under the ACA? 

Mr. WIESKE. So sure, you know, I think the first thing is, is a 

high-risk pool isn’t necessarily the solution for every State. I don’t 

want to speak for other States. I will say that in the State of Wisconsin, while we had a high-risk pool, it was highly effective. It is 

still politically popular amongst both Republicans, Democrats, and 

especially amongst some subscribers of the high-risk pool. And they 

miss the coverage. It was a well-thought-out coverage. It was a 

well-thought-out program. 

So I think, you know, I think the key issue is always how you 

deal with the funding. And that has been one of the bugaboos, I 

think, in a number of States is when there is insufficient funding 

for a high-risk pool. You know, there was one State, California, had 

a waiting list for their high-risk pool. Florida closed their high-risk 

pool in the early 1990s, and it remained closed for a number of 

years. Other States had relatively low dollar caps. 

So there are issues in design, so the important piece is design. 

The other important piece is understanding how the funding works 

and having a stable funding source. I think it has been consistent 

that the insurance industry is required through the individual 

small group and large group market to contribute to the cost of the 

high-risk pool to make sure that it is affordable for consumers. I 

think as well having good medical discounts that attach to it are 

also important, but funding is sort of the key piece in making sure 

that it is maintained over time. 

Mr. BARTON. You think it can be workable. 

Mr. WIESKE. I think it worked incredibly well in Wisconsin and 

it provided great coverage and a lot of options for consumers, yes. 

Mr. BARTON. My time has expired. Thank you, Mr. Chairman, for 

your—— 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman. The Chair recognizes the gentleman from Texas, Mr. 

Green, 5 minutes for questions, please. 

Mr. GREEN. Thank you, Mr. Chairman. Last Congress our committee passed several important pieces of legislation on health 

care, a number of them fixing the SGR, extending FQHCs, and 

21st Century Cures is probably the biggest one. Speaker Ryan once 

described the 21st Century Cures as the most important legislation 

to be passed in the 114th Congress. 

54 

During the process of passing the Cures many members of our 

committee heard stories from patients and advocates across the 

country who were battling tough diseases and hoping for new treatments. Passing the Cures which contained new funding for research on diseases such as cancer we gave so many of them hope 

that one day they would get that treatment to be needed. Nationwide, the ACA is that delivery. It doesn’t do us any good to invest 

in medical research if we don’t have a physician or a facility—and 

I am from the Houston area, we are fortunate to have MD Anderson. 

Although up until the Affordable Care Act, MD Anderson being 

a State institution did not take a significant number of indigent 

persons even though they were Texans, and, but now they have 

something even if it is Medicaid. And, of course, Texas didn’t expand Medicaid expansion, so we need to have this delivery system. 

And we can do things bipartisan, you know, I am hoping that is 

what we can do to fix the ACA, because there has never been a law 

passed by Congress that doesn’t need to be looked at over a period 

of years. And, by the way, I served 20 years in the State legislature 

in Texas, and we wrestled with our high-risk pool. The problem is 

that we didn’t fund it, and if you only have high-risk people, they 

can’t afford the insurance. 

How does Wisconsin, Mr. Wieske, fund your high-risk pools? Is 

it premium? I thought I saw in your remarks it was premium 

taxes. 

Mr. WIESKE. So there are number of funding mechanisms, so it 

was divided out equally. There was no actual State dollars that 

went into it. However, it was divided out between a 40/30/30 share, 

so 40 percent was the cost for consumers, 30 percent was the cost 

for insurers, and 30 percent was the cost for the medical providers. 

They were required to have that level of contribution remain consistently over time which was true-upped every year in order to 

maintain the affordability. There was enough money there that it 

was private sourcing that actually provided the subsidy for folks 

under $34,000 of family income, so there was subsidies for folks 

under $34,000 of income as well. 

Mr. GREEN. Well, again and other States have tried that. I, like 

I said, worked as a State legislator doing work across State lines 

to see what we could do, but—and I have a district in Houston. It 

is very urban. Up until the Affordable Care Act 44 percent of my 

constituents who worked did not get insurance through their employer. 

And so that is why the ACA is so important to an urban area 

and there are places all over the country. I would be interested 

sometime just to talk with you how Milwaukee, a very urban area, 

compares with most of the rest of Wisconsin, but, you know, that 

is my concern, that not every State is like Wisconsin. 

Dr. Lichtenfeld, thank you for being here. This bill requires insurers to cover preexisting conditions like cancer, but the bill 

doesn’t say that insurers can’t charge more for that cancer patient. 

That is one of the major issues, you know, the requirement that 

people have insurance so the insurance companies can spread that 

risk. Insurance is about spreading the risk, and if you only have 

cancer patients in the insurance plan nobody will be able to afford 

55 

it. So that is why—and if they have to, you know, once you are diagnosed and you will have to spend it, tell me, is that one of the 

problems the American Cancer, your client has problems with? 

Dr. LICHTENFELD. I am part of the American Cancer Society and 

honored to be so. Of course it is a concern. You know, nobody goes 

out and says I want cancer or that I know I am going to get cancer, 

and that is what insurance is about, making sure that the benefits 

are adequate, that the cost is affordable and as I mentioned not 

only the premium cost but also the ancillary costs that inevitably 

come along. Making sure that patients and consumers have access 

to care is what this is all about. 

We are not here to in a sense solve all the problems in our testimony today. We are here today on behalf of cancer patients 

throughout this Nation and consumers to try to make sure that 

those principles are adhered to. That some of the fundamental protections in terms of affordability, limits on out-of-pocket expenses—— 

Mr. GREEN. Before I run out of time, you don’t see this proposed 

legislation is serving cancer patients? 

Dr. LICHTENFELD. What we believe is that this is a work in 

progress and we want to participate in that progress and help 

reach solutions in a manner that is acceptable for the people we 

serve. 

Mr. GREEN. Thank you. Thank you, Mr. Chairman. 

Mr. BURGESS. The Chair thanks the gentleman. The gentleman 

yields back. The Chair now recognizes the gentleman from Kentucky, the vice chairman of the Health Subcommittee, 5 minutes 

for questions, please. 

Mr. GUTHRIE. Thank you, Mr. Chairman. I have a chart. I would 

like to start by walking through a chart if we can have that posted. 

Now the chart we see here uses CBO data on where folks get 

their health insurance coverage in 2016. As you can see, roughly 

half of the country received coverage through their employer. That 

is 155 million people. Fifty seven million patients are enrolled in 

Medicare, another 57 million are Medicaid beneficiaries that were 

eligible before the Affordable Care Act. 

When it comes to the Affordable Care Act there are 11 million 

recipients who were made Medicaid eligible by law, and a little 

under 11 million folks on exchange programs and roughly one million enrolled through basic health programs. What this chart illustrates is that we are talking about seven percent of the population 

all at the potential disruption of where 93 percent of people across 

the country receive their health coverage. Even more, the IRS said 

about eight million folks paid the mandate penalty and another 12 

million claimed an exemption from the penalty. 

So of the 27 million uninsured Americans, 20 million chose to either to pay the individual mandate tax or claim an exemption. 

Look, we are going to hear a lot of numbers today and remember 

these. Seven percent of the country can be directly associate their 

coverage through the Affordable Care Act and all but seven million 

uninsured Americans paid the penalty or claimed an exemption. 

So instead about talking numbers let’s talk about people behind 

the numbers. So Dr. Holtz-Eakin, can you tell me the national average of premium increases for on-exchange patients this year? 

56 

Dr. HOLTZ-EAKIN. For the benchmark Silver Plan it is 27 percent. 

Mr. GUTHRIE. And Commissioner Wieske, what is the number for 

your home State of Wisconsin? 

Mr. WIESKE. It was roughly 16 percent. 

Mr. GUTHRIE. Let’s talk about ways to drive these costs down. 

Dr. Holtz-Eakin, as you point out in these reforms noticed today, 

taken individually or separately are good policy and should receive 

bipartisan support. If our immediate task is to stop the leaks before replacing the pipes, is this a good place to start with the bills 

before us today? 

Dr. HOLTZ-EAKIN. I believe so. Yes, these are sensible reforms 

that will get part of the way. 

Mr. GUTHRIE. Thank you, and I agree with your written conclusion this will not fix everything but these are necessary changes. 

One of those longer term changes we strongly considered is continuous coverage. Would you please briefly describe the value of this 

incentive model and how it is aimed at patients keeping health 

care instead of simply getting coverage? 

Dr. HOLTZ-EAKIN. So the basic concept is to deal with preexisting 

conditions in two ways. The first is for existing folks you go to a 

high-risk pool model like has been discussed. But for a young person, the minute they come off their parents’ policy at age 26 they 

are young and cheap and if they buy a policy and keep coverage 

in any form throughout their life, regardless of whatever condition 

they develop, they cannot be medically underwritten and their premium cannot be raised based on their health condition. 

As a result, there is a huge incentive to get the young people in 

the pool and have insurance, because they are keeping the insurance over a lifetime insurers have a very different view of them 

than now. Now they are a 1-year snapshot, they should do everything they can to avoid costs. If you are looking at them over a lifetime you want to do the prevention, you want to do the wellness, 

you want to take care of them in very different ways. So this continuous coverage solves the problem of preexisting conditions by 

getting them in the pool to begin with and provides a better foundation for a different kind of medical model. 

Mr. GUTHRIE. OK, thank you. And Mr. Wieske, you answered 

some of these in your testimony, but I will just give you a couple 

minutes, a minute and a half here, to kind of drill down on some 

of the things that you said and just point it out again. Can you 

compare the market, what the market looked like in your State before and after the passage of the ACA? 

Mr. WIESKE. Yes, I think roughly, I mean we actually did not see 

any gain in coverage if you look at the numbers, if you count our 

exchange folks, the current exchange folks, and then you look at 

the high-risk pool and you look at the market before. And so roughly we saw no gain in coverage as a result of Obamacare, at least 

the numbers don’t bear that out. 

And it is important to note that the methodology to calculate the 

uninsured changed in 2013 so it is an apple to oranges comparison 

to a certain degree. But our market was much more affordable preACA, there was access to coverage. 

57 

Mr. GUTHRIE. What were the difference in options before and 

after? 

Mr. WIESKE. Well, we had roughly 25 carriers operating in the 

individual market in Wisconsin and along with the high-risk pool 

and now we have about 15 in the exchange, but if you look at any 

particular region we have roughly five at the most, closer to three. 

There is only one region where we have one, and I think three 

counties where we have two. 

So there are fewer choices in our individual market. It is more 

costly and the plans are obviously centered, they are sort of Government-designed plans rather than having a lot of different options for—— 

Mr. GUTHRIE. But not an increase in coverage? 

Mr. WIESKE. Pardon me? 

Mr. GUTHRIE. You have fewer options, more costly and not an increase in coverage? 

Mr. WIESKE. Correct. 

Mr. GUTHRIE. Thank you. I am out of time. I yield back. 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman. The Chair recognizes the gentleman from New Jersey, 

5 minutes for questions, please. 

Mr. PALLONE. Thank you, Mr. Chairman. The gentleman from 

Kentucky put up that chart and, you know, acting as if when you 

repeal the ACA the only thing you are impacting is people who 

bought individual policies on the marketplace. But the subject, certainly the Walden bill, the chairman’s bill today is talking about 

standards. He is talking about, you know, preexisting conditions. 

That affects over a hundred million people. 

There is no reference in this half-baked bill we would assume because it doesn’t put it back in that the essential benefit package 

is impacted, which is going to be my question to Mr. Lichtenfeld. 

So, you know, I don’t understand how you are putting up that 

chart and acting as if what we are talking about here today is just 

the people in the marketplace. This affects everyone. The ACA 

guaranteed an essential benefit package. You start cutting back on 

that and offering skeletal or catastrophic plans, that is going to affect everybody on that chart including those who have, the majority 

that have employer-sponsored plans and the same thing with preexisting conditions. 

So, you know, I want everyone to understand. When you start 

talking about standards and repealing this bill, anti-discriminatory 

practices, essential benefits, this isn’t just the people in the marketplace. 

Now Mr. Lichtenfeld, my concern about the Walden draft is it 

would not limit in any way what insurers can charge for insurance. 

Before the ACA under HIPAA some people were guaranteed access 

to nongroup policies for which they could not be turned down nor 

have preexisting conditions excluded, but there was no limit on 

what they could be charged. And left with this only remaining option for discriminating based on health status, insurers charged 

very high rates for coverage effectively blocking access for a lot of 

cancer patients sometimes 2000 percent of standard rates. 

So roughly what percent of cancer patients do you think could afford to pay such highly surcharged premiums, and in your experiVerDate Mar 15 2010 10:31 Nov 08, 2018 Jkt 037690 PO 00000 Frm 00061 Fmt 6633 Sfmt 6633 I:\115THCONGRESS\115X4PATIENTRELIEFASKOK101718\115X4PATIENTRELIEFWORK
58 

ence what happens to people who are diagnosed with cancer who 

can’t afford health insurance? How is their access to treatment affected? 

Dr. LICHTENFELD. What we know at the American Cancer Society is that we did a considerable amount of research in the early 

2000s to help support our views, shall we say, on the necessity of 

insurance. And what we found from that research, which we can 

certainly provide to the committee, is that patients were diagnosed 

at a later stage and did poorly compared to those who had insurance. 

So we do think that the legislation, the current policy has enabled patients in order to get access to care. Certainly there are 

issues. We recognize that there are imperfections that have to be 

worked on. One of our concerns with regard to the essential health 

benefits is the reality that we need to make sure that whatever we 

do here, whatever the committee in its wisdom decides, that we 

have adequate coverage to make sure that patients who have cancer can get the care they need without the limitations that might 

otherwise occur. And clearly affordability is a major issue. 

Most patients, it is no secret the majority of patients who would 

be impacted by this discussion today are people who are age 50 and 

older. And those folks would have, if they end up in a situation 

where there is a high premium and they couldn’t afford it they 

would be put back in a situation where they would have difficulty 

getting the care they need for the illness that they have. 

So in response to your question, these are certainly concerns that 

we have and hopefully we will be able to work with the committee 

moving forward to address those issues. 

Mr. PALLONE. Well, thank you, Doctor. You see, my concern is 

that when the GOP talk about replacement, what they really want 

is competition downward, skeletal, skimpy plans, you know, plans 

that—you know, before the ACA you could buy a plan that didn’t 

cover prescription drugs or even hospitalization. And, you know, 

now we have these essential benefits, but Mr. Walden’s draft assumes to repeal the entire ACA including essential health benefits. 

Sixty two percent of plans before we put the ACA in place lacked 

maternity coverage, I mean there was all kinds of exclusions. 

And, you know, just give me—I mean if the ACA benefit standards were to be repealed how would cancer patients be affected? I 

mean they might—limited doctor visits, much higher deductibles. I 

have only got a few seconds, but if you will just comment. I know 

you kind of mentioned it. 

Dr. LICHTENFELD. Mr. Pallone, I have lived through that experience as a physician and I am aware of what happened in the past 

and we at the American Cancer Society would be very concerned 

if we went back to that. We hope that there are solutions within 

the committee that will avoid that and provide—speaking with my 

colleague to my right, certainly some States have been excellent. 

Unfortunately others have not and we had huge problems in the 

past that we do not want to revisit. Cancer patients really need to 

know that they have insurance that works. Thank you. 

Mr. PALLONE. Thank you, sir. 

59 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman. The Chair recognizes the gentleman from Pennsylvania, Dr. Murphy, 5 minutes for your questions, please. 

Mr. MURPHY. Thank you, Mr. Chairman. Dr. Lichtenfeld, thanks 

for your statement on the importance of maintaining preexisting 

conditions. We all agree with that. Those protections are important 

and guaranteeing issue is part of Chairman Walden’s bill, too. We 

agree that these rating protections are important as well and really 

look forward to working with in your patient community and the 

broader chronic condition patient community. 

Can you talk about how Medicare Part D could serve as a role 

model, as a model for how we do this, how we approach this? 

Dr. LICHTENFELD. Well, as you are aware, Mr. Murphy, sometimes in some respects Medicare Part D works and in some places 

there have been some difficulties with how it has been applied. I 

am not sure that that is necessarily the model. I am not sure that 

there is any single model. I think that this is obviously a work in 

progress to be discussed and we look forward to participating in 

those discussions. 

At the end of the day we need to make certain that cancer patients can afford with regard to Part D, can afford their medications whether given in the doctor’s office, whether they are bought 

over the counter or at a pharmacy. Those are critical. And it is also 

important to make sure that that coverage is uniform across the 

country. That is what we think is—— 

Mr. MURPHY. Dr. Holtz-Eakin, can you comment quickly on that 

too, just in a few seconds comment quickly on that question too 

about how Part D can serve as a role model on that? 

Dr. HOLTZ-EAKIN. I think the Part D program has been enormously successful because it is built on very strong competitive 

pressures and on the ability to have very flexible plan design. And 

so we have seen that in the prescription drug plans competing with 

one another and offering products that seniors very much approve 

of. 

Mr. MURPHY. Thank you. Mr. Wieske, did Wisconsin—let me talk 

about the high-risk pool. So does Wisconsin collect data on patients 

who are in these high-risk pools by medical condition, so cancer, 

certain chronic illnesses and infections, mental health? 

Mr. WIESKE. We did. I served on the board of the high-risk pool. 

They had extensive information obviously on all the patients. It 

was—and some of them were there for an extended period of time, 

others were not. They had an intensive care management. So it 

was a very high number of high-risk conditions. 

Mr. MURPHY. I am wondering how deep you could dive into that 

data. So Kaiser tells us about, in terms of the number of people 

who remain in the high-risk pool, about 45 percent are in their second year. Many have acute conditions and get better. 

And whether it is a chronic condition like cancer or, you know, 

the short term ones, maternity, and other complications like mental health, did you do a deeper dive when multiple illnesses occurred to see who were those people who were the big over utilizers 

by behaviors or high utilizers by medical conditions, so we can help 

analyze what are the differences there? 

60 

Mr. WIESKE. Yes. In short, yes. There weren’t a lot of incentives. 

There were deductibles that attached. I think the lowest was 

$1,000 deductible. So there were specific efforts made to deal with 

high utilizers that were utilizing inappropriately in contacts from 

the administrator. 

But most of the folks on the high-risk pool were there about 3 

to 4 years. They had specific medical conditions. Presumably they 

were covered or had group coverage at the end of their—— 

Mr. MURPHY. So here is an issue in where I think both sides of 

the aisle can agree that when you have a high deductible which is 

meant to discourage people from overutilizing the system that may 

work in some cases to keep people from running to the emergency 

room for every problem. On the other hand it hurts people from 

going to get medical care when they need it early on, which Dr. 

Lichtenfeld was describing the person for early stage cancer. 

I am particularly concerned here about such things as the mental 

health disorders. Generally a person with serious mental illness 

goes 60 to 80 weeks and adults longer between first symptoms and 

first treatment. And those complications were for example in Medicaid, five percent of Medicaid patients it is 55 percent of Medicaid 

spending and virtually all of those have a concurrent mental health 

problem. Your State has gone above and beyond the numbers in 

terms of mental health parity. 

Mr. WIESKE. Right. 

Mr. MURPHY. Have you looked at that also as an issue in terms 

of having parity and making sure people are getting concurrent 

mental health services whether they start with a chronic illness or 

start with a mental illness that does something to help drive down 

costs? 

Mr. WIESKE. Well, I think we have done a number of efforts I 

think both through the Medicaid program has done a fabulous job 

of working through that. I think we have new efforts related to the 

opioid issue which has gotten more attention and certainly in the 

opioid task force. 

There are a number of issues that we get to, but I think you are 

exactly right that there is this management in reflection of that 

this is an illness like any other illness and you need to treat it as 

such is sort of ingrained in Wisconsin. 

We have had mandates that attached mental health for decades, 

so while we have some mental health parity that applies we also 

have requirements that go back into the 1980s. We have had mental health coverage since the 1980s. 

Mr. MURPHY. Well, I might take issue with you when you say 

Medicaid has done a fabulous job on that because we have had a 

lot of problems this committee has discussed. But I mentioned Wisconsin’s data because we have seen from private markets and others that when private companies insure and they make sure their 

employees are covered with mental health benefits and concurrently looking at the impact, the cross pollenation here of chronic 

illness and mental illness, cancer is an example of that—high rate 

of depression, anxiety, panic—it drives people back to the emergency room versus if a doctor is working with them, so a lot of serious concerns there. 

61 

If you are able to give us more data on that or if you and I could 

sit down and talk about that, the same with Dr. Holtz-Eakin and 

Dr. Lichtenfeld, I would love to talk to you. This is an area where 

I have got to believe both sides of this committee can agree we can 

work on more effective health care and driving down costs. 

I realize I am out of time, Mr. Chairman. Thank you for indulging me. 

Mr. BURGESS. The Chair thanks the gentleman. The gentleman 

yields back. The Chair recognizes the gentlelady from Illinois, Ms. 

Schakowsky, 5 minutes for questions, please. 

Ms. SCHAKOWSKY. Thank you, Mr. Chairman. My colleagues on 

the other side of the aisle claim to be concerned with, quote, protecting infant lives, unquote, which is what they called their panel 

last year that investigated Planned Parenthood and failed to prove 

any wrongdoing. But we know full well that that panel was created 

to attack women’s health choices and not protect infant lives. 

But when it actually comes to protecting infant lives, Republicans are happy to put insurance companies back in charge, allow 

them to reinstate lifetime caps on coverage and medical underwriting. This would directly impact some of the most fragile and 

vulnerable patients in our country, including premature infants, infants with congenital abnormalities, and their families. 

So I would like to enter into the record an article featured on 

Slate called ‘‘Our Insurance Paid $2.5 Million to Keep Our Child 

Alive.’’ 

Mr. BURGESS. Would the gentlelady yield? Is that a unanimous 

consent request? 

Ms. SCHAKOWSKY. Yes. 

Mr. BURGESS. Without objection, so ordered. 

[The information appears at the conclusion of the hearing.] 

Ms. SCHAKOWSKY. The author explained that her child was born with congenital defects and their family accrued $2.5 million in 

medical bills by the time that child was 3 years old. This, by the 

way, to make our Ranking Member Pallone’s point, they had employer-based coverage, and the benefit package made sure that 

they were covered. 

And should Republicans have their way and reinstate lifetime 

caps on insurance coverage this child might already have reached 

her lifetime limit on coverage at the age of 3 and would be forced 

to pay all of her future care out-of-pocket if they could possibly afford it. Because of the ACA, more than 27 million children have 

benefitted from the ban on lifetime caps and overall more than 105 

million Americans have benefitted. 

Before the ACA, 89 percent of insurance plans included a lifetime 

limit on benefits. To add insult to injury, under Chairman Walden’s 

bill this child may be subjected to an astronomical premium cost 

for the rest of her live based on her preexisting condition from 

birth. 

Let me ask you, Dr. Lichtenfeld, what does it mean for premature infants or children born with congenital abnormalities if 

these conditions are once again permitted to be medically underwritten? 

Dr. LICHTENFELD. Well, obviously, when speaking about that specific issue, those costs can rise rapidly and last for a lifetime, and 

62 

we are concerned on behalf of cancer patients that lifetime caps or 

annual caps or whatever caps might in fact limit the treatment 

they receive. 

When you deal particularly in the cancer world with young people with cancer whether they be children, whether they be young 

adults, there is a very real issue about the cost of their care over 

time. And if in fact they become rated within the insurance market 

going forward as they age that would become obviously a very serious burden. 

Ms. SCHAKOWSKY. Have you seen that in your practice of young 

people who actually either have or live in fear of these lifetime 

caps? 

Dr. LICHTENFELD. Before the ACA it was a real problem and people even within organizations that I am familiar with would run 

up against, you know, and group insurance, would run up against 

caps and that would be a serious issue particularly patients for example with bone marrow transplants. 

When you talk about young people it is definitely, I can speak 

on information from the bone marrow transplant community, the 

financial toxicity of that care and the inability to work going forward for many of these young folks is a very real issue. And we 

do believe that that is something that needs attention as this again 

as this process moves forward. 

Ms. SCHAKOWSKY. And so once the ACA passed did you see then 

an improvement in those situations? 

Dr. LICHTENFELD. We do believe there was an improvement. It 

certainly removed the major concern that cancer patients have. We 

talk a lot these days about financial toxicity. We talk about the 

stress. We talk about mental health issues as was brought up—— 

Ms. SCHAKOWSKY. What is your phrase, financial—— 

Dr. LICHTENFELD. Financial toxicity. 

Ms. SCHAKOWSKY. That is what I thought. 

Dr. LICHTENFELD. It is a very real issue within the cancer community, the high cost of drugs, the high cost of care, the 

deductibles, the co-pays, whatever it may be, caps is clearly something that is part of that conversation. 

Ms. SCHAKOWSKY. Have you seen Chairman Walden’s bill and 

how it would impact children or adults that have cancer? 

Dr. LICHTENFELD. Well, you know, to be honest with you again 

that is, there are things that are in the bill and things that are not 

in the bill so we still have a ways to go. So rather than supposing 

what is going to be offered, I would rather defer that until we have 

more information. 

Ms. SCHAKOWSKY. OK, thank you. And I yield back. 

Mr. BURGESS. The gentlelady yields back. The Chair thanks the 

gentlelady. The Chair recognizes the gentleman from New Jersey, 

Mr. Lance, 5 minutes for your questions, please. 

Mr. LANCE. Thank you very much, and good morning to the 

panel and I apologize for not being here for all of your testimony. 

We are shuttling back and forth between two subcommittees. 

To Mr. Holtz-Eakin, thank you for being here. In your testimony 

you mentioned that the individual mandate was an ineffective 

mechanism to encourage the enrollment of young people in the exchanges. In what ways is the continuous coverage concept a more 

63 

effective tool to engage people to gain and maintain health insurance coverage? 

Dr. HOLTZ-EAKIN. It is a natural and economic incentive and 

health incentive. You know, most of the replacement plans that 

have been offered that we have looked at would maintain the provision under current law where you can stay on your parents’ policy 

until you are 26. 

At that point a young person who recognizes they are cheap to 

insure so it is easy for them to get insurance, they may develop, 

may not be medically underwritten so they aren’t going to get their 

premiums jacked up because of their health, that is a real incentive 

to get in early. That broadens the risk pool and when people do develop conditions you have both the high risks and the low risks in 

the pool. That is always the goal in insurance. 

Mr. LANCE. Would others on the panel like to comment on that? 

Dr. LICHTENFELD. I would, thank you. 

Mr. LANCE. Certainly. 

Dr. LICHTENFELD. You know, the continuous coverage issue is 

one that is obviously again under discussion, but our concern at the 

American Cancer Society is and on behalf of our constituents, of 

our patients, is the details of what happens because the risk is very 

real. 

I mean what—you know, no one again expects to get cancer, and 

sometimes when it happens it happens very quickly and it absorbs 

people and they can lose their jobs and then they might lose their 

insurance and then they enter the market under the proposals and 

they may be rated at a premium they can’t afford. 

So how the committee addresses this going forward again is a 

major concern of ours to get it right, to make sure that the rules 

are appropriate and that people who get a sudden illness may not 

be capable of dealing with a continuous coverage provision of 30 

days, for example, are able to have some leeway and understanding 

that meets their needs at their particular time. 

Mr. LANCE. I certainly agree that we want to get it right. It is 

just my concern that young people have not been involved to the 

extent we would like them to be involved. And we want to repair 

the ACA and I have never favored its repeal without a replacement. I think it needs to be repaired and we are trying to focus 

on repairing it and that is why we are conducting this hearing 

along with other hearings. 

To the commissioner, given your background as a State insurance commissioner, could you speak to some of the effects you have 

seen at the State level regarding the 3:1 age band, special enrollment periods and the 90-day grace period? 

Mr. WIESKE. I think you can see in our testimony that the impact of cost, the increases have been borne by the young which has 

made it unaffordable, just caused the risk pool to deteriorate which 

has caused, you know, sort of a death spiral. 

We have seen consistent changes from the insurers in the areas 

that they are covering. There is a lot of chaos. We had 37,000 folks 

that lost coverage from their particular insurer in Wisconsin last 

year which pales in comparison to the 100,000 in Minnesota that 

lost their coverage last year. So there have been pronounced effects. 

64 

You know, the problem with the SEP process is it is confusing 

for consumers, it doesn’t make, you know, the current one it doesn’t 

make any sense. It is harm to insurers. If you use magic words 

that go into the, with HHS you get your SEP. If you don’t use the 

right magic words even if you deserve it you don’t get an SEP. That 

has been a consistent problem when it is done at the Federal level, 

so there has been problems. We would like to see it go back to the 

companies to administer. 

Mr. LANCE. Dr. Holtz-Eakin, would you care to comment on that, 

please? 

Dr. HOLTZ-EAKIN. I think all the evidence that we have seen on 

it and summarized in my written testimony suggests that this is 

exactly right. It is not just a Wisconsin problem, this is a pervasive 

problem. It is worse in the risk pool and it has had the insurers 

unable to price things effectively. 

Mr. LANCE. And I hope that the American people who are undoubtedly listening to our deliberations recognize that there has 

been this type of terrible situation across the country, not only in 

Wisconsin and Minnesota, but in other States, as well. And the 

goal of the ACA was a good goal, and the question is how to 

achieve that goal in the most effective and efficient manner recognizing that we want no one to be discriminated against, for example, based upon a preexisting condition. I yield back 5 seconds, Mr. 

Chairman. 

Mr. BURGESS. The Chair thanks the gentleman. Before we go to 

our next question, the Chair would ask that Members on both sides 

of the dais who are engaged in conversations be mindful of the fact 

that I think Mr. Griffith of Virginia is hard of hearing and he is 

having difficulty in keeping up with the important discussions 

going on. So the Chair would ask that side conversations be taken 

off the dais or kept to a minimum. 

The Chair now recognizes the gentleman from North Carolina, 

Mr. Butterfield, 5 minutes for questions. 

Mr. BUTTERFIELD. Thank you very much, Mr. Chairman, for 

yielding time. Let me begin, Mr. Chairman, by just echoing some 

of the sentiments that were expressed by Ranking Member Pallone 

at the outset of this hearing. I share those concerns. This topic is 

very perplexing and very difficult for us to grapple. 

We hear different terminology as we have this debate. I hear Mr. 

Lance talk about repairing the ACA and I hear others talk about 

repealing the ACA, and so I am still trying to grapple with what 

we are talking about today. This appears to be another hearing to 

discuss Republican plans to change the healthcare system and reduce people’s access to care and to make health care more expensive. That is the way it appears to me. 

You are trying to enact these changes that will actually make 

health care more expensive for low-income individuals and children 

and families and older Americans. After 7 years of complaining 

about the ACA and actively trying to disrupt by ripping it apart 

and causing it to fail, it is disheartening now to see a plan that is 

half written and incomplete. I expect more. I think the American 

people expect more. 

And I will say what my colleagues have said repeatedly, we are 

prepared and willing to work with you to improve the Affordable 

65 

Care Act, make no mistake about it. This is the second day we 

have been in this room discussing ways to make it harder for people to access health care. 

I represent one of the poorest districts in the country in North 

Carolina where nearly one in four people live in poverty. Every day 

I hear from constituents about increasing access to health care, not 

decreasing it. Many of my constituents talk to me about expanding 

Medicaid and strengthening the ACA not making it harder to access health care. 

My constituents overwhelmingly, Mr. Chairman—maybe I spent 

too many years in a courtroom, Mr. Chairman. If the committee 

will come to order. 

Mr. BURGESS. The gentleman from North Carolina is correct. 

Mr. BUTTERFIELD. Yes. 

Mr. BURGESS. The committee does need to be respectful to the 

people who are speaking. Can I ask the committee to come to 

order? 

Mr. BUTTERFIELD. My constituents, Mr. Chairman—— 

Mr. BURGESS. The gentleman continues suspend. 

Mr. BUTTERFIELD. Thank you. I guess I was spoiled by being in 

the courtroom, Mr. Chairman. 

Mr. BURGESS. The gentleman may proceed. 

Mr. BUTTERFIELD. My constituents, Mr. Chairman, overwhelmingly support our new Governor in North Carolina who is doing all 

that he can to expand Medicaid. In my district the uninsured rate 

has been cut by one-quarter. More than 35,000 people have insurance as a result of the ACA. Across the country 20 million people 

have obtained health insurance since 2010. The uninsured rate in 

our country is at an all-time low. That is a fact. 

I could talk for hours about the statistics that show North Carolinians and Americans are better off because of the ACA. Our 

healthcare system is better off because of it. It could be in an even 

better situation if detractors had not consistently fought it at every 

turn. 

Now Republicans want to turn back the clock. They want to put 

insurance companies back in charge of health care, make it more 

difficult to keep your healthcare plan and make it more expensive 

for many Americans to pay for health care. 

Chairman Burgess, I agree with your comments yesterday that 

seemed to indicate that this committee has gotten off on the wrong 

foot. I believe it has. Democrats will not stand idly by while we are 

forced to consider proposals that will restrict access to health care. 

Mr. Chairman, I have received a letter from AARP which supports 

the positions that I have just articulated. I would ask unanimous 

consent that it be included in the record. 

Mr. BURGESS. Without objection, so ordered. 

[The information appears at the conclusion of the hearing.] 

Mr. BUTTERFIELD. All right, I have 1 minute remaining. Dr. 

Lichtenfeld, thank you for your testimony in support of many of the 

improvements to our system made by the ACA. Many of my constituents in eastern North Carolina are from minority groups, racial minority groups. 

Can you discuss some of the cancer health disparities experienced by ethnic and African Americans and Hispanic Americans 

66 

and would some of the potential changes to our healthcare system 

discussed today further exacerbate these disparities? 

Dr. LICHTENFELD. Well, Mr. Butterfield, thank you for your question. I mean there is no question that ethnicity plays a role in access to care and there is also no question that socioeconomic status 

plays a role in access to care. Making certain that all individuals 

have appropriate access to affordable care that meets their needs 

particularly for cancer patients is so important. 

I have lived in a rural area. I have experienced and seen the 

issue. I am in a State that did not expand Medicaid as have 19 

other States have not done so, and what the evidence is showing 

us is that access to care through insurance by whatever mechanism 

is important to reduce the burden of cancer. 

So we are aware of that. We are hopeful in the committee going 

forward will address that issue as well. 

Mr. BUTTERFIELD. Thank you, Doctor, and thank you, Mr. Chairman. I yield back. 

Mr. BURGESS. The Chair thanks the gentleman. The gentleman 

yields back. The Chair now recognizes the gentleman from Oregon, 

the chairman of the full committee, Mr. Walden, 5 minutes for your 

questions, please. 

Mr. WALDEN. Well, I thank the chairman. And I have been listening to the various comments and the testimony, and let me say 

again, this is a discussion draft. It is not a finalized bill. We are 

not coming here to cram something through that nobody has had 

a chance to have input on or read. I thought that is what you wanted. It is what I want. 

And so there are some opportunities to weigh in. That is what 

a—this may be unusual for some, but that is kind of what a legislative process is supposed to look like. And I will tell you what. I 

read all your testimony, and I appreciate it from a lot of levels. I 

have heard some of the things hurled my way. I don’t want lifetime 

caps. I care pretty deeply about older people and younger people, 

including infants, very personal place. 

And I have seen markets that work and markets that don’t. I 

fought on insurance companies when they were denying care and 

shouldn’t. I fought to create high-risk pools when in my home State 

you didn’t have the fix on a preexisting condition. I have seen cancer up close. My mother died of ovarian cancer, my sister-in-law, 

brain cancer. Like many of you, you or people in your families or 

in your communities deal with this. The notion that somehow because there is a break in the dais we don’t care about getting this 

right is beyond the pale. 

So I hope going forward we can have a really constructive discussion here about how to make this bill work, how to make sure regardless of what we or some other Congress does going forward 

that if you had a preexisting condition you will always have access 

to care and that there won’t be some artificial cap that says 

through no fault of your own you have a disease that keeps coming 

at you, but sorry, you are on your own and you are destitute. That 

is not the choice here. The choice is how do we get it right. 

The notion that this individual market is in a wonderful place is 

a fiction. All you have to do is listen to the experts that are out 

there and they will tell you this can’t survive the way it is today. 

67 

If Hillary Clinton were in the White House and Democrats controlled everything, I tell you, you would be back because just like 

we had to deal with other problems over the years, just like the 

laws that have been passed and voted on by Republicans and 

Democrats to deal with problems in Obamacare, we are going to repeal this and we are going to come back with a plan that will work 

for everybody. 

Now I want to ask the gentleman from Wisconsin, reading your 

testimony it was pretty evident you had a market that was working, not perfect but working. Tell me what happened when the 

ACA came down on top of what your State was doing, and tell me 

this, too: Is it possible for us here to pass this piece of legislation 

as appropriately written that will guarantee people have access to 

care of their preexisting conditions and that there won’t be caps on 

lifetime coverage, and could you still put together a market with 

those two conditions? 

Mr. WIESKE. We can in Wisconsin. I feel confident that—I mean 

we still have 15 insurers in the marketplace, in the market and 

selling insurance through the exchange. We have another six or 

seven that are selling off-exchange. We think that those will step 

up more to the plate if the rules reflect the actual costs. 

We have had a number of significant market exits. We think we 

can get them to return if the market rules are more reasonable 

across the country. It is not our rules that are the problem it is the 

Federal rules. They are losing money. We have seen significant, if 

you talk to our financial folks you have seen significant loss of capital inside the insurers that will never return under this environment and that is why they are leaving the individual market. 

The individual market is a residual market as was shown in the 

slides. It is roughly, you know, seven percent, five percent of any 

State’s market. It is very small and it is leading the losses and that 

is why they are exiting the market. That is what is causing the 

issue. 

So I think a return to that if it returned to market principles 

with appropriate consumer protections that the market will return. 

It will take some time. Kentucky destroyed their market in the 

1990s. It eventually came back. And so I think it will come back, 

yes. 

Mr. WALDEN. Mr. Holtz-Eakin, do you agree with that concept? 

Dr. HOLTZ-EAKIN. I do agree with that. I think there is a lot of 

evidence that you can put in place sensible market rules and have 

vibrant individual markets. We don’t right now, but it can be done. 

Mr. WALDEN. I know I have used up my time, Mr. Chairman, unless the doctor wants to respond. I would be happy to get his additional comments as well. 

Dr. LICHTENFELD. Thank you. Thank you, Mr. Chairman, I appreciate that. 

Mr. BURGESS. Proceed. 

Dr. LICHTENFELD. You know, we sit here and we talk in certain 

words such as market principles, and I understand that. I accept 

that and that is not the problem. But when market principles get 

in the way with people having affordable care particularly the older 

people, then we run into difficulty. 

Mr. WALDEN. Right. 

68 

Dr. LICHTENFELD. So as you said and I said earlier in my testimony or in my comments, this is a work in progress, understood, 

here to help try to meet a resolution. 

Mr. WALDEN. We appreciate that. 

Dr. LICHTENFELD. That is what we are aiming for so that we 

don’t run into the problem where a principle becomes a barrier that 

then prevents people from getting access to care. 

Mr. WALDEN. Right, thank you. Thank you for your indulgence 

and your help. 

Mr. BURGESS. The Chair thanks the gentleman. The gentleman 

yields back. The Chair now recognizes the gentlelady from California, Ms. Matsui, 5 minutes for your questions, please. 

Ms. MATSUI. Thank you, Mr. Chairman. When we started writing 

the ACA over 7 years ago, I consulted with a full range of 

healthcare leaders in my community in Sacramento. We called together the hospitals, the health plans, the community health centers, the patients, and all those that contribute to our healthcare 

systems. Everything was fully constructed because we knew that 

each policy affected the next and the system as a whole. 

We all know that health care is complicated. You can’t simply 

consider these changes in a vacuum. The Republicans have been 

saying for almost 7 years that they have a better way, but what 

we have seen today does not protect people. It really does take coverage away. 

One of the bills shortens grace periods to 30 days, which means 

that if someone misses just 1 month’s premium payment they can 

be kicked off of their health plan. For many workers with fluctuating income they may need to forego a payment 1 month in 

order to put food on the table and then pay it back the next when 

they receive their paycheck. 

Now, if getting kicked off your plan wasn’t bad enough, the second policy kicks—which says, or we assume it will say, that you 

must maintain continuous coverage or else insurance companies 

will charge whatever they want the next time you sign up. If they 

know you are sick, they could offer you a plan, but only if you paid 

thousands of dollars a month, and what good is that? So now if a 

person ever misses even a single payment, they could be locked out 

of receiving health coverage for years or even for life. 

Now we talk here in statistics and charts and things like that, 

and that is very important. But I think we have to all understand 

that health care is very personal, to all of us here it is personal. 

Chairman Walden mentioned how personal it is to him with his 

mother having ovarian cancer. My mother had ovarian cancer. 

Many people here have had individuals with lymphoma, blood cancer. It is very personal. And I think to a certain degree we have 

to understand that there are certain diseases like cancer that may 

hit you with such a shock at the very beginning and you have to 

figure out what you are going to be doing next. 

So this is really a journey for most people with cancer, is that 

type of disease. So Dr. Lichtenfeld, in your experience, do cancer 

patients often spend a lot of time with their doctors and care teams 

to help get them well? 

Dr. LICHTENFELD. I am sorry. Can you rephrase the question 

again? I may have missed it. 

69 

Ms. MATSUI. Do your patients, cancer patients, often spend a lot 

of time with their doctors and their care teams to try to figure out 

what to do next, how to get them well? 

Dr. LICHTENFELD. Cancer is a complex disease and there is no 

question that the most important objective is to get the patient well 

and that takes time, it takes effort and it takes teams. There are, 

as I mentioned earlier there is increased attention to mental health 

issues with respect to cancer, financial toxicity issues, which are 

above and beyond the care discussion, and there are now requirements being put into place that expect that type of discussion. 

So yes, I mean it is not a simple process. It is complex. It is 

much more complex as time goes on. The drugs are more complex, 

the treatment, trying to help people get to the treatment, all of 

these are issues that have to be addressed as part of the cancer 

journey. 

Ms. MATSUI. So during this process do cancer treatments like 

chemotherapy have side effects that make it hard for patients to 

accomplish daily tasks? 

Dr. LICHTENFELD. There is no question that the treatment is 

toxic for many situations and the fact that many patients are so 

impacted. I mean the fatigue issues are well known, the ability to 

work, whether someone, as I mentioned earlier the substantial 

number of people are not able to work. Meeting payment requirement is important, but yet perhaps the 30 days is not the right 

number that we should be talking about. 

Ms. MATSUI. So cancer patients don’t get a pass at all on taking 

care of the finances. 

Dr. LICHTENFELD. No, they don’t get a pass. So I think we have 

to look through that cancer lens to understand the implications of 

what we do, and understanding it through that lens will give us 

guidance, we believe, in terms of how this should be constructed 

going forward. 

Ms. MATSUI. So it is possible that a cancer patient has to deal 

with so much that even when a loved one is managing their affairs 

a month’s payment can be overlooked? 

Dr. LICHTENFELD. It is incredibly complex. We have many life 

situations that are complex and cancer is certainly one of the most 

complex that we have to deal with. 

Ms. MATSUI. So if that patient is kicked off their plan for missing 

one payment what happens to that patient? 

Dr. LICHTENFELD. Well, they end up, whether they could get the 

care the care would be interrupted, and then when they come back 

into the system so to speak their premiums under some discussions 

may be much higher than they would have been otherwise and that 

may last a lifetime. 

Ms. MATSUI. OK. I yield back. 

Mr. BURGESS. The gentlelady yields back. The Chair thanks the 

gentlelady. The Chair recognizes the gentleman from Virginia, Mr. 

Griffith, 5 minutes for your questions, please. 

Mr. GRIFFITH. Thank you very much, Mr. Chairman. I have 

heard a lot of folks talk about things and what their constituents 

are telling them. And while I have constituents who certainly have 

liked the ACA, a vast majority of my constituents have had problems similar to Mark from Stuart, Virginia, who writes in part, 

70 

talking about the increased premiums that he has had to pay, he 

says, ‘‘It has cost my family around $21,000 over the last 3 years.’’ 

He goes on to say, ‘‘I would like nothing more than to see this 

law repealed as fast as possible and relegated to the trash heap of 

history.’’ He goes further, ‘‘Please be responsible in what it is replaced with and make sure it consists of commonsense measures 

that will help, not hurt, middle-class families.’’ 

And I think that is why we are here. We are trying to figure out 

how we can do things that balance it out which is why, Mr. Wieske, 

I want to talk to you about the high-risk pools that were successful 

in your State. How many people did you all cover? 

Mr. WIESKE. Roughly 25,000. 

Mr. GRIFFITH. OK. And what rates were you able to offer these 

patients? I know you said they were affordable but just give me 

some idea of what they were. 

Mr. WIESKE. They varied, so the deductibles varied from $1,000 

deductible all the way up to a $7,500 deductible. I believe the rates 

for the typical, in my testimony I compared it to the rates that 

what a Silver Plan would be and it was a little bit lower than what 

the ACA plans are in Wisconsin currently. 

Mr. GRIFFITH. OK. 

Mr. WIESKE. So roughly about, depending on—it varied based on 

age—so between 200 and 500 dollars, roughly. 

Mr. GRIFFITH. OK. And I thought it was interesting you said that 

40 percent was paid by the insured, 30 percent by the insurers, 30 

percent by the medical folks taking some discounts—— 

Mr. WIESKE. Correct. 

Mr. GRIFFITH [continuing]. But then at one point I thought I 

heard you say there was also some private money? 

Mr. WIESKE. There were subsidies that were also included as 

part of those assessments. So consumers who had, or members who 

had, incomes at or below $34,000 received subsidies, at the lowest 

end was up to a 43 percent subsidy on the premiums. 

Mr. GRIFFITH. And the subsidy came from? 

Mr. WIESKE. It came from the high-risk pool. 

Mr. GRIFFITH. It came from the high-risk pool. 

Mr. WIESKE. The high-risk pool funds, yes. 

Mr. GRIFFITH. OK, so that would have been some State money? 

Mr. WIESKE. No State money. There was no State money at that 

time. 

Mr. GRIFFITH. Explain that to me. It came from the high-risk, 

was that the insurers? 

Mr. WIESKE. It was the insurers and the providers, the discounts. 

So they were able to provide—— 

Mr. GRIFFITH. So that was part of the 40/30/30 that you were 

talking about? 

Mr. WIESKE. Correct, right. 

Mr. GRIFFITH. All right. And I think you have already answered 

it was not a one size fits all? You could make some choices within 

the high-risk pool itself? 

Mr. WIESKE. Yes, yes. 

Mr. GRIFFITH. All right, so we are trying to figure out how to 

craft which is why, you know, it is interesting. I have heard some 

criticism that Chairman Walden’s bill has a placeholder in it, but 

71 

we are trying to figure out exactly, you know, what we can do to 

make this and get all the ideas, Democrat and Republican. 

So what in your opinion, if we are going to set up a high-risk 

pool what are the most important factors to consider when States 

design these high-risk pools? When we say to the States if we decide that is where we want to go, what should the States be doing 

to make their high-risk pools work as yours did? 

Mr. WIESKE. Yes, I think affordability is the key. I think having 

a good partnership between the providers and the insurers and 

having a strong board that is interested in governing, a long-term 

board. It was outside of the—it was a quasi-governmental entity 

that ran the high-risk pool. I think that was effective. They hired 

outside experts. 

They had, instead of taking the claims in-house they hired an administrator. They had a great administrator who did great work. 

So I think having a strong structure in place is the most important 

piece and then having the funding mechanism that is stable. 

Mr. GRIFFITH. All right. And, you know, one of the things that 

I had thought we might have to do, but you all didn’t have any 

State money, do you think we need to at least prime the pump, so 

to speak, and have some Federal money to help the States get their 

high-risk pools started, or do you think they can take your model 

and not have any Federal money? 

Mr. WIESKE. I think you see if you look at the Federal, so early 

on the ACA did include funding for high-risk pools, and I think if 

you look at the premiums for that they dropped considerably. There 

was about a 150-$200 drop depending on the age in premiums. So 

I think Federal funding could certainly help make that coverage 

much more affordable. 

And, again, I will say that high-risk pools are not for every State 

so there may have to be other options like reinsurance schemes or, 

you know, maybe some States do want to do guaranteed issue, but 

we found high-risk pools effective. 

Mr. GRIFFITH. OK, I really do appreciate that. You know, this is 

a tough nut to crack on all those bills that we are considering, not 

only the ones for today but other bills you see us considering. All 

three of the witnesses, if you would please let us know. 

I mean I am making suggestions to Chairman Walden’s team to 

make some improvements on his bill that I think might need to be 

in there, but we encourage you to let us know what you see and 

what you think you can do because we are looking for constructive 

criticism. We want to take the time to get this right for the American people, and so as Mark from Stuart said to make that we are 

helping folks and not hurting middle class families in America. But 

thank you so much for being here today. I yield back. 

Mr. BURGESS. The Chair thanks the gentleman. The gentleman 

yields back. The Chair now recognizes the gentlelady from Florida, 

Ms. Castor, 5 minutes for your questions, please. 

Ms. CASTOR. Well, thank you, Mr. Chairman, and thank you to 

the witnesses for being here. I wanted to make sure that we go 

back again to the point because we have the chart that was up on 

the screen and the impression that may have been left that repealing the ACA applies just to the healthcare.gov marketplace. 

72 

And I think folks really need to understand that when you repeal 

the ACA as my Republicans are on track to do that affects all 

Americans, everyone. Medicare, Medicaid, or the folks, the 20 million Americans who did get coverage under healthcare.gov, the 

marketplace—and in Florida that was 1.7 million, larger than the 

population of some States have enrolled in the marketplace in Florida—but the employer based insurers where most of our neighbors 

get their insurance. 

There are vital consumer protections that have improved the 

lives of our neighbors and you simply can’t gloss over that or ignore 

it and people need to really understand what they have gained, and 

Florida is a great place to look. In Florida we have 8.8 million that 

have their insurance through their job that means that all of those 

folks can no longer be discriminated against if they have a preexisting condition like cancer, diabetes, asthma, heart disease—we 

estimate that that is about 7 million Floridians. 

Under the Affordable Care Act, under your private policy your 

kids can stay on your policy until they are 26 years old. Insurance 

companies cannot cancel your policy if you get sick and they can’t 

impose lifetime limits or caps. All of that will be lost under the 

ACA Republican appeal plan. These consumer protections have 

been a godsend to our neighbors. 

And let’s talk a little bit about cost because I am very, I am sensitive to the fact that the markets are different across the country, 

but you can’t deny that before the ACA healthcare costs were out 

of control. And if you look just in my State, the ACA has generated 

significant savings for Florida families. 

And we have got to do more to control the cost. If we can really 

tackle pharmaceutical costs that would be a great help for families. 

I don’t see any bills on the agenda today that do that but that 

would be very positive. Florida families with employer coverage 

saw their premiums grow only 1.3 percent from 2010 to 2015 compared to 8.2 percent over the previous decade before the Affordable 

Care Act. That means, if you look at it in real dollars, a savings 

of about $7,600 per family. 

The ACA also requires, and this doesn’t get a lot of play but it 

is very important. The ACA also requires health insurance companies to spend at least 80 percent of their premium dollars on actual 

health care, not administrative costs or profits, and if the insurance 

companies go over that 80 percent they have to—consumers get a 

refund. HHS reports that Floridians with employer coverage have 

received $109 million in refunds since 2012. That really makes a 

difference for the working families I represent. 

So one of the bills that is on the agenda for discussion today is 

age rating. Boy, have you really hit a nerve back in Florida to ask 

that our older neighbors, and we are talking about those that are 

under 65, are going to pay a whole lot more for their insurance coverage. 

The thing about the Affordable Care Act, it is this very considered, thoughtful balance. Over time it is going to need rebalancing. 

Like I said, markets like mine are very competitive even in the individual market with 61 plans to choose from. Not all parts of the 

country are like that. But if you start tinkering here and asking 

my older neighbors to pay a whole lot more before they go into 

73 

Medicare that is not smart. We want them to be as healthy as possible before they go into Medicare because we have our challenges 

there as well. 

So watch out for this age rating, and I go back to the woman that 

I mentioned during my opening remarks who is 60 years old, working part-time in a small business, taking care of her youngster in 

high school, going to school. You ask her to pay five times the going 

rate instead of what is in the ACA now you probably price her out 

of this. 

So let’s be thoughtful in what we do. We have got to turn back 

this repeal effort, though, and make more considered and thoughtful policy here in Washington, DC. I yield back my time. 

Mr. BURGESS. The Chair thanks the gentlelady—the gentlelady 

yields back—and recognizes the gentleman from Florida, Mr. Bilirakis, 5 minutes for questions, please. 

Mr. BILIRAKIS. Thank you, Mr. Chairman. I appreciate it very 

much, and I thank the panel for their testimony as well. 

Mr. Holtz-Eakin, I understand you run your, CBO, and you currently run a think tank? 

Dr. HOLTZ-EAKIN. That is correct, sir. 

Mr. BILIRAKIS. Your organization recently did a review on the 

various replacement plans that conservatives had introduced. 

There is the Better Way by House Republican Conference, the Patient CARE Act, the Improving Health and Health Care Act, Empowering Patients First Act, the American Health Care Reform 

Act, the 2017 project in the World’s Greatest Health Care Plan. 

When people say Republicans don’t have a plan that is simply 

not true. There are many plans and competing ideas. However, it 

would be fair that there are certain common areas that are in most 

of these plans. Can you talk about the ACA provisions that in your 

expert opinion would most likely be kept? If you would elaborate, 

please. 

Dr. HOLTZ-EAKIN. Yes, I mean one of the reasons we wrote the 

paper is that there is an enormous amount of overlap and so it 

seems to me to be sensible to expect those to be present in any replacement plan. 

So all of them allow children to stay on the parents’ policy until 

age 26 as in current law, all prevent discrimination against those 

with preexisting conditions and guarantee the issuance of an insurance policy, all of them ban caps on annual or lifetime out-of-pockets for individuals, and then they all have subsidies for individuals, 

typically age based so the elderly, the older and more likely to be 

expensive patients get some help. 

All of them have some sort of risk pool for those who can’t be 

managed in the normal pool and all have some sort of approach to 

the continuous coverage idea where the differences quite frankly 

are in how do you handle the gaps. Handling the gaps, I want to 

echo what was said, is a really important issue. All of them have 

some provision to cap the most exposure that an individual would 

face if somehow they did develop a coverage gap for reasons outside 

of their control. So there is always common elements in these replace plans. 

Mr. BILIRAKIS. Very good, thank you. 

74 

Mr. Wieske, when the ACA was passed there were several promises made about it. The American people were promised it would 

bend and cost curve through increased competition the health insurance market. In Florida today 73 percent of the counties have 

only one health insurer and average premiums increased by 19 percent last year. I fear that what it will look like 2018. 

You mentioned that in Wisconsin you have an active insurance 

market pre-ACA—— 

Mr. WIESKE. Yes. 

Mr. BILIRAKIS [continuing]. And then how was the health market 

before ACA and now with the ACA? Can you discuss it? 

Mr. WIESKE. Yes, I think we saw the highly competitive markets 

were fortunate. We still have a lot of choice in our market, but it 

is evaporating slowly but surely. And we see carriers consistently 

move their market around, move their coverage areas around, so 

there is a lot of instability. They have changed their networks. 

They have changed their networks around in order to deal with affordability and competition and issues, and the net result for a consumer is consumers don’t have as many choices as they had before 

the ACA. They have fewer choices in coverage. 

Mr. BILIRAKIS. Thank you. Mr. Holtz-Eakin, again just in case 

members of the minority might not be familiar with our Better 

Way agenda, can you please detail that the Center for Health and 

Economy analysis finds the plan broadly what it accomplishes. 

Again, the impact on premiums would they increase or decrease? 

What about provider access? Would there be an impact on the Federal budget? Can you go ahead and discuss that? 

Dr. HOLTZ-EAKIN. The Center for Health and Economy, of which 

I am a board member, did an analysis of the Better Way plan. I 

won’t remember all the numbers right, but broadly speaking the insurance market deregulation lowers premiums something in the vicinity of 15 percent or so. Lower premiums improve private coverage in that plan and expand coverage. As a result of both the 

lower premiums and the subject structure there is less stress on 

taxpayers and there is budget savings in the Better Way Plan. 

And underneath the plans is important I identify what kind of 

networks and provider access are available, and access has improved. And there is an index of medical productivity, something 

to think about in terms an index for bending the cost curve, and 

there is improved medical productivity in the plan. 

Mr. BILIRAKIS. Thank you very much. I yield back, Mr. Chairman, appreciate it. 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman. The Chair recognizes the gentleman from Oregon, Dr. 

Schrader, 5 minutes for your questions, please. 

Mr. SCHRADER. Thank you very much, Mr. Chairman. I appreciate the panel for being here. I just want to put some emphasis 

on the goal of what we are trying to do here and that is not to just 

beef up an insurance market, but to provide good health care for 

Americans. That is really our goal. 

The vehicle we currently have is dealing with the insurance market, I get that. But I think when we are talking about you can’t 

have the plans you want, et cetera, the goal here is to provide the 

essential benefits that basically provide health care for the scope 

75 

of the people of this great country. And if everyone just pays in 

their little bit just like you do in any insurance program everyone 

benefits at the end of the day. 

I think we have to focus on the health care aspects here. I am 

a little concerned about the tenor of the hearing. I want to make 

sure we are talking apples to apples as we go forward. 

Mr. Holtz-Eakin, you talked about that some of these fixes could 

help stabilize the markets, so I assume you don’t see these as replacement for the ACA but to stabilize the current market structure? 

Dr. HOLTZ-EAKIN. Yes, the special enrollment periods, grace periods, those kinds, again these are what I think of as near term 

Band-Aids to make sure the current deterioration doesn’t continue 

and it works—— 

Mr. SCHRADER. I think that is fair. So they are not going to replace the ACA in and of themselves. 

Mr. Wieske, you talked a lot about the high-risk pools and you 

have a robust market in Wisconsin. Knock on wood we still do in 

Oregon, but some States don’t, some counties don’t, depending on 

the State they are in. I get that. You talked about the Federal subsidy driving down the cost of the program if you will making it 

more affordable for Wisconsinites. 

You know, if we get rid of the ACA in its entirety which has been 

proposed, and all the revenues, the 800 billion plus some of the 

other policy changes that make sure this is a deficit reduction, a 

piece of legislation, you know, what do you think? Don’t we need 

some Federal revenues to make whatever system we have going 

forward affordable for Wisconsinites? 

Mr. WIESKE. I mean I think Federal revenues obviously make it 

easier, but functionally, I mean I will say our market functioned 

pretty well. There was guaranteed issue available. Nobody could be 

turned down in most States, I think all States, because of a health 

condition once they were insured, so that didn’t exist and that 

didn’t exist in Wisconsin. People were not dropped off their coverage due to—— 

Mr. SCHRADER. So I have to interrupt, I apologize. I don’t have 

a lot of time. Yes, and I think there is different opinions about, you 

know, who should get, you know, well, apparently some different 

opinions about who should get covered. I think everyone should 

have coverage and that means making it affordable and maybe 

even giving some people more of a break than some people think 

they deserve, because it all costs us at the end of the day if they 

don’t have health insurance and that is just not productive. 

I want to make a statement and I would like everyone to think 

about this both Democrat and Republican and you certified smart 

people over there on the dais. I am very worried these young people 

we are trying to get onto the individual marketplace they don’t 

exist. I see no evidence that these people are out there no matter 

what we do—age bands, difference in premiums. 

The reason I say that is, and I would love to be proven wrong 

but no one has been able to give me the information, insurers, you 

know, providers, whatever is that a lot of young people are on their 

parents’ plan, age 26. A lot of people have jobs, especially right 

now. They are working. The people that are on the individual marVerDate Mar 15 2010 10:31 Nov 08, 2018 Jkt 037690 PO 00000 Frm 00079 Fmt 6633 Sfmt 6633 I:\115THCONGRESS\115X4PATIENTRELIEFASKOK101718\115X4PATIENTRELIEFWORK
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ket are, in my State and I think most States, adversely selected. 

They are 50 to 65 years old. They have got a bunch of medical conditions. 

And last but not least, with the Medicaid expansion that has 

been successful across the country and is part of the ACA—I think 

we have to understand that the Medicaid expansion is part of the 

ACA—the biggest portion of that population that signed up, they 

are young. Well, younger than me, under 45 years of age, eh. So 

that is good. 

I am worried that we are chasing a unicorn here, folks. I am worried we are chasing a unicorn. I don’t care what plan I have heard 

from my Republican colleagues or as Democrats. So I think we 

need to put that into the mix as we think about how do we make 

sure this individual market is stabilized. It has been a boon for a 

lot of folks. It has worked very well for a lot of folks. It has some 

problems and maybe some of these fixes would get to them. 

And I would hope that the majority party would look at working 

with the minority party on some of these. The age bands don’t have 

to be 5:1. The grace period doesn’t have to be 3 months, you know, 

there is accommodations that we have talked about in previous 

hearings. 

And I think we keep in mind that this is to stabilize the current 

ACA marketplace while my colleagues, trying to chase maybe a 

unicorn, maybe we have been chasing it and now it is their turn, 

but I hope we look at this and the goal again is to provide excellent 

health care to every single American in the greatest nation on 

earth. And I yield back. 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman. The Chair now recognizes the gentleman from Indiana, 

Dr. Bucshon, 5 minutes for your questions, please. 

Mr. BUCSHON. Thank you, Mr. Chairman. Dr. Holtz-Eakin, your 

written testimony is packed with incredible statistics on age rating 

bands and I would like to read a few, just some facts. Average 

healthcare expenses for a 64-year-old are 4.8 times greater than 

that of a 21-year-old, and according to U.S. Census data, the insured rate for those age 19 to 34 is 4.6 percent higher than the uninsured rate for those age 35 to 64. 

I raise this because you note that the administration predicted 

that the individual market would need about 40 percent in the enrollee population to be made up of young, healthy patients. Today 

that number is 28 percent. So the 3:1 age band in my view is just 

not an actuarially sound principle based on that. Would you agree 

that modifying the age variation in premiums would help balance 

risk and help stabilize the marketplace? 

Dr. HOLTZ-EAKIN. Yes, it would help. It would allow insurers to 

offer relatively cheaper policies to the young and relatively inexpensive. It is true that they would be relatively more expensive for 

the older and sicker. That is a financial reality. But getting those 

into the pool helps everyone over the long term. 

Mr. BUCSHON. So at the end of the day, do you think one of the 

biggest problems with what is happening in the exchange marketplace is mostly based on the fact that it is 28 percent young, 

healthy people versus 40 percent? Would you consider that the 

major factor or are there other reasons? 

77 

Dr. HOLTZ-EAKIN. There are probably some other reasons. I think 

this sort of grace period or the special enrollment periods or things 

like that have exacerbated the fundamental problem. But this is a 

core problem and because of the exits and the rising premiums it 

is getting worse not better. 

And we have discussed a little bit about the design of high-risk 

pools today, my basic theory is we have a high-risk pool, and it is 

called the exchange market, and it is just getting more and more 

like one every day. 

Mr. BUCSHON. OK. Mr. Wieske, do you have any comments on 

that? 

Mr. WIESKE. No, I think that is exactly right. And part of to understand is as you get more of the young folks in that drives the 

average rate down so that 5:1 may still be a 5:1, but it is not necessarily the same 5:1. It is a lower figure that you are starting with 

when you multiply it times 5. 

Mr. BUCSHON. Correct. So the 1 will be a lower starting point. 

Mr. WIESKE. Correct. 

Mr. BUCSHON. And I think that is one of the concepts I think 

that people try to overlook. If you take changing the age rating 

band and the concept that the 1 will stay in the same place that 

it is today, you can make the argument yes, costs will be so high 

for the older, sicker patients that it might price them out of the 

marketplace. 

But my, you know, shifting the idea is to shift the whole marketplace back to a more actuarially sound position.So it is not just 

this, but there is some other actuarially unsound principles in the 

ACA that in my view have predictably resulted in where we are 

today. 

Do you have any other final comments, Dr. Holtz-Eakin, on that? 

Anything else that is what you consider nonactuarially sound other 

than the age bands that we might be addressing that we haven’t 

addressed? Do you have any other thoughts? 

Dr. HOLTZ-EAKIN. I think the more you delegate the sort of regulatory process and the review process to the State insurance commissioners, the better you are going to get this because the pools 

are different State by State, dramatically different. 

Mr. BUCSHON. Very important concept. 

Dr. HOLTZ-EAKIN. And so I think you should recognize that in 

going forward. 

Mr. BUCSHON. OK. Mr. Wieske. 

Mr. WIESKE. Obviously we agree. And I think, you know, I think 

the other piece here is that you can take a look at the testimony 

and you can see the disparate impact that the ACA had on rates 

when it was implemented. And in my testimony we have numbers 

that show that the increases were substantially higher on the 

younger folks than they were on the older folks, so it is a return 

back to where it was before. 

Mr. BUCSHON. Dr. Lichtenfeld, I was a cardiac surgeon before I 

was in Congress, so I am going to ask and this is a serious question. Before the ACA, prior to the ACA, if you were referred a patient, you know, that has cancer for example, say, a GI doctor referred you someone that has a colon cancer and that person did not 

have medical coverage how did you handle that situation? 

78 

Dr. LICHTENFELD. With difficulty, quite frankly. 

Mr. BUCSHON. Yes. Did the patient get medical care? 

Dr. LICHTENFELD. Well, they may have gotten some medical care 

but they didn’t get adequate medical care. 

Mr. BUCSHON. So if they needed follow-up chemo from their colon 

cancer for example what, a 5FU or whatever you guys do these 

days, did they get that or they didn’t get it? 

Dr. LICHTENFELD. 5FU is one question, the newer treatments we 

have today are entirely different, OK. 

Mr. BUCSHON. OK, the newer treatments then, yes. OK. 

Dr. LICHTENFELD. And certainly, sir—— 

Mr. BUCSHON. I haven’t done GI or colon stuff in 25 years so I 

am behind. 

Mr. BUCSHON. I respect the work that you have done. In fact, one 

time in my life I wanted to be a cardiac surgeon and didn’t make 

it, so—— 

Mr. BUCSHON. You made the right decision. 

Dr. LICHTENFELD. But the reality is, you know, we as physicians 

always want to do what we can to stabilize somebody in their time 

of need. That is very important. 

Mr. BUCSHON. Yes. 

Dr. LICHTENFELD. Unfortunately cancer is a complex, long-term 

disease. 

Mr. BUCSHON. Understood. 

Dr. LICHTENFELD. And those folks will fall through the cracks. 

They did, and they are doing less so today. 

Mr. BUCSHON. OK, thank you. I yield back. 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman. The Chair recognizes the gentleman from Massachusetts, Mr. Kennedy, 5 minutes for your questions, please. 

Mr. KENNEDY. Thank you, Mr. Chairman, and I want to thank 

the witnesses for their testimony today, touch on a couple of issues. 

Mr. Wieske, you had testified and you spoke an awful lot today 

about the benefits of Wisconsin’s high-risk pool, sir. I wanted to 

make sure we just fleshed that out a little bit. My understanding 

is that when you talk about the comprehensive coverage that was 

provided to consumers and that the cost coverage closely mirrored 

the cost of private coverage in the State, I believe though that the 

premiums for the Wisconsin high-risk pool were set at twice the individual marketplace; isn’t that right? 

Mr. WIESKE. No, that is not correct. They were set based on an 

actuarial basis, so the—— 

Mr. KENNEDY. So that is information coming from Kaiser Foundation. 

Mr. WIESKE [continuing]. I am sorry. 

Mr. KENNEDY. I am sorry. The information coming from the Kaiser Family Foundation indicated that those prices were twice 

the—— 

Mr. WIESKE. The numbers in my testimony were actually provided through the Legislative Audit Bureau, which did an audit of 

the State high-risk pool. I sat on the State high-risk pool board. 

The rates were set based on the actual contribution to costs by 

each of those that split the 40/30/30 that I talked about. 

79 

So that was where it was. It was not set in an artificial 200 percent of the Federal—I don’t know where they got that number, unless it came from the Federal high-risk pool piece, which is separate, and they had their own separate rules of how they set their 

rates. 

Mr. KENNEDY. So if it is not—I understand that you are saying 

they weren’t pegged that way. Were the premiums though twice as 

high as they were for the high-risk pool as they were for the individual markets? 

Mr. WIESKE. Yes. I don’t think so, no. 

Mr. KENNEDY. No, OK. Didn’t Wisconsin’s high-risk pool exclude 

coverage for 6 months for a preexisting condition that made patients actually eligible for that pool in the first place? 

Mr. WIESKE. It depended on how you came into the pool. So folks 

who had continuous coverage it mirrored the preexisting condition 

piece so that is something that could certainly be fixed. But folks 

that came from no coverage similar to folks who were facing a 

grace period who have not signed up for the ACA and can’t sign 

until the open enrollment period and have to wait until then to 

sign up if they don’t have coverage, if they came from no coverage 

they did have a 6-month waiting period. 

Again it would be like an open enrollment period except you get 

to sign up anytime, but only for coverage of that condition. Now 

folks who came from other coverage that lost their coverage involuntarily did get preexisting condition credit and did not have a preexisting—— 

Mr. KENNEDY. So if I were, just to make sure I understand that 

if I did not have coverage before and came down with cancer I 

would have to wait 6 months for those cancer treatments to get 

covered? 

Mr. WIESKE. Similar to if you did not have—— 

Mr. KENNEDY. Yes. 

Mr. WIESKE [continuing]. Coverage right now you could not buy 

coverage in the individual market. You have to wait until open enrollment. 

Mr. KENNEDY. Dr. Lichtenfeld, can you tell me what the impact 

of having a cancer patient wait 6 months for treatment might be? 

Dr. LICHTENFELD. We have actually been through that in the 

past where in fact some of the commercial plans in the group plans 

had exclusions of 9 months, so it is a pretty serious issue. And we 

have also had issues with regard to women who were screened for 

cancer, mammography for example, who did not get automatic coverage. 

So the question was, well, you have screening, you know you may 

have breast cancer but you can’t get the care. So that has been addressed in some respect through the breast and cervical cancer 

early detection program. So it is a very real issue cancer doesn’t 

wait, and there is acute conditions that really don’t wait. So obviously the 6-month exclusionary period which has existed in the 

past in some places is something to be concerned about. 

Mr. KENNEDY. So let me shift topics a little bit here, but I would 

appreciate your medical opinion on this. We have, as I mentioned 

in my opening comments a while ago now, this committee has 

dived into a partial examination of the failures of our mental 

80 

health system across our country and some of the systemic failures 

with that marketplace. 

As you might be aware, the largest provider of mental health, or 

payer for mental health service in the country is Medicaid. And so 

the combination of mental health parity and the Medicaid expansion and some of the clauses in the Affordable Care Act themselves 

were a sea change in terms of access to care, understanding we 

still have an awfully long way to go. 

I was hoping you might be able to comment on what the impacts 

of either doing away with that Medicaid expansion or issues 

around preexisting conditions what that would mean for folks suffering from mental illness. 

Dr. LICHTENFELD. Mental health issues are serious and as I mentioned earlier they certainly impact patients with cancer and families of patients with cancer. Access to those services is very important. And clearly within the community and now with the opioid 

addiction epidemic that we have and the stress that that is putting 

on mental health services, we have to make certain that everyone 

has adequate access to mental health services just as we have 

talked about with respect to services for patients diagnosed with 

cancer. 

Mr. KENNEDY. Thank you, sir. I yield back. 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman. The Chair recognizes the gentlelady from Indiana, Mrs. 

Brooks, 5 minutes for your questions, please. 

Mrs. BROOKS. Thank you, Mr. Chairman. I just want to clarify, 

Dr. Lichtenfeld, under current law, current law, if a patient is diagnosed with cancer they also have to wait, do they not, to get into 

a market? 

Dr. LICHTENFELD. I am going to share with you that I can’t respond to that directly. To my, you know, depending on the circumstances—I am trying as I think through this—they really are 

individual. If I may, they are individually specific to that person as 

to what happens to them, have they been engaged or not, and that 

is a very real—— 

Mrs. BROOKS. If they had not been engaged. 

Dr. LICHTENFELD. If they have not been then that could be problematic. 

Mrs. BROOKS. OK, so that—and Commissioner Wieske, would 

you—and I am sorry. How do you say your last name? 

Mr. WIESKE. Wieske. 

Mrs. BROOKS. Wieske, I am sorry. Is that your understanding—— 

Mr. WIESKE. Yes. 

Mrs. BROOKS [continuing]. That under current law if an individual had paid the penalty or had, you know, and was not insured 

right now, if they develop cancer they too have to wait for open enrollment? 

Mr. WIESKE. Healthy or not they have to wait until open enrollment. They cannot enroll until January of the next year unless 

there is a special enrollment period. 

Mrs. BROOKS. OK, thank you. I would like to talk about what we 

are trying to explore which has to do with continuous coverage and 

the importance of continuous coverage as a potential tool in 

81 

incentivizing individuals to stay covered. And so some folks would 

suggest that this could lead to higher premiums based off of health 

status or preexisting conditions, but I believe that to be false. 

And because we want to prohibit rating based off of health status, we want to prohibit rating based off of preexisting conditions, 

critically important, but in order to accomplish this fairness goal 

we have to stabilize the markets, as I understand actuarially sound 

market stabilizers. 

And so, Commissioner Wieske, as Chair of the NAIC Health Care 

Reform how do both the State of Wisconsin and the association 

view the concept of continuous coverage? 

Mr. WIESKE. Well, I think it is important. I mean I think a lot 

of the issues that surround the individual health insurance market 

are driven by the fact that again it is a residual market and the 

fact that folks jump in and out from carrier to carrier which has 

been exacerbated by the ACA. 

So I think insurers—— 

Mrs. BROOKS. Can you expand on that please? 

Mr. WIESKE. Sure. That in the ACA that you have seen people 

typically jump from one carrier to another obviously based on price, 

based on their interest. 

Mrs. BROOKS. And when you say they jump from one carrier to 

another what is the time period in which they have been doing 

that? 

Mr. WIESKE. Every year they look to switch as to what their best 

options are. That is appropriate shopping. But I think if you can 

design a system that where their coverage is more continuous, I 

think that the interest of the insurers change in driving more longterm health and I think that is really where the issue is, is that 

if you have only got somebody for a year or 2, your investment in 

their long-term health never pays off. It pays off for the next insurer. 

So if you can have a long-term coverage with a single insurer you 

end up having a system where those further investments pay off 

for the insurer. 

Mrs. BROOKS. And do we have some circumstances where people 

might be insured for 9 months and then drop out? 

Mr. WIESKE. Yes, definitely we have heard that the—yes, consistently. 

Mrs. BROOKS. Dr. Holtz-Eakin, I understand—what are your 

thoughts with respect to continuous coverage with respect to a 

mechanism for stabilizing the healthcare markets? 

Dr. HOLTZ-EAKIN. As I said before, I think it is a very important 

concept. Obviously there are details that need to be worked out, 

but the incentives to get the young into the pool are very powerful. 

The issue of having a balanced pool gets taken care of organically 

because the young are always jumping in. Some will become more 

expensive as they get older; they are all in the pool. 

But the fundamental issue has always been how do you get quality care at lower costs, and this gives insurers the correct incentives to look over a lifetime, work with the providers not just for 

short-term purposes but for the long term and that would be beneficial. We don’t have those incentives in the system right now. The 

closest place for that quite frankly is employers. Self-insured emVerDate Mar 15 2010 10:31 Nov 08, 2018 Jkt 037690 PO 00000 Frm 00085 Fmt 6633 Sfmt 6633 I:\115THCONGRESS\115X4PATIENTRELIEFASKOK101718\115X4PATIENTRELIEFWORK
82 

ployers often have employees for an average of 7 years. That is a 

time period over which you can make a big difference. 

And I consider it no surprise that that is the place where we 

have seen the slowest cost growth in the U.S. health system. 

Mrs. BROOKS. Can you share any actuarial cautions we should 

consider as we are shaping this process and what are some of the 

incentives that you believe could be really helpful? 

Dr. HOLTZ-EAKIN. I think the most important thing is to separate 

what the system looks like from how we get there, and today’s discussion is largely that sort of stabilizing it so that you can get 

something in place. The high-risk pools will be at a minimum a 

very important part of the transition mechanism. Figuring out who 

goes in and who comes out and gets back into the regular pool, I 

think, is going to be a really important part of this. 

Mrs. BROOKS. Thank you. I yield back. 

Mr. BURGESS. The gentlelady yields back. The Chair thanks the 

gentlelady. The Chair recognizes the gentlelady from California, 

Ms. Eshoo, 5 minutes for questions, please. 

Ms. ESHOO. Thank you, Mr. Chairman, and thank you to the witnesses for being here today. I guess it is an advantage to come 

early and hear what everyone has had to say and the questions 

that are asked and the answers that you have proposed. 

I want to start out by commenting on Chairman Walden’s remarks. He is a good man, and I take him at his word in terms of 

what he believes in. But for each one of us, we are legislators. We 

are legislators. So while we can all talk about what we believe in 

what is actually written down in legislation which you are here to 

give testimony on, we came to a hearing where Title II Continuous 

Coverage Incentive is blank, blank. It is blank. So I can’t help but 

comment on that first. 

There are so many things that have been said that I find either 

curious or really menacing. First of all, the Affordable Care Act in 

its promise which has been kept so far is that no one can take it 

away from you. That is not what the American people experienced 

before that legislation became law. Now today the only ones that 

can take it away from you are the Republicans. And that is what 

repeal is. Repeal is a heavy, heavy word. It is a wrecking ball. 

We are sitting in a hearing room that was recently remodeled. 

The entirety of the Rayburn Building was not taken down. It 

wasn’t destroyed and then rebuilt simply because these daises 

needed to be adjusted or the room repainted. So when the word repeal is used, it is chilling and, you know what, it is chilling to markets. It is chilling to markets. And I don’t think that has been 

taken into consideration by our witnesses today. 

Now this whole issue of insurance across State lines and what 

it is going to do, I can buy an insurance policy across State lines 

today. Maybe I pick Idaho, I don’t know, Arizona, wherever. Terrific. Maybe it is lower cost than what I have now. The only problem is, when I get sick I have to travel to that State in order to 

take advantage of it. And within our 50 States, there are many different standards. Some States are low-ball States. They have practically no protections for consumers, so if that is what is opened up, 

that is a disaster, in my view. 

83 

Now what I want to ask each one of you is, do you support national insurance for people in our country, each one of you, yes or 

no? Quickly, because my time is running out. 

Dr. HOLTZ-EAKIN. I don’t know what national health insurance 

is. 

Ms. ESHOO. That everyone in this country is able to get health 

insurance. 

Dr. HOLTZ-EAKIN. Everyone has an opportunity to buy a policy, 

sure. 

Mr. WIESKE. Everybody should have access to affordable health 

insurance. 

Ms. ESHOO. Just access or be able to get it? I can go to Nieman’s. 

I can have access at Nieman’s. 

Mr. WIESKE. I think access means that they can get it. If it is 

affordable, access means they can get it. 

Ms. ESHOO. Dr. Lichtenfeld. 

Dr. LICHTENFELD. Ms. Eshoo, and my personal thoughts are not 

relevant to my presentation today, I am here on behalf of—— 

Ms. ESHOO. Well, you are here on behalf of—say yes or no. 

Dr. LICHTENFELD. I am here on behalf of the American Cancer 

Society and we are—just like everything else, we will certainly consider proposals if they are made. Our concern today is to make sure 

that—— 

Ms. ESHOO. That is it. I am losing my time. 

Dr. LICHTENFELD [continuing]. Going forward that we—— 

Ms. ESHOO. Do you support, you all say that you support the 

very good things that are in the ACA—no discrimination, preexisting conditions, women, up to 26 on their parents’ policy—so 

you would support a mandate in whatever replaces the ACA to include those, because it is a mandate. 

Dr. HOLTZ-EAKIN. I didn’t say that. I said every replacement we 

have studied continued those—— 

Ms. ESHOO. No, I am asking you do you support that? You accept 

that it is a mandate or is it voluntary? How are these things going 

to come about if they are not baked in as a mandate for an insurance policy? 

Dr. HOLTZ-EAKIN. People are permitted to have their children on 

their policies up to age 26. They are not mandated to have them 

until 26. 

Ms. ESHOO. But there is a mandate to the insurance industry 

that those reforms which cover everyone—— 

Dr. HOLTZ-EAKIN. Yes, it is the current law. 

Ms. ESHOO [continuing]. So you accept that? 

Dr. HOLTZ-EAKIN. Yes. 

Mr. WIESKE. We had these reforms in place—— 

Ms. ESHOO. Do you, Mr. Wieske? 

Mr. WIESKE. We had these, we performed—— 

Ms. ESHOO. No, I don’t want to hear about that. I just want to 

know if you—— 

Mr. WIESKE. But Wisconsin believes that it has a good market 

and it doesn’t need a Federal mandate to tell us what to do. 

Ms. ESHOO. But do you support those being mandated relative to 

the insurance industry in our country, those reforms? 

Mr. WIESKE. We would look at it in State law, yes. 

84 

Ms. ESHOO. Do you think that beyond your State it should be? 

Mr. WIESKE. I can’t speak for other States. 

Ms. ESHOO. Do you want it for your State? 

Mr. WIESKE. We will work with our legislature and the legislature will figure out what is—— 

Ms. ESHOO. Well, you know what, this is like nailing Jell-O to 

a wall because I don’t think there is a commitment. I think you 

talk about these things and that they are good things, but unless 

these reforms are held onto that were made and have made an 

enormous difference in people’s lives, including all the cancer patients in our country, then there isn’t a commitment to them. And 

I think that this is part of the basics of what the integrity of what 

insurance plans need to have in the country. This has revolutionized people’s lives. 

Mr. BURGESS. The Chair thanks the gentlelady. The gentlelady’s 

time has expired. The Chair recognizes the gentleman from Oklahoma, 5 minutes for questions, please. 

Mr. MULLIN. I feel sorry for the panel. It is funny, because it 

seems like when I go after a panel like that they always get upset 

because I am badgering the witness or something. I understand 

everybody’s opinions runs high on this, I get that. But I will be real 

frank with everybody. The Federal Government should get out of 

the people’s way and we shouldn’t be mandating anybody to do 

anything. That is not the role of the Federal Government. The Federal Government is to provide opportunities and resources for them 

to have access and affordable access, and that is what we are trying to do here: affordable access. 

Oklahoma, which I represent, is one of the States that only has 

one insurer carrier in there. We are one of the one of five. We saw 

premiums rise by 76 percent last year. It is not because the Blue 

Cross Blue Shield is trying to be greedy, it is because they are trying to stay in business. I understand that. The regulatory environment is such that they have to continue to change so they can afford to provide the health care. 

But because of the regulatory environment underneath, ironically, Affordable Health Care—which is anything but affordable— 

it is causing premiums to skyrocket, and then it causes less affordability, which means less access to our constituents. And all this 

committee is trying to do is find a way to bring those premiums 

down and allow access to be created. 

So Mr. Wieske—and I hope I pronounced that right. 

Mr. WIESKE. You did. 

Mr. MULLIN. OK. My first questions to you: Could you help explain why the regulatory environment that we are finding ourselves in right now is causing the premiums to literally skyrocket? 

Mr. WIESKE. Sure. I think it starts with the risk pool. You know, 

you may have a large risk pool, but when you have loaded dice it 

is very difficult to get a representative, you know, 1 through 6, a 

representative sample when the dice are loaded. In other 

words—— 

Mr. MULLIN. What do you mean by loaded dice? 

Mr. WIESKE. What I mean is, is that the risk pool, the people 

who are purchasing coverage tend to need it and they tend to—that 

the folks who don’t need coverage who are young and healthy are 

85 

outside of the market. And so, when you are looking at the people 

that are buying coverage through the ACA, that they are tending 

to be sicker. 

And I think as Doug had indicated that it looks a lot like our 

high-risk pool looked from a risk perspective. It is a little bit better, 

but it looks a lot like that from that perspective. That is the concern. I think you need to lower the premiums for younger folks to 

get them into the marketplace. 

I think a lot of the burdens, you know, the SEP issue I think is 

one. There is a number of others where the Obama administration 

has set such stringent rules that make no sense. Their three Rs 

program has been a disaster as far as hearing out how you pay for 

the reinsurance and adequately price for the risk. The timelines 

are ridiculous. You are pricing a policy in March for something that 

starts in January. You know, it used to be a month, month in a 

half before, insurers don’t have the data. There is a whole host of— 

I could go on probably for hours and bore everybody here. 

Mr. MULLIN. Well, so if I am hearing you correctly, if we keep 

things the way they are right now are we going to create an environment for more access or is it going to drive more insurers out 

of the market? 

Mr. WIESKE. I think there will be a few States like Wisconsin 

that will hang on by our nails for a while, but I think you can see 

in a number of States where the Tennessee commissioner who testified yesterday in front of Senate Health indicated that her market 

was near collapse, I think that is what you are going to be looking 

at over time in a number of States in the current environment. 

Mr. MULLIN. Well, you know, what we have been hearing is that 

both people, my side of the aisle and the other side of the aisle, we 

are passionate about our constituents. What strikes me is that here 

we are actually holding hearings on trying to fix a problem. I just 

wonder how much input you guys got to have when this thing was 

jammed down you all’s throat. At least now we are trying to open 

it up and allow you guys to comment on it. If it is really about our 

constituents, then why would the other side be so upset that we 

are actually having public hearings on trying to fix it and get it 

better? I don’t understand that. 

So I appreciate, I appreciate that you guys are coming here, giving your perspective, the States’ perspective, and we are getting 

input. And I appreciate the chairman, who has taken the time to 

listen and actually put up with some of the shenanigans that is 

going on on the other side, your patience, as you can tell, I 

wouldn’t put up with. I appreciate you doing that, Chairman. 

But at the end of the day this is about getting it right and fixing 

it for our constituents. So thank you for your time, thank you for 

coming in here and giving your expert opinion and we look forward 

to working with you to bring down the premiums so it can be affordable and it can create access for our constituents to have 

healthcare coverage if they so choose to, not mandate to do. Thank 

you. 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman. The Chair would advise the subcommittee and the witnesses that a series of votes have been called on the floor. We are 

going to hear questions from Ms. DeGette for 5 minutes and then 

86 

I am sure the panel would appreciate a break. We will have one 

and then we will reconvene back here immediately after the vote 

series is over. So Ms. DeGette, you are recognized 5 minutes for 

questions, please. 

Ms. DEGETTE. Thank you, Mr. Chairman. I will just say before 

I start asking questions, my colleague from Oklahoma says, well, 

at least we are having hearings on legislation. But I would point 

out that we just learned today that we are going to have a markup 

of these bills that we are allegedly having the hearings today on, 

next Tuesday. And as my colleague from California said, Title II 

of the bill isn’t even a title. It is Continuous Coverage Incentive, 

placeholder, and we are going to mark this up next Tuesday. 

Mr. MULLIN. At least we are having an opportunity to read it. 

Ms. DEGETTE. I think we should work together on this. Now I 

want to welcome the panel here. I especially want to welcome you, 

Dr. Holtz-Eakin. I know when you were director of CBO you appeared in front of this committee many times and I am glad to welcome you back. I want to ask—I want to focus most of my questions on you. First of all, you State in your testimony that the ACA 

is in a downward spiral, correct? 

Dr. HOLTZ-EAKIN. Correct. 

Ms. DEGETTE. And a downward spiral—well, you State in a 

downward spiral prices rise and insurers will continue to leave the 

market, correct? 

Dr. HOLTZ-EAKIN. Yes. 

Ms. DEGETTE. And the result of that is because people are leaving plans and therefore the programs will not be sustainable; isn’t 

that correct? 

Dr. HOLTZ-EAKIN. And there will be less competition and it will 

affect prices. 

Ms. DEGETTE. Right. So declining enrollment would be one characteristic of a death spiral would it not? 

Dr. HOLTZ-EAKIN. Yes. 

Ms. DEGETTE. Yes, it would. So I want to—my assistant is going 

to hand you actually a chart from the Congressional Budget Office, 

and it shows that Obamacare enrollment will hold steady from 

2017 to 2027 and there won’t be decreasing enrollment. Do you see 

that chart? 

Dr. HOLTZ-EAKIN. I do. 

Ms. DEGETTE. Thank you very much. Now also, Dr. Holtz-Eakin. 

Mr. BURGESS. Will the gentlelady yield? 

Ms. DEGETTE. No, I will not. Also, Dr. Holtz-Eakin, the Congressional Budget Office, your former employer, issued a report in January 2017 called ‘‘How Repealing Portions of the Affordable Care 

Act Would Affect Health Insurance Coverage and Premiums.’’ Are 

you familiar with that report? 

Dr. HOLTZ-EAKIN. I am not an expert on it, but I have read it. 

Ms. DEGETTE. OK. So what the report basically looked at was 

the plan President Obama vetoed before, but what that plan did 

was it eliminated in two steps the laws mandate penalties and subsidies, but it left the ACA’s insurance market reforms in place like 

the preexisting condition and age 26 and all of that so it is pretty 

much like what we are talking about here today. 

87 

And here is what the Congressional Budget Office found. It found 

that under a schematic like that, quote, the number of people who 

are uninsured would increase by 18 million in the first year following enactment of the plan. Later, after elimination of the ACA’s 

expansion of Medicaid eligibility and the subsidies for insurance 

purchased through the marketplaces that number would increase 

to 27 million and then to 30 million in 2026. Are you aware of that 

finding? 

Dr. HOLTZ-EAKIN. Yes, and I think it is wrong. 

Ms. DEGETTE. OK. OK, I appreciate that, but that was their 

finding. 

Dr. HOLTZ-EAKIN. It is also out of date. 

Ms. DEGETTE. Now let me—— 

Dr. HOLTZ-EAKIN. You should, no, you should know before 

you—— 

Ms. DEGETTE. No, no. Excuse me, sir. I am asking the questions. 

Dr. HOLTZ-EAKIN. I am giving you some question advice. 

Ms. DEGETTE. The next finding that they made, on page 1 of 

their findings—and I do apologize, I only have 5 minutes. If you 

would like to supplement your testimony, I would welcome that, 

OK. 

The next finding was premiums in the nongroup market for the 

individual policies purchased through the marketplaces or direct 

from insurers would increase by 20 percent to 25 percent. Are you 

familiar with that finding, sir? 

Dr. HOLTZ-EAKIN. I don’t remember that one. 

Ms. DEGETTE. You are not. OK, well, Mr. Chairman, I am going 

to ask unanimous consent to put both this chart from the CBO and 

also the report from January 2017 in the record. 

Mr. BURGESS. Without objection, so ordered. 

[The information appears at the conclusion of the hearing.] 

Ms. DEGETTE. Thank you. Now were you—so if you want to talk 

about a death spiral, it seems to me that a death spiral would be 

caused if you left all of the things, the requirements for the insurance companies, in place but then you eliminated the Medicaid expansion, you eliminated the exchanges and the subsidies, and people left the markets in droves. 

One more thing I just want to talk about, and that is premiums, 

because there have been a lot of allegations thrown around today 

that premiums have been skyrocketing. Are you aware of the CMS 

data that showed from 2000 to 2005 premiums were growing at 8 

percent, from 2005 to 2010, 5.5 percent, and then under the ACA 

average premiums were growing at only 3.6 percent, Mr. HoltzEakin? 

Dr. HOLTZ-EAKIN. What premiums? 

Ms. DEGETTE. Private insurance premiums. 

Dr. HOLTZ-EAKIN. Employer? 

Ms. DEGETTE. Yes. 

Dr. HOLTZ-EAKIN. The ACA didn’t touch employers. 

Ms. DEGETTE. Yes, it did. 

Dr. HOLTZ-EAKIN. That is why it continued to perform well. 

Ms. DEGETTE. Yes, it did. Thank you very much, Mr. Chairman. 

Mr. BURGESS. The gentlelady yields back. The Chair thanks the 

gentlelady. I do note the series of—— 

88 

Ms. DEGETTE. Mr. Chairman, may I just put this chart, ask 

unanimous consent to put this chart in the record, because it also 

talks about Medicare and Medicaid going down. 

Mr. BURGESS. If the gentlelady is willing to share that with the 

committee, unanimous consent request is made, and without objection, so ordered. 

Mr. BURGESS. We have 6 minutes left in our vote on the floor. 

The Chair advises that the committee will stand in recess until immediately after votes. 

[Recess.] 

Mr. BURGESS. Call the subcommittee back to order, and to start 

I want to yield to Mr. Green for a point of personal privilege. 

Mr. GREEN. Thank you, Mr. Chairman, for the time and if I could 

have everybody’s attention. I want to—there is a decorum requirement we do in this committee, and it was after we went to vote but 

our witnesses are here as guests and if you get up and insult, 

whether it is Republican or Democrat, that is not part of the decorum, no matter what. And I am just going to admonish that that 

is not acceptable. 

And so that is enough, Mr. Chairman. I just want to make sure 

that witnesses know they are here to answer questions and not to 

engage in arguments. Thank you. 

Mr. BURGESS. The Chair thanks the gentleman and certainly 

once again thanks the witnesses for being here. And I know it has 

been a long day for all of us. 

At this time, the Chair would recognize the gentleman from New 

York, Mr. Collins, 5 minutes for questions, please. 

Mr. COLLINS. Thank you, Mr. Chairman. I am going to pretty 

much direct this to Dr. Holtz-Eakin. And I know we touched on the 

SEPs, the special enrollment periods. Representative Blackburn, 

who was chairing the Telecom, she is a sponsor of H.R. 706, I am 

a co-sponsor. It goes back to the last Congress, and to the two of 

us and I think to many, there is a lot of common sense in working 

on our special enrollment periods. 

And what we have noticed is, during the Obama administration, 

the enforcement seemed to be quite lax when it came to the SEPs 

and in effect giving individuals what I would call presumptive eligibility instead of verified eligibility, and in doing so there is always 

some costs that would come around. 

So, Dr. Holtz-Eakin, the last time that you testified before this 

subcommittee, you used the term, talking about the verification 

process, as being ‘‘extremely generous.’’ I think there was a little 

bit of tongue in cheek on that. Would you agree that that is still 

the case today, maybe if you want to expand on that at all? 

Dr. HOLTZ-EAKIN. I think this is an important issue simply as a 

matter of the arithmetic as the risk pool. As many as up to a third 

of people in the pool entered through an SEP, and there are a lot 

of SEPs compared to other programs, like Medicare has seven. 

So, you know, that is a big part of it and in the data these are 

more expensive participants than other members of the pool. So in 

a system where the fundamental problem has been the cost and 

the inability of insurers to appropriately plan for costs and bake 

into their premiums those costs, this seems to me like a candidate 

for reform and a place that you should look right away. 

89 

Mr. COLLINS. So in studying this how would you say it impacts 

the market? 

Dr. HOLTZ-EAKIN. It does two things. It brings costs into the pool 

and those costs were unanticipated and that leads directly to insurer losses. The second thing it does is it makes insurers quite 

nervous about next year’s unknowables and puts upward pressure 

on premiums just as a matter of caution to try to anticipate some 

of these people entering. 

Mr. COLLINS. So Commissioner, in your past life—and I know 

you are familiar with the SEPs as well. I think in your written testimony you actually say what we found up in Wisconsin was extremely problematic. Even more problematic, it was clear many 

consumers were using the process to receive costly medical care 

and then immediately dropping coverage. 

Mr. WIESKE. That is correct. We actually did this on a national 

basis, looked at this on a national basis as well. We chair the 

Health Care Reform Alternatives Working Group at the NAIC and 

one of the plans indicated loss ratios on that business in excess of 

180 percent, so significant losses and because of the dropping of 

coverage and they did not maintain it throughout the year. 

Mr. COLLINS. So I will ask somewhat of a rhetorical question, but 

when that happens who is stuck paying for that? 

Mr. WIESKE. The whole pool is stuck paying, so the folks who are 

in the individual market because it is a single risk pool are paying 

higher premiums as a result. 

Mr. COLLINS. And I think it is also safe to say when—I will just 

call this out for what it is, cheating, and when someone is cheating 

the system they are also cheating the sick and the vulnerable patients and potentially driving up their costs. There is always a cost 

to someone and, you know, that is just kind of a point taken. 

So Mr. Chairman, I will yield back. I know there is some airplanes to catch and thank you all for your testimony. 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman, and the Chair recognizes the gentleman from New 

York, Mr. Engel, 5 minutes for your questions, please. 

Mr. ENGEL. Thank you very much, Mr. Chairman. We all know 

the phrase be careful what you wish for. It is a saying that I think 

my friends on the other side of the aisle are finding particularly 

poignant lately. I think our colleagues are on the other side of the 

aisle are finally realizing that it is easy to make promises, it is a 

lot harder to deliver progress as the Affordable Care Act has. You 

know, there is no such thing as a free lunch. If all the good things 

about the Affordable Care Act are going to be kept costs are going 

to go up and a lot of people will not be insured. 

And so I think it is leading us down a primrose path. We should 

have been working together all these years not to try to eliminate 

the Affordable Care Act 62 or 63 times, but to try to improve it. 

All major acts, all major bills, all major programs have to be implemented and then you see how it goes, what works, what doesn’t 

and you tweak, you change it, you try to improve it. But all we 

have had here for the past several years is just ill-conceived votes 

to eliminate it entirely, and now that they apparently are they are 

going to be careful what they wish for. 

90 

Mr. Green said this hearing is taking place on Groundhog Day. 

It is fitting because today Republicans are holding another hearing 

not on new ideas but the same ill-advised bills we have debated before in this committee. There is one exception, a half written draft 

that they claim would protect Americans living with preexisting 

conditions, but when you look closely we punish them instead. 

So I want to underscore how indefensible the situation is. My 

constituents are frightened. They are worried that their preventive 

services that the ACA guaranteed them free of charge are going to 

disappear. They are worried that insurance companies will again 

impose caps on their coverage. They are worried that without the 

ACA’s protections they will be charged more for insurance. And my 

colleagues on the other side of the aisle are really doing nothing 

to allay their fears. 

Dr. Lichtenfeld, I would like to give you an opportunity to speak 

one more time on a matter you were asked about earlier. Speaking 

for the American Cancer Society, can you tell me whether you support every American having high quality health insurance? 

Dr. LICHTENFELD. Thank you, Mr. Engel, and let me clarify the 

answer to that particular question which I may have misheard previously was that yes, I personally am the American Cancer Society. 

I do support universal access to adequate and affordable healthcare 

coverage. 

Mr. ENGEL. Thank you. This draft would require insurance companies cover people with preexisting health conditions, however 

there is nothing in this text that prevents insurance companies 

from charging you more if you have a preexisting condition like 

asthma or diabetes. 

So is it fair to say, Dr. Lichtenfeld, that under legislation without 

a ban on medical underwriting Americans with preexisting conditions like cancer could be priced out of the care they need? 

Dr. LICHTENFELD. Once again thank you for the question. And it 

is our read and our concern that in fact that could happen. 

Mr. ENGEL. Before the Affordable Care Act I think you did say 

in your testimony that cancer patients who could get coverage 

which didn’t always happen were still vulnerable to enormous 

costs; isn’t that right? 

Dr. LICHTENFELD. Yes, sir. 

Mr. ENGEL. And that would happen again without the ACA. So 

I want to talk about that last point for a moment because lately 

we often hear Republicans use the phrase universal access as in 

they want everyone to have universal access to health care. 

They are careful to say universal access not coverage because 

this is what universal access is, a scheme in which insurers must 

cover you but can charge you whatever they want making it all but 

impossible for you to actually afford coverage. This is why they 

chose their words so carefully because the access they are promising isn’t truly access at all. 

Democrats aren’t making pie in the sky promises, they are showing progress. Thanks to the ACA 129 million Americans with preexisting conditions cannot be turned away or charged more because 

of their health status. Healthcare costs have been growing at the 

slowest rate in more than 50 years, and I could continue. Let me 

just say this. 

91 

For 7 years Republicans have claimed to have a better way to reform America’s healthcare system. If that were true then I believe 

that this hearing would have been the perfect opportunity to lay 

out that path forward. But instead after 7 years we have the same 

old bills, tired bills and half of a draft. Our constituents have serious concerns. It is going to take a lot more than this to put those 

concerns to rest. 

So I just want to say that because I think there is nothing more 

important than people’s health care, and I truly believe that if they 

destroy the ACA there is going to be a lot of people in this country 

that are going to be angry and scared. Thank you, I yield back. 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman. The Chair now recognizes the gentleman from Georgia, 

Mr. Carter, 5 minutes for your questions, please. 

Mr. CARTER. Thank you very much, Mr. Chairman, and thank all 

of you for enduring this. We appreciate you being here and for seeing through this and for participating. 

I want to start with you, Mr. Holtz-Eakin. You pointed out 

throughout the hearing today that premiums are rising and that 

insurers are dropping out of certain markets and we know the horror stories of some States don’t have but one insurance company 

that is participating now. And in full disclosure, before I became 

a Member of Congress I was a pharmacist and I owned three independent retail pharmacies at that time and I am a firsthand witness to what has happened to the free market in health care since 

the Affordable Care Act has taken, and I think that is the worst 

thing that has happened is that it has taken the free market out 

of health care. 

How do we get it back? How do we get back to where we are 

competing? I often tell the story that right now Adam Smith is rolling over in his grave to see what we have done to the free market 

in health care. And how do we get the competition back? That is 

what is going to drive prices down, competition. 

Dr. HOLTZ-EAKIN. It is a hard question. I think in the hallmark 

of a good competitive system is some flexibility in the rules that 

surround competition. And I think the mistake of having something 

that is the same across all States where, you know, the market 

structures are very, very different is piece number one. 

And piece number two is you compete on whatever you pay for, 

and so if you pay for procedures people will compete by producing 

procedures that we want to pay for good outcomes. And that would 

be—— 

Mr. COLLINS. You know, there are really three things that we 

want to do. We want to make health care accessible, we want to 

make it affordable and we want to cut out the red tape. We want 

to get the Federal Government out of the way of physicians and patients. And right now, there are so many, there is so much bureaucracy between the patients and the healthcare professionals, 

and that is what we are trying to do is to cut it out. 

Mr. Wieske, I want to ask you because you have obviously experience in this. One of the things that I am concerned about is the 

anti-trust laws as they pertain to the insurance companies, and I 

really feel like this is hindering the competition in a number of different ways. 

92 

I am really big on trying to find exactly what is going on with 

prescription drug prices and particularly the role that PBMs play 

in that because I don’t feel like they bring any value whatsoever 

to the healthcare system. They only raise prices and cause them to 

rise. And when you look at the PBMs, you have three PBMs that 

have 80 percent of the market. That is not competition yet they are 

protected by the anti-trust laws. I mean did you address that in 

Wisconsin at all? 

Mr. WIESKE. So, you know, I think what is interesting about the 

ACA market from an anti-trust standpoint is actually that the insurers are competing not to get business, and I think that is where 

the problem is coming in. In fact, in one State they specifically 

wanted to get out of the cities and one company only wanted to do 

the rural areas so they would have less enrollment. 

And so, you know, I think that is what is interesting is they are 

actually not competing to get this business, they are competing to 

survive and just hope to live another day. 

Mr. COLLINS. OK. Let me ask you this, because you said something earlier that really tweaked my interest. And you said that in 

your high-risk pool that you had in the State of Wisconsin that all 

providers participated. 

Mr. WIESKE. They did. 

Mr. COLLINS. Did you require them to? 

Mr. WIESKE. It was required. 

Mr. COLLINS. How do you require them to? 

Mr. WIESKE. So it was when they—— 

Mr. COLLINS. Do you tie it in with licensing or something? 

Mr. WIESKE. It was a requirement that they had to accept the 

high-risk pool patients and the rate that the high-risk pool set. 

They were part of the boards. They got the opportunity to work on 

setting those rates, but they were expected to contribute 30 percent 

to the surplus of the cost, 30 percent of the cost—— 

Mr. COLLINS. OK, you explained that. But what was the penalty 

if they didn’t participate? 

Mr. WIESKE. We never ran into that so we didn’t have a penalty 

because they all participated. The patients went to the doctor, the 

doctor billed the high-risk pool for the services. I mean, ultimately, 

if they didn’t participate, they just wouldn’t get paid in the same 

rate, I guess, but, you know, functionally—— 

Mr. COLLINS. You know, I find that hard to believe, especially if 

you have a favored nations clause in there and they are forced to 

accept that rate payment, and then they are forced to give it to another insurance company as well. 

Mr. WIESKE. We had a—I mean, before and after, I mean, we do 

have an extremely competitive market. We don’t have a dominant 

insurer that can get the most favored nation. The market share in 

Wisconsin, you know, the top about 18 comprise 80 percent, so, and 

the top 10 only comprise roughly about 45 percent or less of the 

market. So it is a different market. 

Mr. COLLINS. Well, again I just want to stress, and again thank 

all of you for being here. I want to stress again what we are trying 

to do here is to make health care accessible, to make it affordable 

and to cut out the red tape and to bring the free market back. Let 

competition drive prices down. That is what is going to do it. That 

93 

is what we are trying to do. Thank you again, all of you, for being 

here. And I yield back, Mr. Chairman. 

Mr. BURGESS. The Chair thanks the gentleman. The gentleman 

yields back. The Chair recognizes the gentleman from New Mexico, 

Mr. Luja ́n, 5 minutes for your questions, please. 

Mr. LUJA ́ N. Mr. Chairman, thank you very much. Before I begin, 

there was a line of questioning from Mr. Kennedy to Mr. Wieske 

pertaining to a Kaiser report titled ‘‘High-Risk Pools for Uninsurable Individuals, Appendix Tables, 8903, the Henry J. Kaiser Family Foundation,’’ which referenced the premium increases in the 

State of Wisconsin amongst other States. I would ask unanimous 

consent that that be submitted to the record. 

Mr. BURGESS. If the gentleman is willing to share it with the 

Chair, without objection, so ordered. 

[The information appears at the conclusion of the hearing.] 

Mr. LUJA ́ N. Just to note so that there is no question about this, 

what this report says is that the premiums were double in Wisconsin, so I know that we will get the chance to maybe go over that 

a little bit later. 

Mr. Chairman, if I could ask the staff to pull up the first slide 

upon our new smart screen, one thing that I wanted to go over was 

the question associated with where we are today with the bills that 

have been presented to this committee. 

President Trump recently said that he insists that everyone will 

have health insurance, insurance for everybody, he said. President 

Trump also said that there will be lower numbers, much lower 

deductibles. He went as far as to say that he is ready to reveal it 

alongside Senate Majority Leader Mitch McConnell and Speaker 

Paul Ryan. That was January 16th, 2017. And here is the important quote. It is a very much formulated down to the final strokes. 

So if we could go to the next slide, this is what we have today, 

down to the final strokes. So as we talk about these details I think 

it is just important that we keep an eye on what those final strokes 

really look like because that bracket sure is empty. 

If we could go to the next slide I wanted to answer a question 

that was brought up by one of my colleagues about this being 

shoved down people’s throats. This is just a list of some of the hearings in the House and in the Senate that took place associated with 

the markup of the Affordable Care Act. I brought my copy in if 

anyone wants to take a look at it, which is coffee stained and 

marked up, highlighted up for everyone to see that we used not 

only to study this bill but to go and explain it to our constituents 

and answer questions from our constituents. 

And if we could just go to the next slide, the next slide shows 

what this committee alone did with different amendments that 

came up before this committee. So Mr. Lichtenfeld, I understand 

that you are—or Lichtenfeld, I understand that you are a physician. Have you read Chairman Walden’s discussion draft? 

Dr. LICHTENFELD. I have read the paper that you have shown 

here to the committee. 

Mr. LUJA ́ N. Do you remember it saying anything about protecting 

young people and making sure they can stay on their parents’ 

plans until they are 26? 

94 

Dr. LICHTENFELD. My understanding is, Congressman, and so as 

I said before a work in progress and that there is obviously language that is still to be discussed and debated. 

Mr. LUJA ́ N. I will ask the question differently. Was it in the text 

that you read? 

Dr. LICHTENFELD. I am sorry, sir? 

Mr. LUJA ́ N. Was it in the text that you read? 

Dr. LICHTENFELD. No, sir. 

Mr. LUJA ́ N. Do you remember the text reading anything about 

establishing minimum standards of care to ensure Americans 

aren’t sold a lemon health insurance plan? 

Dr. LICHTENFELD. I do not recall that, sir. 

Mr. LUJA ́ N. Do you remember it saying anything about making 

sure behavioral and mental health services are covered? 

Dr. LICHTENFELD. Again I don’t recall seeing that. 

Mr. LUJA ́ N. Mr. Lichtenfeld, you are an oncologist, correct, sir? 

Dr. LICHTENFELD. Yes, sir. 

Mr. LUJA ́ N. I thank you for your work. My father sadly passed 

from a fight with stage 4 lung cancer a little more than 4 years 

ago. We appreciate the experts that provided our loved one’s care. 

Do you remember in Chairman Walden’s bill saying anything about 

making sure individuals are not penalized by lifetime caps on their 

insurance coverage? 

Dr. LICHTENFELD. I do not recall seeing that, sir. 

Mr. LUJA ́ N. So the discussion that we are hearing today is that 

there be an environment set up so that individuals rather than 

having a 90-day grace period with their coverage would be shortened to a 30-day grace period if they had a preexisting condition. 

And if they missed a payment, and the text doesn’t protect anyone 

that may be late with a payment, then they lose coverage. What 

I have heard today is the notion that people with preexisting conditions that would lose coverage would still be able to get coverage 

from somewhere else, right. But there is nothing saying that they 

will not pay a higher premium fee. 

And under the notion of, again if you could please bring up the 

first slide. Under the notion that our colleagues are saying that 

premiums will be lowered, deductibles will be lowered, care will be 

better, no one is going to be cut off, I just don’t see it in anything 

that has been read to us. 

And then the last thing, after 7 years, if they bring the first slide 

up, please, the one with Fox News, we have not seen the Republican consensus plan before us. There was a lot of talk by one of 

our witnesses about a plan that was before us. There is no consensus plan before us. This is not a secret. For 7 years, over 60 

times my Republican colleagues have voted to repeal the Affordable 

Care Act. For 7 years we have not seen this text. 

I think it is important that when we are having these hearings 

about how to improve the Affordable Care Act it shouldn’t be about 

repealing the Affordable Care Act. And I will just point that the 

text in Chairman Walden’s discussion draft, in its title it says, 

‘‘upon repeal of the Affordable Care Act.’’ So people can spin this 

all that they want, please look at the text and what is happening 

right now. And there is a willingness for us to work together to 

make things better to improve things, but not under the guise of 

95 

repealing this. Let’s find a way to really come together and do the 

right thing for the American people and not just the political thing. 

Mr. BURGESS. The gentleman’s time is expired. The Chair is advised that one of the witnesses needs to catch an airplane. Is this 

accurate? The Chair would ask unanimous consent that we allow 

the witness to make their—no, we don’t allow the witness. OK, the 

Chair would advise that the witness who identified himself as having travel plans will actually be leaving at 2:15. 

And I do ask all Members to try to adhere to the 5-minute 

timeline. I have been lenient today because this is such an important topic. 

Mr. GREEN. Mr. Chairman, I ask unanimous consent to place 

into the record—if you want me to start the list—a statement from 

the Asian Pacific Islander American health care—— 

Mr. BURGESS. Without objection, so ordered. All of your—— 

Mr. GREEN. All of it. 

Mr. BURGESS [continuing]. Yes, consent requests will be honored. 

The Chair recognizes Mr. Sarbanes 5 minutes for questions. 

Mr. SARBANES. Thank you, Mr. Chairman. I just got in here 

under the wire, so I want to thank the panel. I wanted to ask Dr. 

Holtz-Eakin, what are some of the pieces of the Affordable Care 

Act that you think we ought to keep in place? 

Dr. HOLTZ-EAKIN. Well, I think that, you know, the ban on, caps 

on benefits for annual and lifetime, 26 staying on your parents’ policy. I certainly think that you should have some sort of provisions 

for preexisting conditions and access to insurance. 

Mr. SARBANES. What about the efforts to close the exposure in 

the so-called donut hole in terms of the prescription drug costs that 

our seniors had been facing, is that a piece we want to keep in 

place? 

Dr. HOLTZ-EAKIN. I think there is, I would be happier if there 

was a more comprehensive approach to Medicare reform that sort 

of put together a more sensible insurance policy A, B and D, provided a broader coverage there. 

Mr. SARBANES. But generally speaking this idea of trying to reduce the exposure that our seniors have to the prescription drug 

costs which the ACA addressed through this effort to close the 

donut hole, is that something you think we ought to hold onto? 

Dr. HOLTZ-EAKIN. I guess the reason I am hesitating, my understanding is part of this is the private industry’s agreement to cover 

50 percent of costs in the donut hole. I honestly don’t know how 

that works whether that has the force of law or if that is a voluntary action by them. 

Mr. SARBANES. I think the industry’s agreement to voluntarily 

address 50 percent of their costs in the donut hole was something 

that they were going to do transitionally as the donut hole was 

being closed through actually providing additional benefits under 

Part D. 

What about, you probably know that many seniors now as a result of the Affordable Care Act can have certain kinds of preventive 

screenings, annual wellness exams, other things where they used 

to have to come out of pocket for those expenses, those are now covered by the Affordable Care Act which is obviously a huge benefit 

96 

for our seniors. Is that a piece of the Affordable Care Act that you 

think ought to stay in place? 

Dr. HOLTZ-EAKIN. Truthfully I don’t know. The question there is 

what has been the effectiveness versus the cost, and I would be 

happy to get back to you on that. 

Mr. SARBANES. Well, I think the effectiveness has been significant in terms of enhancing care and there is actually savings as 

well, because if you catch some things earlier that then don’t lead 

to acute care on the back end which have high costs associated 

with it, because you do the screenings and the preventive care 

service because you actually are reducing costs as well. 

So I guess I am asking the questions just to make the point, Mr. 

Chairman, that once you break—there is this kind of slogan of repeal the Affordable Care Act, you know, it hasn’t delivered, et 

cetera. When you actually break it down into its component parts 

and look at the benefits that it is bringing, frankly, the public has 

a very positive view of a lot of these components to the plan. 

And as you just indicated in your answers, I think there is a recognition by the experts that there is many, many pieces of the Affordable Care Act that it would be regrettable to leave behind. So 

I think we need to start in an honest place of conversation when 

we are talking about this landmark healthcare reform and the benefits that it has brought to so many Americans and move forward 

from that point. With that I yield back. 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman. The gentleman recognizes the gentleman from New 

Jersey, Mr. Long, 5 minutes for questions, please. 

Mr. LONG. Thank you, Mr. Chairman. Mr. Wieske, you mentioned in your testimony that a number of your insurers have lost 

significant capital because of Obamacare. How has that affected 

coverage options as well as provider network access for individuals? 

Mr. WIESKE. So as I said just a few minutes ago, I think there 

are actually—— 

Mr. LONG. My apologies if you—— 

Mr. WIESKE. No, no, no. My apologies. My apologies. 

Mr. LONG. I sat here all morning long for my turn to ask and 

we went to votes, so—— 

Mr. WIESKE. No, no, no. And they are competing not to get the 

business in a lot of cases and, you know, they want a limited number of coverage and they are losing money on that coverage and so 

they have dialed back their presence across the State. They have 

limited their networks. Most plans have gone to narrower and narrower networks. They have changed their networks. They have 

partnered with providers, provider groups to do it differently. They 

have done it under different insurance licenses. So they have taken 

a number of steps to sort of minimize their exposure to the market. 

Mr. LONG. If nothing changes between now and next November, 

what would you see at that point? 

Mr. WIESKE. I think we will see a number of carriers that—I 

think we will see every year where we are sort of—my fear because 

we deal directly with the filings and I deal directly with the filings, 

my fear is that I am a little bit panicked that we are going to have 

counties that are uncovered. 

97 

We have one county that has one right now. We have three counties that only had one for a number of years. I am deathly afraid 

that four or more of our counties will be left uncovered with no insurer offering coverage. 

Mr. LONG. OK. And coming from an adverse State in terms of regions, have some areas of your State been hit harder by these 

changes? 

Mr. WIESKE. Yes, there were big differences. I mean, you know, 

one of the issues is it almost feels like, and this is not insurance 

across State lines, but it narrowed the market considerably. So 

some of our plans that offered coverage that were near the border 

left those areas because of the rules and the way things work, and 

so that left those areas more exposed. 

So the areas near the borders have more problems than some of 

the other areas. Absolutely there has been winners and losers in 

the ACA. 

Mr. LONG. And what has that meant for consumers? We call 

them consumers, I call them constituents, but what has that meant 

for consumers and our constituents in those areas? 

Mr. WIESKE. We have seen, you know, rising costs over time, you 

know, more than doubling of the average premiums that most consumers pay over the course of, you know, from what they were paying pre-ACA, so there are significant increases. The deductibles 

have increased over time. They are higher than they were pre-ACA 

on average. 

And the networks are narrower. They are finding, you know, less 

choice in the type of providers they want to see because there are 

fewer, you know, they just want to offer narrower and narrower 

networks. 

Mr. LONG. When you say they are higher, I remember back at 

Christmastime went to a Christmas party the Saturday, I think, 

before Christmas, and a local business owner came up talking 

about just his family’s premium had gone up 360 percent since the 

advent of the Affordable Care Act. I would hate to think what it 

was like if it wasn’t affordable, but these are the type of stories 

that we get from our constituents that everybody acts like everything is a panacea and everything is great out there. 

But these numbers, I mean health care, health insurance always 

was going up, and the other side will argue, I have constituents 

that like it and they say oh, you know, health care goes up anyway. 

But 360 percent in that short of time is a pretty healthy increase, 

isn’t it? 

Mr. WIESKE. It is. And I think what I am afraid of is States like 

Wisconsin that took advantage of the transition options, so-called 

grandmother plans, those plans will go the way at the end of ’17 

in the small group market. Roughly about 180–190,000 of our 225– 

230,000 small group individuals are on those transition plans. They 

are going to get a significant increase when we roll from 2017 at 

the end of this year into ’18. 

Mr. LONG. That is kind of what I was—— 

Mr. WIESKE. On pre-ACA plans, yes. 

Mr. LONG. That was kind of what I was getting to earlier when 

I asked you about November, what you foresaw for next November. 

And what are your projections and concerns of what the market is 

98 

going to look like after that period in a few years if the current trajectory continues in your State? 

Mr. WIESKE. We are expecting fewer carriers, probably regional. 

They happen to be regional in a lot of cases and probably only carriers, insurers that have a relationship, a contractual relationship 

with a health system. So you will have one health system and one 

insurer teamed up in a particular area and that will be the only 

coverage option. That is what we are afraid of in the future, no 

choice. 

Mr. LONG. Do you view plan solvency in the market as a basic 

consumer protection? 

Mr. WIESKE. Yes, we do. We do extensive work on solvency. Yes, 

sir. 

Mr. LONG. What does that mean for consumers when their insurers exit the market like they have in droves in a lot of places? 

Mr. WIESKE. It means that they obviously lose the coverage. 

They end up in what I would call ghost plans or phantom plans 

that don’t exist anymore but they still have coverage, and then you 

have to deal with the issue of the guarantee funds and making 

sure the consumers are covered. And it ends up, it is for a consumer it is confusing and it is problematic and it is a little bit of 

a nightmare if their insurer—now we have been lucky. We haven’t 

had any go insolvent in the State of Wisconsin. We have had carriers leave the market but we have not an insolvency in health that 

has had those problems so we have been lucky. 

Mr. LONG. I have two daughters. One of them has a year and a 

half left in her residency program in pediatrics, so the future of 

health care is very concerning to her. And her younger sister just 

got a report out about 4 months ago from Hodgkin’s lymphoma and 

she has been off chemo for 15 months, I guess. 

And so I know how important it is that people have coverage and 

stay covered because we had a little incident mid-chemo treatment 

when the Affordable Care Act told us she wasn’t covered one day 

when we got over there for treatment. That was kind of hair raising. So there is no easy answers to any of this that we are doing 

today. 

And like I said, I was late because I was doing, to the first part 

of it because I had to do a telecom deal on rural broadband, so I 

wasn’t here for the gavel, and then I was here by the time we 

voted. 

Mr. BURGESS. The Chair accepts the gentleman’s apology. The 

gentleman’s time has expired. I do need to note it is past 2:15. We 

have a witness that needs to leave. We will continue our—and will 

be excused. We will continue our hearing with the remaining witnesses. Of course, written questions may be submitted for Dr. 

Holtz-Eakin. 

And Dr. Holtz-Eakin, we appreciate you being here. You have always been a friend to this committee, and we appreciate your participation today. So you are excused. 

Dr. HOLTZ-EAKIN. Thank you, Mr. Chairman. 

Mr. BURGESS. And the Chair recognizes the gentleman from California, Mr. Ca ́ rdenas, 5 minutes for your questions, please. 

Mr. CA ́ RDENAS. Thank you, Mr. Chairman. I am glad we are discussing this incredibly critical and important issue that is critical 

99 

to every American. I would like to read the following true story 

from a constituent from my city of Los Angeles, California. 

This is before the Affordable Care Act was made available to her 

and her family: ‘‘In 2012 I was in between jobs and discovered that 

I was pregnant. My husband and I were thrilled to be expecting 

our baby. When I tried to sign up for insurance I was informed that 

my pregnancy was considered a precondition, preexisting condition, 

and no insurance company would cover me. 

‘‘My husband was working as a contract employee and was uninsured. I considered Medi-Cal and Medicaid program in California, 

but I was told that it could take months until I could actually visit 

a clinic. Fortunately, I was hired about a month later and I got 

back on a company’s insurance. However, if I had not been hired, 

I don’t know what I would have done. It was that we almost missed 

seeing a doctor until the second trimester. 

‘‘And as I experienced extreme daily stress worrying about 

whether I would be insured before I gave birth or be charged tens 

of thousands of dollars, such stress is never good for a baby. The 

fact that becoming pregnant prevented me from buying insurance 

was truly outrageous. I was so horrified that our system could do 

something like this.’’ 

True story, it happened, and unfortunately, before the Affordable 

Care Act, there were way too many stories like that. What I hope 

that we can prevent as Members of Congress, as legislators, as responsible elected officials, that we not go back to those days. This 

is America, and this true story goes to the heart of what we are 

all here to talk about. 

Why are we spending time analyzing a half-finished bill that 

doesn’t take care of all the issues that were promised both by presidential candidates and people all over this United States Congress? 

Things like to ensure that a woman and a man pay the same price 

for their plans. This bill here that I have in my hand, which was 

introduced and what we are discussing today, does not guarantee 

coverage for a preexisting condition. A lot of Americans don’t realize that if your 8-year-old daughter has asthma, that is considered 

a preexisting condition. 

Also to ensure coverage that we actually have access, this bill 

that I have before me talks about access, but it doesn’t talk about 

ensuring coverage. The Affordable Care Act has stronger language 

such as ensuring coverage. This document speaks to access, but it 

doesn’t spell out what we really should be talking about. Are people 

going to be denied coverage for a preexisting condition? Are women 

going to be allowed just like before to pay more for their health 

care than it is for a man at the same age, conceivably right next 

door? 

We have had nearly 8 years of talk about replace, but we have 

come up with nothing better in that time. Why aren’t we talking 

about enhancing the Affordable Care Act instead of these ideas of 

just repealing it? 

I have a question for Dr. Lichtenfeld. I want to first thank you 

for coming today and for sharing your expertise with us and also 

for making sure that we can get some more information before the 

public. Under the half-written plan, could individuals with preVerDate Mar 15 2010 10:31 Nov 08, 2018 Jkt 037690 PO 00000 Frm 00103 Fmt 6633 Sfmt 6633 I:\115THCONGRESS\115X4PATIENTRELIEFASKOK101718\115X4PATIENTRELIEFWORK
100 

existing conditions like cancer, asthma, or diabetes be priced out of 

the care they desperately need? 

Dr. LICHTENFELD. Thank you, Mr. Ca ́ rdenas. And our concern is 

that that could in fact happen unless it is absolutely laid out clearly what the plan is, that there could be problems down the line. 

Mr. CA ́ RDENAS. And the bill as written today doesn’t have any 

language guaranteeing that that would not happen, correct? 

Dr. LICHTENFELD. As I mentioned previously, that is correct. Yes, 

sir. 

Mr. CA ́ RDENAS. OK. My next question is, Were the health insurance premiums across America in general going up year over year 

before the Affordable Care Act, or were they on their way down 

year over year before the Affordable Care Act? 

Dr. LICHTENFELD. Premiums were going up. 

Mr. CA ́ RDENAS. OK. Now on those premiums going up, people 

were still denied coverage because of a preexisting condition, correct? 

Dr. LICHTENFELD. Yes, sir. 

Mr. CA ́ RDENAS. But under the Affordable Care Act, that is not allowed in America today, correct? 

Dr. LICHTENFELD. That is correct. 

Mr. CA ́ RDENAS. OK. So I just wanted to point out a few things 

in the short time that I get to speak on this committee and just 

wanted to make sure that everybody out there understands we are 

talking about you. We are talking about your health, your grandparents to your grandbabies and everybody in between. We need to 

get this right. And right now the bill that we have isn’t even close. 

I yield back. 

Mr. BURGESS. The Chair thanks the gentleman. The Chair would 

remind the gentleman he receives the same amount of time as 

every other member on the subcommittee and some who have 

waived on the subcommittee, and the chairman has been most generous with not hitting the gavel. 

The Chair would like to recognize the gentlelady from Tennessee, 

Mrs. Blackburn, 5 minutes for your questions, please. 

Mrs. BLACKBURN. Thank you, Mr. Chairman, and thank you all 

for being here. I want to go to the bill that we are looking at on 

the special enrollment plans, the special enrollment periods. This 

is legislation that I have drafted and the reason I did it was because of what we saw happening with lack of verification in the 

special enrollment periods. 

And I saw us going down a road that we traveled in Tennessee 

with TennCare which was back in the mid-90s. No verification, all 

of a sudden your plan is, your enrollees are being crowded out if 

you will, people that really need services. You begin to see networks narrow, reimbursements drop, the length of time you wait 

for reimbursements goes from 30 days to 60 days to 90 days to 120, 

180 days. And you all know the path. And my bill is just very 

straightforward and you need to prove why you need that special 

enrollment period, you need to prove that you are who you are and 

that you qualify. I think that is an important thing for us to be 

able to do. 

So the question, I have a couple of questions and I would like to 

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101 

ment periods. I think it is important for the integrity of any program and I think it is fair for the taxpayers who foot the bill. 

But shouldn’t we simply be able to confirm if someone qualifies 

for special treatment that they self-attest that they are eligible that 

indeed they are, and especially if taxpayer subsidies are involved? 

Shouldn’t we require that? And would a very small, but modest improvement to the plan be to move this verification from post-enrollment, which experience has told us very seldom gets done, to 

preenrollment? And I would like to hear what you all have to say 

on that. 

Mr. WIESKE. Your bill is exactly right. I mean this is not actually 

that hard to get verification in my experience. This is something, 

special enrollment periods did not start with the ACA. Special enrollment periods existed with HIPAA and existed prior to that in 

the Newborn and Mothers Act and other pieces. Insurance companies were doing these verifications for years prior to the ACA. 

The problem that we have run into is when the Federal bureaucracy takes it over that that creates other problems and they don’t 

have the time or the resources to verify. We had one person in our 

office who had spent months trying to solve the issue because he 

was not using the magic words that the customer service wanted 

them to use. So I think it shouldn’t be that hard to get to a 

verification. 

Dr. LICHTENFELD. Well, Mrs. Blackburn, thank you for the question. And we are aware of some of the issues that have come up 

with regard to special enrollment. However, when we look at it 

through that cancer lens we also need to understand that there are 

some other issues that have to be looked at. 

So it may be someone who is working and loses their job and has 

to go get insurance and within the cancer focus how quickly that 

is going to be done, what is going to be required and will it be done 

expeditiously. Should it be done pre- with the presumption of correctness and then later, or should it be done later when there may 

be a gap in care? Those gaps in care can be significant. 

Also aware that how the one that administers it, whether it be 

Federal or whether it be insurance company, what the guidelines 

are that set around those requirements in terms of timeliness, all 

those are things that have to be considered. 

Mrs. BLACKBURN. I think you might have missed the point that 

I am trying to drive forward. I think that—I am not saying you 

don’t need special enrollment periods. 

Dr. LICHTENFELD. No, I understand. 

Mrs. BLACKBURN. Just what you are inferring. I am saying that 

if we have a special enrollment period and one is necessary that 

it is out of fairness to the taxpayer and to the integrity of a program that an individual before they are admitted to a program that 

they prove that they need it and that they prove that they are who 

they attest to be. That those attestations that they have made to 

get that coverage that those are vetted before they are allowed into 

that program. 

Dr. LICHTENFELD. Mrs. Blackburn, I apologize if I wasn’t clear on 

my statement. I didn’t say we don’t need special—I mean it wasn’t 

my intent to say we don’t need special enrollment. 

Mrs. BLACKBURN. OK, right. 

102 

Dr. LICHTENFELD. I said it is the construct of how it is done that 

is important where we may have discussions about that issue. 

Mrs. BLACKBURN. OK, thank you. Yield back. 

Mr. BURGESS. The gentlelady yields back. The Chair thanks the 

gentlelady. The Chair recognizes the gentleman from North Carolina, Mr. Hudson. 

Mr. HUDSON. Thank you, Mr. Chairman, and I thank the panel 

for your time today. But since I arrived here directly from a dental 

procedure I will probably yield the balance of time, without objection from you, Mr. Chairman, to Mr. Griffith from Virginia. 

Mr. BURGESS. The gentleman is recognized. 

Mr. GRIFFITH. Thank you very much. I thank my colleague from 

North Carolina, so I think I ought to ask my North Carolina question first. My district shares a border with North Carolina. Mr. 

Wieske, you indicated earlier in answering one of the questions 

that there were some issues around the borders. Could you tell me 

what was going on there and how that affected you all? 

Mr. WIESKE. Sure. I mean I think when you are dealing with the 

exchange and the subsidy market it sort of shut down the sort of, 

you know, moving between the borders that happen, that those borders became a little bit harder than they were before. And so because you are one exchange versus another exchange it wasn’t just 

buying health insurance it was that became an issue. 

Mr. GRIFFITH. And let me ask you if you ran into any of the problems in your State that I ran into with constituents when it first 

rolled out. I had folks who were going to medical facilities—because 

my district is the corner of Virginia so I border North Carolina, 

Tennessee, Kentucky and West Virginia. And so one of the things 

that popped up almost immediately was, and it was particularly a 

North Carolina situation, I had a constituent who was receiving 

cancer treatment in Winston-Salem. It might have been Duke, but 

I am pretty sure it was Bowman-Gray. 

And all of a sudden found out when she, she had to go on the 

exchange. She went on the exchange and found out that she could 

not leave the Commonwealth of Virginia more than one county. 

Well, that created all kinds of problems because she couldn’t keep 

with her cancer team. Did you have some of those issues as well? 

Mr. WIESKE. A few of those, but more insurers withdrew from 

the neighboring counties. So Pierce, Polk and St. Croix County 

typically use, which is on the western part of our State, typically 

use providers in Minnesota, have Minnesota systems. All the Wisconsin systems essentially withdrew from that area and at least exchange wise, and so it was primarily a Minnesota company that 

provided coverage that was licensed in Wisconsin. So they just had 

fewer choices. They had to go, they had to go, across the border. 

Mr. GRIFFITH. Right. And so it is kind of interesting because earlier one of the folks was making a statement on the other side of 

the aisle and seemed to indicate that whatever plans we were coming up with they wouldn’t work because you couldn’t go, you would 

have to go back to the other State, I believe she said, to see the 

doctors, and yet my experience in my district was that that problem exists with Obamacare. 

And it may be one of the things we need to take a look at it fixing, because that one county rule—and I described my district to 

103 

you and I only had problems in North Carolina. But one of the hospitals in the area that specializes in children’s care in Tennessee 

serves a big chunk of southwest Virginia but because independent 

cities, Bristol, Virginia is an independent city, Bristol, Tennessee, 

and the county surrounding it is the one county you could go to and 

the hospital is just over the line in the next county. 

So it was not just the problem in North Carolina with cancer 

treatment, it was also problems with people being able to go see 

the specialists in North Carolina, because I had Bristol, Virginia 

and Tennessee, where as you know from the GEICO commercial 

the line runs right down the middle of the main commercial street 

there. And then I also have Bluefield, Virginia, which also has 

Bluefield, West Virginia, and you have to figure out which side of 

the line you are on there. It is not quite as clear cut as Bristol, Virginia and Tennessee. 

So a lot of my constituents were impacted by that. And I know 

that it is—I assume that it is not a good idea to change, Dr. 

Lichtenfeld, it is not a good idea to change your doctors midstream 

particularly when you are satisfied with the cancer treatment you 

have been getting. And so it is not a good idea to switch even 

though Virginia has some very good medical schools as well; would 

that be correct? 

Dr. LICHTENFELD. Well, actually my son was just interviewed at 

University of Virginia so we respect the medical schools for sure. 

Mr. GRIFFITH. Yes. 

Dr. LICHTENFELD. You know, yes, that is correct. I mean continuity of care is important, how it is constructed, what the rules 

are, whether, what hospitals are allowed in the network, the location of the network, all that is important. 

Mr. GRIFFITH. Right, and closeness matters too. And in fact, big 

parts of my district they are a lot closer to other States’ hospitals 

then they are to the University of Virginia which would be closest 

to my district. Not to negate MCV, also another fine institution and 

others. 

Let me switch gears, and I apologize, Mr. Wieske, you may not 

know the answer to this because it was a question for Dr. HoltzEakin about continuous coverage requirements. And he had said 

that that pushes providers and plans to invest in preventive and 

wellness programs to keep patients healthy, and the question 

would have been how does this impact the overall market, the overall risk pool? Are you in a position to answer that question? My 

team says you are but I don’t know. 

Mr. WIESKE. I think in general, I mean I think if you are able 

to keep people in the market and they stay in it and they stay with 

their insurer it provides better health, better health outcomes, and 

potentially over time it should lower, make the risk pool more representative and overall lower costs. 

Mr. GRIFFITH. So similar to what I was talking about before. I 

see that Mr. Hudson’s time is up and I yield back. 

Mr. BURGESS. The Chair thanks the gentleman and now recognizes the gentleman from New York, Mr. Tonko, 5 minutes for 

questions, please. 

Mr. TONKO. Thank you, Mr. Chair. And Mr. Wieske, first let me 

thank you for your service to the people of Wisconsin and for your 

104 

testimony today. In your written statement you refer numerous 

times to Wisconsin’s well-functioning health insurance market preACA and expressed a desire to see the ACA repealed and returned 

to a pre-ACA marketplace. 

So I would like to learn a little more about what Wisconsin’s 

health insurance market looked like prior to the Affordable Care 

Act. I took and downloaded a publication from your office’s website 

entitled ‘‘Fact Sheet on Mandated Benefits in Health Insurance 

Policies,’’ and with the permission of the Chair I would like to ask 

unanimous consent that this document be entered into the record. 

Mr. BURGESS. Without objection, so ordered. 

[The information appears at the conclusion of the hearing.] 

Mr. TONKO. Thank you. Now Mr. Wieske, prior to the Affordable 

Care Act did Wisconsin mandate that all health insurance plans 

serving the individual market cover hospital services or prescription drug coverage? Yes or no on that, by the way. 

Mr. WIESKE. I don’t believe—— 

Mr. TONKO. Yes or no. 

Mr. WIESKE. I don’t believe it was mandated, but—— 

Mr. TONKO. The answer is no. Pre-ACA, did Wisconsin mandate 

that all insurance plans serving the individual market cover mental health or substance use care, yes or no? 

Mr. WIESKE. No. 

Mr. TONKO. The answer is no. Pre-ACA, did Wisconsin mandate 

that all insurance plans serving the individual market cover maternity care, yes or no? 

Mr. WIESKE. No. 

Mr. TONKO. Would it be fair to assume that plans in Wisconsin 

that offered these fundamental healthcare services in the individual market pre-ACA would be more expensive than plans that 

didn’t offer these services, yes or no? 

Sir, can we move—— 

Mr. WIESKE. Well, the problem is—— 

Mr. TONKO. Yes or no, because I have got to move on with my 

time here. 

Mr. WIESKE. I am sorry, I can’t answer the question, because you 

have three there. 

Mr. TONKO. Well, fundamental healthcare services in the individual market pre-ACA, would it be more expensive than plans 

that didn’t offer those services? 

Mr. WIESKE. For maternity and for the mental health, the answer is yes. 

Mr. TONKO. So given your expressed support for the pre-ACA 

marketplace where plans that covered even the most basic 

healthcare services were astronomically expensive in the individual 

market pricing out anyone who might actually need care, you clearly support returning to a system where women and all people with 

preexisting conditions are charged higher prices for the care they 

need? 

Mr. WIESKE. No. My assumption is that the States would be able 

to—— 

Mr. TONKO. Yes or—so you are a no on that? 

Mr. WIESKE. Yes, because the States will reform their laws and 

better reflect the market. 

105 

Mr. TONKO. Well, we are looking at a Federal plan that would 

cover all States, so thank you, Mr. Wieske. To summarize what we 

just learned for all the folks watching on TV, health insurance in 

Wisconsin was less expensive before the Affordable Care Act unless 

you actually wanted to go to the hospital, fill a prescription, be covered for mental health services, or see a doctor. Women in Wisconsin were hit particularly hard, paying up to 42 percent more for 

their health insurance than men before the Affordable Care Act. 

So when my Republican colleagues talk about their supposed desire to protect people with preexisting conditions, it is important to 

remember that you can’t address this problem with a half-baked 

bill that doesn’t actually require insurance plans to offer benefits 

to those who are sick. Otherwise, insurance companies will deny 

care to those with preexisting conditions with restrictive benefit designs that fail to cover basic services like hospitalizations, prescription drugs or mental health care. 

I appreciate this hearing today because I think it is really critical 

to clarify the stakes of this healthcare debate for the American people. What Mr. Wieske and my Republican colleagues want to do is 

to rip health care away from millions and take us back to a 

healthcare system controlled by the big insurance companies, the 

system where your health insurance is worth less than the paper 

it is printed on, a system where you get charged through the nose 

if you need mental health care or are a woman, or God forbid, man 

or woman, if you get sick and have to go to the hospital. 

I don’t want to go back. The American people don’t deserve to go 

back. We should instead be moving forward and building on the 

promise of high quality, affordable health care for all. And with 

that Mr. Chair—— 

Ms. DEGETTE. Will the gentleman yield? 

Mr. TONKO [continuing]. I yield back the balance of my time. 

Ms. DEGETTE. Will the gentleman yield? Will the gentleman 

yield me his 39 seconds remaining? 

Mr. TONKO. Yes, I will. I will yield. 

Ms. DEGETTE. Mr. Wieske, I thought that what Mr. Tonko was 

asking you was really important, which is with this bill that we are 

looking at today, there is no requirement that the States not 

charge people with preexisting conditions. That is just your hope 

that States wouldn’t do that, right? 

Mr. WIESKE. We had limits in place—— 

Ms. DEGETTE. Yes, Wisconsin did, but maybe—— 

Mr. WIESKE. Correct. 

Ms. DEGETTE [continuing]. Utah or Colorado or Idaho didn’t, 

right? 

Mr. WIESKE. Right. 

Ms. DEGETTE. That is just your hope? 

Mr. WIESKE. Correct. 

Ms. DEGETTE. Thank you. 

Mr. BURGESS. The Chair thanks the gentleman. The gentleman 

yields back. The Chair once again observes that I have delayed my 

time for questions until the end because I was delayed arriving this 

morning, so I recognize myself for the balance of the time. 

No, and I do appreciate our witnesses being here. I am sorry Dr. 

Holtz-Eakin had to leave, because he always brings a lot to the disVerDate Mar 15 2010 10:31 Nov 08, 2018 Jkt 037690 PO 00000 Frm 00109 Fmt 6633 Sfmt 6633 I:\115THCONGRESS\115X4PATIENTRELIEFASKOK101718\115X4PATIENTRELIEFWORK
106 

cussion. Mr. Wieske, let me just ask you—and again I asked you 

while we were kind of in between on the votes—you have not testified before our committee before, have you? 

Mr. WIESKE. I have not. 

Mr. BURGESS. And so that graphic that one of our members put 

up of all the hearings that were held prior to the Affordable Care 

Act, you never participated in any of those hearings, did you? 

Mr. WIESKE. Correct. 

Mr. BURGESS. And I think that is a shame, because I think you 

would have added to the discussion and you would have added to 

the debate and maybe some of the problems that we are now encountering and trying to fix could have been avoided had we listened to sane, rational voices like yours. 

I will also point out our two members from Indiana have had to 

leave, but we didn’t hear from Governor Mitch Daniels, and Mitch 

Daniels was reported in the Wall Street Journal, while all the discussion of the Affordable Care Act was going on during the 2008 

election cycle and we were having hearings here in this very room, 

Mitch Daniels with his Healthy Indiana Plan had actually reduced 

costs by 11 percent over 2 years’ time when every other HMO, 

PPO, Medicare, Medicaid was going up by 7 or 8 percent across the 

country. 

Why would not we have asked people who were experts and who 

were performing well, why would not have asked their opinions before writing this big law that changed health care from soup to 

nuts in this country? And I—it is obviously a rhetorical question— 

I think we should have. 

Much was made at the beginning of this session about the fact 

that Republicans wouldn’t help, and I have to tell you that is not 

true. I contacted the transition team in 2008 and I said, ‘‘Look, I 

didn’t give up a 25-year medical career to come sit on the sidelines 

while you guys do this. Talk to me. I am willing to talk to you.’’ 

Dr. Lichtenfeld, they could have put me in a tight spot, you 

know, because what if I had been offered to choose between—you 

talked about toxic financial situations, what about our medical liability in a lot of States? That is a toxic situation. What if they had 

said to me, Dr. Burgess, we know you care a lot about medical liability. We would like to help you, but we have got to have your 

help on the public option. I don’t know what I would have done. 

That would have been a pretty tough spot to put me in. 

I don’t know, maybe somebody who is familiar with making a 

deal might have, that might have occurred to them, but I was frozen out. I was frozen out by the then-chairman of this committee, 

Henry Waxman. I went to see him personally and said I didn’t give 

up a career in health care to come sit on the sidelines. So the notion that we have simply dug our heels in and refused to help, it 

is offensive to me when I hear that espoused on the panel. 

Now let me just ask in particular with these bills that we have 

that we are considering, just on the issue of narrow networks now. 

Dr. Lichtenfeld, I mean you encountered narrow networks probably 

before the ACA was passed and after it was passed. Do you have 

a feeling? Is it better or worse? Are narrow networks less restrictive now than they were before? 

107 

Dr. LICHTENFELD. Speaking personally, they are certainly more 

restrictive, and the testimony to that effect was made earlier. So 

the answer to that question is yes, they are more narrow. 

Mr. BURGESS. You know, we all give our own experiences. And 

I will confess that there was a special deal set up for Members of 

Congress, the Grassley Amendment required us all to buy insurance under the Affordable Care Act and there was a special deal 

worked up between President Obama and then-Majority Leader 

Reid in the Senate that allowed us to receive a subsidy and walk 

it into the exchange. I didn’t do that because my constituents back 

home would never understand that kind of a special deal. 

So I understand the difficulties that people felt in the individual 

market. My insurance was canceled at the end of 2013. I was one 

of the 5.7 million people who lost their insurance. I liked my coverage. I liked my doctor. But I couldn’t keep it because I was told 

I had junk insurance and I had to get rid of it. I had to do something else. I had to buy all of these other things. It was not something that I asked for. 

And when my constituents come to my town halls and say why 

did I have to do this, why did I have to make these changes, I 

wasn’t asking for that—well, I felt their pain. And so I didn’t have 

an answer for them but I could look them in the eyes and say, yes, 

I agree with you. I think it was bad policy. I hope we get a chance 

to rectify things someday. 

So when people ask me did you lose your doctor or did you go 

on a narrow network, to tell you the truth I don’t even know, because unlike every other American I bought on price, show me the 

cheapest Bronze Plan out there and that is what I bought and I 

really have no earthly idea who the people are that I had available 

to me. 

On the issue of this 30 days, 90 days, I worried about that when 

the law was in the enactment phase in 2014 because, Dr. 

Lichtenfeld, now correct me if I am wrong here, but you have a 90- 

day grace period. You know, the insurance companies actually were 

talking a lot to the Democrats in those days, they weren’t talking 

to Republicans. But 30 days, the insurance company is on the hook 

for that coverage. What happens to the rest of those 60 days, Dr. 

Lichtenfeld? Who covers that bill if the patient doesn’t pay their 

premium? 

Dr. LICHTENFELD. The answer to your question is that the person 

who provides the service ends up not getting paid under the current situation, if in fact the patient or the family doesn’t pay that 

bill by 90 days. 

Mr. BURGESS. And I do need to point out this is only for someone 

receiving a subsidy in healthcare.gov exchange, because I actually 

thought I had a 90-day grace period on my premium. It turns out, 

no, you only get 30 days because you are not receiving a subsidy, 

so that 90-day period does not cover you. 

But I did worry about that because I worried that former colleagues who practiced medicine would in fact be on the hook for 

those bills and it hasn’t turned out to be the problem I thought it 

was going to be, but I think it is a problem that should be corrected. We shouldn’t allow for the system to be manipulated where 

108 

physicians and hospitals actually don’t receive the compensation 

for the care that they provide. 

There are a lot of things that we could still talk about. I have 

some questions that I will submit for the record. We have been 

here a long time. I do appreciate both of you being here. This is 

not easy. This is complex. I don’t know. I don’t know at the end 

of the day where this all shakes up but I do know this. If it was 

working perfectly, if it was working perfectly we wouldn’t be here 

today. It is not working perfectly. There are serious problems. 

There are serious fractures and we have been charged with fixing 

them. 

So that is what this subcommittee does. You have got some of 

the smartest Members of Congress on this subcommittee, and I appreciate each and every one of them, those that are here and those 

that have had to leave. This is a good subcommittee, a great subcommittee. We are up to the task, and we will deliver. 

So with that, I will yield back the balance of my time and then— 

oh my gosh, what have I got to do, all of these unanimous consent 

requests. Seeing there are no further Members wishing to ask 

questions, I would like thank all of our witnesses again for being 

here today. 

Before we conclude the hearing, I would like to submit the following items for the record: a statement from Representative Bill 

Flores, a statement from Blue Cross Blue Shield, a statement from 

the American College of Obstetricians and Gynecologists, a letter 

from the Alliance for Retired Americans, a letter from the 

Healthcare Leadership Council, and a statement from America’s 

Health Insurance Plans. 

[The information appears at the conclusion of the hearing.] 

Mr. BURGESS. Pursuant to committee rules I remind Members 

they have 10 business days to submit additional questions for the 

record. I ask the witnesses to submit their response within 10 business days upon receipt of the questions. Without objection, the subcommittee is adjourned. 

[Whereupon, at 2:51 p.m., the subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 

PREPARED STATEMENT OF HON. ANNA G. ESHOO

Republicans have threatened to take health care away from 30 million Americans 

through the repeal of the Affordable Care Act. My constituents are terrified that 

they will lose their health care. Hundreds have written and called me to express 

their fears. Republicans have said that they will protect them by passing something 

‘‘better’’ than the ACA. 

The majority now has the White House, the Senate, and the House, and you’ve 

had seven years to come up with a plan. Yet today, you show up with a half-written 

bill that does not guarantee protections for Americans with preexisting conditions. 

Today is your first opportunity to show the American people that you will protect 

them, to assuage their fears about losing their health care, and to show the American people that you have a better plan. 

The plan we’re discussing today is not better, and as it is written, it does not protect those with preexisting conditions from exorbitant premium increases, because 

it does not include medical underwriting for those with preexisting conditions, leading to higher premiums. 

This proposal is irresponsible and ignores the gravity of the situation for the millions of Americans who are afraid of what ‘‘repeal and replacement’’ of the ACA 

means for them. 

109 


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[DISCUSSION DRAFT] 

115TH CONGRESS 

lS'I' SESSION H.R. 

-113H5328 

To amend the Public Health Service Act to prohibit application of preexisting 

condition exclusions and to guarantee availability of' health insurance 

coverage in the individual and group market, contingent on the enactment 

of legislation repealing the Patient Protection and Affordable Care Act, 

and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

Mr. WALDEN introduced the following bill; which was referred to the 

Committee on ______ ----·····---

A BILL 

'fo amend the Public Health Service Act to prohibit application of preexisting condition exclusions and to guarantee 

availability of health insurance coverage in the individual 

and group market, contingent on the enactment of legislation repealing the Patient Protection and Affordable 

Care Act, and for other purposes. 

Be it enacted by the Senate and House of RepTesenta2 tives of the United States of AmeTica in CongTess assembled, 

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2 

1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the "Preexisting Conditions 

3 Protection and Continuous Coverage Incentive Act of 

4 2017". 

5 TITLE I-PROHIBITION OF PRE6 EXISTING CONDITION EXCLU7 SIONS AND GUARANTEED 

8 AVAILABILITY OF HEALTH IN9 SURANCECOVERAGE 

10 SEC. 101. PROHIBITION OF PREEXISTING CONDITION EX11 CLUSIONS. 

12 (a) GROUP lVlARKET.-Subject to section 103(a) of 

13 this Act, subpart 1 of part A of title XXVII of the Public 

14 Health Service Act (42 U.S.C. 300gg· et seq.), as restored 

15 or revived pursuant to PPACA repeal legislation described 

16 in section 103(b) of this Act, is amended by striking sec17 tion 2701 and inserting the following: 

18 "SEC. 2701. PROHIBITION OF PREEXISTING CONDITION EX19 CLUSIONS. 

20 "(a) IN GENERAI,.-A group health plan or a health 

21 insurance issuer offering group health insurance coverage 

22 may not impose any preexisting condition exclusion with 

23 respect to such plan or coverage. 

24 "(b) DEFINITIONS.-For purposes of this section: 

25 "(1) PREEXISTING CONDITION EXCLUSION.-

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3 

"(A) IN GEl'\ERAL.-The term 'preexisting 

2 condition exclusion' means, with respect to a 

3 group health plan or health insurance coverag·e, 

4 a limitation or exclusion of benefits relating to 

5 a condition based on the fact that the condition 

6 was present before the date of enrollment in 

7 such plan or for such coverage, whether or not 

8 any medical advice, diagnosis, care, or treat9 ment was recommended or received before such 

10 date. 

11 "(B) TREATMEKT OP GENETIC INFORlVIA12 TION.-Genetic information shall not be treated 

13 as a preexisting condition in the absence of a 

14 dia,onosis of' the condition related to such infor15 mation. 

16 "(2) DATE OF ENROLLMENT.-'l'he term 'date 

17 of' enrollment' means, with respect to an individual 

18 covered under a group health plan or health insur19 ance coverage, the date of enrollment of the indi20 vidual in the plan or coverage or, if' earlier, the first 

21 day of the waiting period for such enrollment. 

22 "(3) WAlTI?\G PERIOD.-The term 'waiting pe23 riod' means, with respect to a group health plan and 

24 an individual who is a potential participant or bene25 ficiary in the plan, the period that must pass >vith 

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4 

1 respect to the individual before the individual is eli2 gible to be covered for benefits under the terms of 

3 the plan.". 

4 (b) INDIVIDUAL MARKET.-Subject to section 103(a) 

5 of this Act, subpart 1 of part B of title XXVII of the 

6 Public Health Service Act (42 lT.S.C. 300gg-41 et seq.), 

7 as restored or revived pursuant to PP ACA repeal legisla8 tion described in section 103(b) of this Act, is amended 

9 by adding at the end the following: 

10 "SEC. 2746. PROHIBITION OF PREEXISTING CONDITION EX11 CLUSIONS OR OTHER DISCRIMINATION 

12 BASED ON HEALTH STATUS. 

13 "The provisions of section 2701 shall apply to health 

14 insurance coverage offered to individuals by a health in15 surance issuer in the individual market in the same man16 ncr as it applies to health insurance coverage offered by 

17 a health insuranee issuer in the group market.". 

18 SEC.l02. GUARANTEED AVAILABILITY OF COVERAGE. 

19 (a) GROUP 1\IL\RKET.-Subject to seetion 103(a) of 

20 this Act, subpart 3 of part A of title XXVII of the Public 

21 Health Service Act, as restored or revived pursuant to 

22 PPACA repeal legislation described in section 103(b) of 

23 this Act, is amended by striking section 2711 ( 42 U.S.C. 

24 300gg-11) and inserting the following: 

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5 

"SEC. 2711. GUARANTEED AVAILABILITY OF COVERAGE. 

2 "(a) GUARANTEED ISSUANCE OF COVERAGE IN THE 

3 GROUP MARKET.-Subject to subsection (b), each health 

4 insurance issuer that offers health insurance coverage in 

5 the group market in a State shall accept every employer 

6 and every individual in a group in the State that applies 

7 for such coverage. 

8 "(b) ENROLLMENT.-

9 "(1) RESTRICTION.-A health insurance issuer 

10 described in subsection (a) may restrict enrollment 

11 in coverage described in such subsection to open or 

12 special enrollment periods. 

13 "(2) ESTABJ,ISIIMENT.-A health insurance 

14 issuer described in subsection (a} shall establish spe15 cial enrollment periods for qualifying events (as such 

16 term is defined in section 603 of the Employee Re17 tirement Income Security Act of 1974).". 

18 (b) INDIVIDUAL 11ARKET.-Subject to section 103(a) 

19 of this Act, subpart 1 of part B of title XA'V1I of the 

20 Public Health Service Act, as restored or revived pursuant 

21 to PPACA repeal legislation described in section 103(b) 

22 of this Act, is amended by striking section 2741 of such 

23 Act (42 l;.S.C. 300gg-41) and inserting the following: 

24 "SEC. 2741. GUARANTEED AVAILABILITY OF COVERAGE. 

25 "The provisions of section 2711 shall apply to health 

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6 

surance issuer in the individual market in the same man2 ner as such provisions apply to health insurance coverage 

3 offered to employers by a health insurance issuer in con4 nection with health insurance coverage in the group mar5 ket. Por purposes of this section, the Secretary shall treat 

6 any reference of the word 'employer' in such section as 

7 a reference to the term 'individual'.". 

8 SEC. 103. EFFECTIVE DATE CONTINGENT ON REPEAL OF 

9 PPACA. 

10 (a) IN GENERAh-Sections 101 and 102 and the 

11 amendments made by such sections shall take effect upon 

12 the enactment of PPACA repeal legislation described in 

13 subsection (b) and such sections and amendments shall 

14 have no force or effect if such PPACA repeal legislation 

15 is not enacted. 

16 (b) PPACA REPEAI"' LEGISLATION DESCRIBED.-

17 I<' or purposes of subsection (a), PP ACA repeal legislation 

18 described in this subsection is legislation that19 (1) repeals Public Law 111-148, and restores 

20 or revives the provisions of law amended or repealed, 

21 respectively, by such Act as if such Act had not been 

22 enacted and without further amendment to such 

23 provisions of law; and 

24 (2) repeals title I and subtitle B of title II of 

25 the Health Care and Education Reconciliation Act of 

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1 2010 (Public Ijaw 111-152), and restores or revives 

2 the provisions of law amended or repealed, respec3 tively, by such title or subtitle, respectively, as if 

4 such title and subtitle had not been enacted and 

5 ·without further amendment to such provisions of 

6 law. 

7 TITLE II-CONTINUOUS COVs ERAGE INCENTIVE 

9 [PLACEHOLDER] 

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115TH CONGRESS 

1ST SESSION H.R. 

[114II5921] 

{Original Signature of Member) 

To amend title XXVII of the Public Health Service Act to change the 

permissible age variation in health insurance premium rates. 

IN THE HOUSE OP REPRESENTATIVES 

1\fr. Bucsno:-~ introduced the following bill; which was referred to the 

Committee on----~----

A BILL 

To amend title XXVII of the Public Health Service Act 

to change the permissible age variation in health insurance premium rates. 

Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the "State Age Rating 

5 Plexibility Act of 20 17". 

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2 

SEC. 2. CHANGE IN PERMISSffiLE AGE VARIATION IN 

2 HEALTH INSURANCE PREMIUM RATES. 

3 Section 2701(a)(l)(A)(iii) of the Public Health Serv4 ice Act (42 U.S.C. 300gg(a)(l)(A)(iii)), as inserted by sec5 tion 1201(4) of Public r,aw 111-148, is amended by in6 serting after "3 to 1 for adults (consistent with section 

7 2707(c))" the following: "or, for plan years beginning on 

8 or after January 1, 2018, 5 to 1 for adults (consistent 

9 with section 2707(c)) or such other ratio for adults (con10 sistent with section 2707(c)) as the State involved may 

11 provide". 

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115nr CONGRESS 

1ST SESSION H.R. 

[114H5589j 

(Original Signatut·e of Member) 

To amend title I of the Patient Protection and Affordable Care Act to 

require verif1cation for eligibility for enrollment during special enrollment 

periods in PPACA insurance plans, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

Mrs. Blu\CKBURN introduced the follov\ing bill; which was referred to the 

Committee on ~-------··---·---·--·-

A BILL 

To amend title I of the Patient Protection and Affordable 

Care Act to require verification for eligibility for enrollment during special enrollment periods in PPACA insurance plans, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the Um:ted States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may he cited as the "Plan Verification and 

5 Fairness Act of 2017". 

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2 

1 SEC. 2. REQUIRING VERIFICATION FOR ELIGIBILITY FOR 

2 ENROLLMENT DURING SPECIAL ENROLL3 MENT PERIODS IN PPACA INSURANCE PLANS. 

4 (a) IN GE:\'ERAL.-Section 1311(c) of the Patient 

5 Protection and Mfordable Care Act (42 U.S.C. J8031(c)) 

6 is amended by adding at the end the following new para7 graph: 

8 "(7) VERIFICATION REQUIREMENT I<'OR SPE9 CIAL ENROLLlVIJ;}NT PERIODS.-

10 "(A) IN GENERAL.-The Secretary shall 

11 provide that, in the case of a special enrollment 

12 period provided for under paragraph (6)(C) 

13 that is with respect to a plan year that begins 

14 on or after January 1, 2018, qualified health 

15 plans offered through an Exchange may not 

16 make coverage effective with respect to an indi17 vidual enrolling during such period until the 

18 

19 

20 

21 

22 

23 

24 

25 

26 

G:\VHLC\010417\010417.214.xml 

January 4, 2017 (3:16p.m.) 

Exchange verifies, through an approved 

verification process described in subparagraph 

(B), that the individual, with respect to such 

Exchange, is a qualified individual who is eligible to enroll during such period. 

"(B) APPROVED VERIFICATION PROCESS 

DESCRIBED.-For purposes of subpara,OTaph 

(A), an approved verification process described 

in this subparagraph is a process specified by 

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G:\M\15\BLACKB\BLACKB_OOS.XML 

3 

the Secretary through interim final rulemaking 

2 that requires an individual described in sub3 para~:,JTaph (A) seeking to enroll in a qualified 

4 health plan described in such subparagraph to 

5 submit to the Exchange such documents as the 

6 Secretary determines are necessary in order for 

7 the Exchange to verify that the individual, with 

8 respect to such Exchange, is a qualified indi9 vidual who is eligible to enroll during a period 

10 described in such subparagTaph. To the extent 

11 practicable, such process shall be similar to the 

12 review and assessment process pertaining to 

13 special enrollment periods described at 81 Fed. 

14 Reg. 12274 in the final rule entitled 'Patient 

15 Protection and Affordable Care Act; HHS No16 tice of Benefit and Payment Parameters for 

17 2017', published at 81 Fed. Reg. 12203 (March 

18 8, 2016).". 

19 (b) S'I'UDY AND REPORT.-

20 (1) STUDY.-The Inspector General of the De21 partment of Health and Human Services shall con22 duct a study on enrollment by individuals in quali23 fied health plans (as defined in section 130l(a) of 

24 the Patient Protection and Affordable Care Act ( 42 

25 U.S.C. 18021(a))) during special enrollment periods 

G:\VHLC\010417\010417.214.xml 

January 4, 2017 (3:16p.m.) 

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G:\M\15\BLACKB\BLACKB_OOS.XML 

4 

1 provided for under section 1311(c)(6)(C) of such Act 

2 (42 U.S.C. 18031(c)(6)(C)) that are with respect to 

3 plan year 2016. Such study shall include, with re4 spect to each such period, an identification of each 

5 of the following: 

6 (A) The number of individuals who sought 

7 to enroll in such a plan through an Exchange 

8 established under such Act during such period 

9 but who were not allowed to so enroll during 

10 such period. 

11 (B) The number of such individuals who 

12 were not allowed to so enroll through such an 

13 Exchange during such period on account of 

14 each of the following: 

15 (i) The individual did not provide to 

16 the Exchange documentation to dem17 onstrate that the individual was, with re18 spect to the Exchange, a qualified indi19 vidual (as defined in section 1312(f)(1) of 

20 such Act (42 U.S.C. 18032(f)(l))) who 

21 was eligible to enroll during such period. 

22 (ii) Such documentation provided to 

23 the Exchange by the individual was invalid. 

24 (2) REPOR'l'.-Not later than June 1, 2018, 

25 such Inspector General shall submit to Congress a 

G:\VHLC\010417\010417.214.xml 

January 4, 2017 (3:16p.m.) 

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G:\M\15\BLACKBIBLACKB_OOS.XML 

5 

report on the findings of the study conducted under 

2 paragraph (1). 

G:\VHLC\010417\010417.214.xml 

January 4, 2017 (3:16p.m.) 

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G:\P\15\H\ACA\GRACEPD_OI.XML 

115'l'H CONGRESS 

1ST SESSION H.R. 

-114H5410 

(Original Signature of Member) 

To amend the Patient Protection and Affordable Care Act to better align 

the grace period required for non-pa~m1ent of premiums before discontinuing coverage under qualified health plans with such grace periods 

JWO\~ded for under State law. 

IN THE HOUSE OF REPI~ESENTATIVES 

Mr. l<'LORES introduced the following bill; which was referred to the 

Committee on 

A BILL 

To amend the Patient Protection and Affordable Care .Act 

to better align the grace period required for non-payment 

of premiums before discontinuing coverage under qualified health plans with such gTace periods provided for 

under State law. 

Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 'l'his Act may be cited as the "Health Coverage State 

5 Flexibility Act of 2017". 

g:IVHLC\0126171012617.154.xml 

January 26, 2017 (3:05 p.m.) 

(64967511) 
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G:\P\15\H\ACA\GRACEPD_Ol.XML 

2 

SEC. 2. ALIGNING QUALIFIED HEALTH PLAN GRACE PE2 RIOD REQUIREMENTS WITH STATE LAW 

3 GRACE PERIOD REQUIREMENTS. 

4 Section 1412(c)(2) of the Patient Protection and Af5 fordable Care Act (42 U.S.C. 18082(c)(2)) is amended6 (1) in subparagraph (B)(iv)(II), by striking "a 

7 3-month grace period" and inserting "a grace period 

8 specified in subparagraph (C)"; and 

9 (2) by adding at the end the following new sub1 0 paragTaph: 

11 "(C) GRACE PERIOD SPECIFIED.-l<1

or pur12 poses of subparagraph (B)(iv)(II), the grace pe13 riod specified in this subparagraph is14 "(i) for plan years beginning before 

15 January 1, 2018, a 3-month grace period; 

16 and 

17 "(ii) for plan years beginning during 

18 2018 or a subsequent year, such grace pe19 riod for non-payment of premiums before 

20 discontinuing coverage as is applicable 

21 under the State law of the State in which 

22 the Exchange operates to health insurance 

23 coverage offered in the individual market 

24 (or, in the case such a State law is not in 

25 place for the State involved, a 1-month 

26 gnce period).". 

g:\VHLC\012617\012617.154.xml 

January 26, 2017 (3:05 p.m.) 

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I MOI'IEYIIOX COM!>IfNTA.RYA.!IOUTVU5fi'IESSA,N!)ffNA.NCE. 

It Cost $2.5 Million to Keep My Child Alive 

We're fortunate that our Insurance paid for most of it. But if Republicans remake the health care system. kids like her may 

not be so lucky. 

By Virginia Sole·Smlth 

y daughter Violet is 3 years old. She loves ladybugs and donuts and asking the question "Why?" She was also bom with a singleventricle heart, thanks to a rare collection of congenital defects. Violet lived for six months in a hospital bed. Her heart has been 

stopped, its essential pumping action taken over by a bypass machine in three separate 12-houroperations., and she's had nine 

other surgeries. She spent almost two years in physical therapy and feeding therapy learning to sit, walk, and eat. 

Violet Is 3 years old and has accrued $2.5 million in medical bills. When you add the bills still under dispute, the number is more than $3 

million. 

Advertisement 

But we are a lucky family. My husband, Dan, and I are both college-educated, well-compensated professionals, and his job provides 

excellent health insurance that has covered all but a few thousand dollars of those bills. His employer also extended his pald family 

leave benef1t Jndefmite!y so he never had to miss a day that Violet spent in the hospital. And we received tremendous support from our 

extended family and friends, many of whom sent food, books, toys, and yes, checks. 

Still, as the Republicans continue plotting how to dismantle the Affordable Care Act following President Trump's ftrst executive order,! 

am worried, Violet faces a lifetime of medical interventions. Dan could lose his job and, with it, our medical coverage. But even if he 

doesn't, the GOP has talked about repealing provisions of the Affordable Care Act that would change the rules for employment-based 

insurers as welL 

Get Slate In your inbox. ENTER YOUR EMAil 

Ethics violations, Conflicts of Interest. We'll tell the truth about the new administration. Join Slate P1us, 
126 


Violet may no longer be permitted to stay on our health insurance plan, it necessary, until she's26. !>he may have met her Htet!me cap 

on coverage before her first birthday. (We racked up those early medical bills so carelessly, never thinking we mlght have to choose 

between saving her life then and saving it later.) And she may not be able to get another Insurance plan because she's one of 129 million 

Americans with a pre-existing condition that insurers could refuse to cover. In her case, It developed sometime around the 10th week of 

my pregnancy. Pregnancy is a high-risk proposition for women with Violet's condition, and yet she may not have access to free or lawcost contraception when she's old enough to need it. 

Yet, Violet is not the kid I'm worried most about. My husband and I have begun saving for these scenarios. And we come from uppermiddle-class fam!!les, which means Violet has grandparents and great-grandparents who can do the same. 

Advertisement 

But there are more than 27 million other children who have benefited from the ban on lifetime limits under the Affordable Care Act and 

may be left scrambling for coverage sometime in the future. Meanwhile, 40 percent of all kids and 75 percent of poor kids rely on 

Medicaid or its partner program, the Children's Health Insurance Plan {or CHIP), for their health coverage, according to the Kaiser 

Family Foundation. In addition to repealing the ACA, House Republicans are also working to tum Medicaid funds Into block grants, 

which would allow states to restrict eligibility for both programs. All together, an estimated 29.8 million Americans could be uninsured 

by 2019, reports the Urban Institute. Nearly 4 million of them are children. Nine hundred thousand of them are under age 5. And many 

of them are very, very sick. 

VIolet 

About half of American kids with complex health needs are on Medicaid or CHIP, compared with just35 percent of healthy kids, 

according to the Data Resource Center for Child & Adolescent Health. That's because families who might not otherwise have 

qua lifted often lose jobs in their quest to care for a sick child or need Medicaid to ftll gaps In an employer-sponsored plan as their child's 

medical bills rack up. "Medicaid block grants would be devastating for these children," says Dr. James M. Perrin, a professor of 

pediatrics at Harvard Medical School. Anne Garcia, the founder of OpHear~ a nonprofit research and advocacy organization in 

Houston, puts it even more bluntly: "Half of the 40,000 babies born each year with congenital heart defects require expensive surgeries 

In the first few months of life," she says. "These cuts in coverage could return us to the Dark Ages of pediatric cardiac medicine, when 

doctors had to send babies home to die In their mothers' arms." 

I worry about those babies, because doctors could have told me the same thing, and Instead have worked unstintinglyto save Violet's 

life. I worry about the family who llved In the room next door to us in the pediatric intensive care unit last summer. They have one child 

on the kidney transplant list and another displaying early signs of autism, In addition to extensive hospital stays, they face years of 

therapy and home nursing bills. 

Slate Academy: The United States of Debt How did debt get so bad ln the United States? Join personal fmance columnist Helaine Olen as she takes ln~depth look at the reality of debt in Amedca. What's It like to empty out your 401(k} to help a family member? What works-and what doesn't-for people struggling 

to get out of debt7 Find out. Join us today. 

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127 


1 am scared tor the k.1ds who aren't getting access to the satcst and most advanced surgical techniques because the best surgeons don't 

take their Insurance, When VIolet had a feeding tube implanted in her abdomen in 2014, our nurses were relieved that we had chosen a 

surgeon who did that as a laparoscopic procedure because it's less risky and has a much shorter recovery. The poor kids in our area get 

sent to an older surgeon who still slices their abdomens wide open to Insert the tube-because he's the only one who takes Medicaid. 

On Friday, the Centers for Disease Control and Prevention published a report f1nding that babies born with birth defects were 45 to 49 

percent more likely to die in the first year of life if they had Medicaid coverage than if they were privately insured. Now imagine how 

much worse that death rate would be If even Medicaid was beyond their grasp. 

Top Comment 

The GOP plan for children llke Charlotte Is a mayonnaise jar for coins on the counter of your local7·11. M2.mw. 

847 Comments Join In 

And I'm frightened for the babies who lie alone in cribs everyday, on every floor of every children's hospital in the country. Their 

mothers, fathers, or other caregivers aren't there because they can't afford to miss work to be with their sick children. They can't lose 

that job. They can't lose their house. They can't lose that health insurance. 

Violet is 3 years old and she loves ladybugs, donuts, and asking the question "Why?" Those children also have passions and questions 

and potential. I don't have their photos, so I'm including one of my own kid, the one who wll! be mostly OK, no matter what the 

Republicans do to our health care system. But If Congress guts Medicaid and repeals the Affordable Care Act without a viable 

replacement, Violet will be asking why. And so wl!! the rest of America for generations. 

Ethics violation$. Conflicts of Interest. We'll tell the truth about the new administration. Joln Slate PIU$. 
128 


Real Possibilities 

February 1, 2017 

601 E Street, NW i Washmgton, DC 20049 

202-434-2277 I 1-888-0UR-AARP I 1-BSB-687-2277 i TIY: 1-877-434-7598 

www.aarp.org 1 twitter; @aarp facebook.com/aarp I youtube.com/aarp 

Dear Chairman Burgess and Ranking Member Green: 

Thank you for holding this week's hearing entitled "Patient Relief from Collapsing Health 

Markets." AARP shares the subcommittee's desire to examine ways in which health care 

costs can be lowered and better care can be provided to all Americans. However, we are 

concerned that the proposed State Age Rating Flexibility Act of 2017 -- that would loosen age 

rating bands to allow insurers to charge older Americans significantly more for health 

insurance-- would severely limit, not expand, access to quality, affordable healthcare. In 

addition, ample evidence suggests that relaxing restrictions on age rating bands could 

increase - not reduce -federal outlays on health care. 

AARP, with its nearly 38 million members in all 50 States and the District of Columbia, Puerto 

Rico, and the U.S. Virgin Islands, is a nonpartisan, nonprofit, nationwide organization that 

helps people turn their goals into real possibilities, strengthens communities, and fights for 

the issues that matter most to families such as healthcare, employment & income security, 

retirement planning, affordable utilities and protection from financial abuse. 

Impact on Older Americans 

The Affordable Care Act (ACA) addressed key obstacles in availability and affordability of 

health coverage for older Americans not yet eligible for Medicare. The result has been a 

dramatic drop - by half-- of the number of Americans age 50-64 who are uninsured. 

The 3:1 age band restriction included in the ACA's market reforms ensured that older 

Americans could no longer be charged more than three times the amount charged to younger 

Americans. Prior to the ACA, health insurance coverage was simply unavailable or 

unaffordable for millions of 50-64 year aids not yet eligible for Medicare. Many paid much 

more for less coverage than they do today -- state departments of insurance permitted 

insurers to charge older Americans five times or more than younger people for the same · 

insurance coverage. For older adults without access to employer-based coverage, the 

average out-of-pocket costs for premiums and health care purchased on the individual 

market were typically two-and-a-half times higher than those of similar age with employersponsored coverage. This limitation, combined with coverage subsidies, is critical to ensuring 

that pre-Medicare eligible Americans can afford coverage. 

Alabama :Alaska ! Arizona I Arkar.sas i CaEforr,,a I Colorado i Cwne<:ticut ! Delaware ! D,stnct of Co!umb1a 1 Florida : Gaocg1a i Hawa1i j ld<>ho 1 !llmoiS j Jndial'\a 

Iowa i Kansas 1 Kentucky i Lm.ltstan<> i M<ltne l Maryland ! Massachusetts i MKhtgan I Mmnesota I M•sslsstppi I Mtssouri I Montana 1 Nebraska 1 Nevada 

New Ha,..psh•rc j New Jersey I New Mex•co I New ! North Carol:n<> j North Dakota ! Ohto I Oklahoma ! Oregon j Pennsylvania 1 Puerto R1co 

Rhode Island I South Carolm,;o I South Dakota l 1ennessee i Texas I Utah I Vermont I Vtrgm Islands jV1rg'flla I Wash1ngton I West Y1rg,nta I W1sconsmj Wyommg 
129 


Changes Would Increase Cost for Older Americans 

Weakening or eliminating the 3:1 age band restriction would increase dramatically premiums 

for older adults, making coverage less affordable for 50-64 year olds. Meanwhile, such a 

change would provide only marginally lower costs for younger adults. Estimates show that 

changing the age rating limit to 5:1 would increase yearly premiums for an average 64 year 

old on a silver plan by $2,100 (from $8,500 to $10,600), while reducing premiums for a 21 

year old by only $700 (from $2,800 to $2,1 00). 

The even larger disparity created by a 5:1 age band fails to take into account the impact on 

affordability for seniors. Income analysis done prior to implementation of the ACA found that 

the median family income for uninsured 18-24 year olds was approximately $28,500 while it 

was about $30,000 for 50-64 year olds --a difference of just over $1500. Despite the small 

difference in income, seniors who already pay as much as $5000 or more would be asked to 

pay as much as $8000 more. 

A September 2015 Commonwealth Fund analysis also found that such a change would result 

in 400,000 older Americans losing health coverage altogether. The study also found that the 

increase in premiums caused by 5-to-1 rate banding would be financed in large part by the 

federal government-- if the coverage is more expensive, it will necessitate higher subsidies 

to ensure affordability. 

A 3:1 Age Band is More Price Accurate 

According to a 2013 Urban Institute study, the 3:1 band "results in age-based premiums that 

more accurately match age-related costs among likely purchasers than would a looser rate 

band." The study further concludes that higher rate bands would significantly increase out-ofpocket rates paid by older Americans and that a 5:1 band tends to overcharge older adults 

relative to their actual health expenses. 

Relaxing the current 3:1 age band is a bad deal for Americans and will lead to higher costs 

and reduced coverage. For these reasons MRP strongly opposes the State Age Rating 

Flexibility Act of 2017 and urges you to reject any efforts to expand age rating bands that shift 

large to older Americans. 

Thank you for the opportunity to submit this letter. If you have further questions, please feel 

free to contact me or have your staff reach out to Brendan Rose of our Government Affairs 

staff at brose@aarp.org or 202-434-3770. 

Joyce A Rogers 

Senior Vice President 

Government Affairs 

2 
130 

131 


2/612017 Today in Obamacar-e: The GOP say,> the !a-N is "collapsing." CBO say.; otherv-.ise. - Vox 

Today in Obamacare: GOP says the law is 

"collapsing." CBO says otherwise. 

Updated by Sarah Kfiffsarah@voxcom Jan 24, 2017, 4:10pm EST 

Photo by Joe Raed!e/Getty Images 

CBO: Obamacare enrollment will stay steady next year, hit 13 million in 2027. One of 

Republicans' favorite ways to describe Obamacare is as "collapsing." 

"We're acting quickly because Obamacare is collapsing under its own weight, and things 

will continue to get worse otherwise," Senate Majority Leader Mitch McConnell (R-KY) said 

in a January 9 op-ed for Fox News. 

"Obamacare is collapsing," House Speaker Paul Ryan (R-WI) said at a press conference 

this week. "Don't forget that" 

http://www.l.()x.conVpol!c'f'and-politi cs/2017/1/24/14371 098fobarnacare-col tapse-gop.cbo 1!2 
132 


2/6/2017 Today in Obamacarc: The GOP say.> the !awis "collapsing." CBO say.; othervvlse.- Vox 

The latest data from the Congressional Budget Office, however, begs to differ. The 

nonpartisan budget agency released its long-term economic forecast earlier today, 

which predicts that enrollment in the Obamacare marketplaces will increase slightly and 

then hold constant for the next decade. 

Forecasters: Obamacare enrollment 

will hold steady 

Health insurance coverage through the Affordable Care Act 

marketplaces (in millions) 

20 

15 --------------------------------------------------

10 

5 

0 2017 2019 2021 2023 2025 2027 

Credit: Sarah Kllff/Vox 

Source: Congressional Budget Office 

Vox 

To be clear: The insurance marketplaces are way smaller than CBO had initially expected. 

Back when the law passed, the agency estimated that there would be 26 million people in 

the marketplace in 2017. We're on pace to have a market less than half that size. A market 

with more people would likely have lower premiums, as it would mean more healthy people 

had decided to join. 

Though the Obamacare marketplaces are smaller, they're not, in CBO's view, anywhere 

near collapsing. They are on pace to provide a relatively small but stable number of 

Americans with health coverage. This is in line with a memo that the ratings agency S&P 

put out last month, which projected that if the ACA stays in place, "2017 will likely see 

continued improvement [in the marketplaces], with more insurers getting close to breakeven 

or better." 

http://w.mwx.corntpollcy-and-politics/2017/1/24/14371098/obamacare-col!apse-gop-cbo 212 
133 


JANUARY 2017 

How Repealing Portions of the 

Affordable Care Act Would Affect 

Health Insurance Coverage and Premiums 

A little more than a year ago, the Congressional 

Budget Office and the staff of the Joint Committee on 

Taxation QCT) estimated the budgetary effects of 

H.R. 3762, the Resroring Americans' Healthcare Freedom Reconciliation Act of 2015, which would repeal 

portions of the Affordable Care Act (ACA)-eliminating, 

in two steps, the law's mandate penalties and subsidies 

but leaving the ACA's insurance market reforms in place. 

At that time, CBO and JCT offered a partial assessment 

of how H.R. 3762 would affect health insurance coverage, but they had not estimated the changes in coverage 

or premiums that would result from leaving the market 

reforms in place while repealing the mandate penalties 

and subsidies. 1 This document-prepared at the request 

of the Senate Minority Leader, the Ranking Member of 

the Senate Committee on Finance, and the Ranking 

1. Congressional Budget Office, letter to the Honorable Mike 

Enzi regarding the budgetary effects ofH.R. 3762, the Restoring 

Americans' Healthcare Freedom Rewnci!iation Act, as passed 

by the Senate on December 3, 2015 (December 11, 2015), 

WW'N.cbo.gov/publication/51090. CBO andJCT later updated 

those budgetary estimates following enactment of the 

Consolidated Appropriations Act, 20 16; see Congressional 

Budget Office, cost estimate for RR. 3762, the Restoring 

Americans' Healthcare Freedom Reconciliation Act, as passed 

by the Senate on December 3, 2015, and following enactment 

of the Consolidated Appropriations Act, 2016 Qanuary 4, 2016), 

www.cbo.gov/publication/Sll07. The estimated effects on 

insurance coverage in that document did not substantially differ 

from those described in the letter transmitted on December 11, 

2015. 

Member of the Senate Committee on Health, Education, 

Labor, and Pensions-provides such an estimate. 

In brief, CBO and JCT estimate that enacting that 

legislation would affect insurance coverage and premiums 

primarily in these ways: 

• The number of people who are uninsured would 

increase by 18 million in the first new plan year 

following enactment of the bill. Later, after the 

elimination of the ACA's expansion of Medicaid 

eligibility and of subsidies for insurance purchased 

through the ACA marketplaces, that number would 

increase to 27 million, and then to 32 million in 

2026. 

• Premiums in the nongroup market (for individual 

policies purchased through the marketplaces or 

directly from insurers) would increase by 20 percent to 

25 percent-relative to projections under current 

law-in the first new plan year following enactment. 

The increase would reach about 50 percent in the year 

following the elimination of the Medicaid expansion 

and the marketplace subsidies, and premiums would 

abour double by 2026. 

The ways in which individuals, employers, states, 

insurers, doctors, hospitals, and other affected parties 

would respond to the changes made by H.R. 3762 are 

all difficult to predict, so the estimates in this report are 

uncertain, But CBO and JCT have endeavored to 
134 


2 HOW REPEALING PORTIONS OF THE ACA WOt.:W AFFECT HEALTH I~SURANCE COVERAGE AND PREMIUMS JANUARY 2017 

develop estimates that are in the middle of the distribution of potential outcomes. 

In an effort to make this information more useful, CBO 

and JCT have updated their estimates of H.R. 3762's 

effects on health insurance coverage and premiums using 

CBO's most recent baseline projections, which were 

released in March 2016, and adjusted the effective dates 

in the legislation to reflect an assumption that enactment 

would occur one year later. 

The Restoring Americans' Healthcare 

Freedom Reconciliation Act of 2015 H.R. 3762 would make two primary sets of changes that 

would affect insurance coverage and premiums. First, 

upon enactment, the bill would eliminate penalties associated with the requirements that most people obtain 

health insurance (also known as the individual mandate) 

and that large employers offer their employees health 

insurance that meets specified standards (also known as 

the employer mandate). Second, beginning roughly two 

years after enactment, the bill would also eliminate the 

ACA's expansion of Medicaid eligibility and the subsidies 

available to people who purchase health insurance 

through a marketplace established by the ACA. 

H.R. 3762 also contains other provisions that would have 

smaller effects on coverage and premiums. 

Importantly, H.R. 3762 would leave in place a number 

of market reforms-rules established by the ACA that 

govern certain health insurance markets. Insurers who 

sell plans either through the marketplaces or directly to 

consumers are required to: 

• Provide specific benefits and amounts of coverage; 

• Not deny coverage or vary premiums because of an 

enrollee's health status or limit coverage because of 

preexisting medical conditions; and 

• Vary premiums only on the basis of age, tobacco use, 

and geographic location. 

Analysis of H.R. 3762 Relative to 

CBO's March 2016 Baseline 

According to CBO and JCT's analysis, upon enactment, 

H.R. 3762 would reduce the number of people with 

insurance; and in the first new plan year, premiums in 

the nongroup market would rise and participation by 

insurers in that market would decline. Starting in the year 

following the elimination of the expansion of Medicaid 

eligibility and the marketplace subsidies, the increase in 

the number of uninsured people and premiums would be 

greater, and participation by insurers in the nongroup 

market would decline further. 

Estimated Changes Before the Elimination of the 

Medicaid Expansion aod Subsidies 

Following enactment but before the Medicaid expansion 

and subsidies for insurance purchased through the 

marketplaces were eliminated, the effects ofH.R. 3762 

on insurance coverage and premiums would stem primarily from repealing the penalties associated with the individual mandate. 

Effects on Insurance Coverage. CBO and JCT expect 

that the number of people without health insurance 

coverage would increase upon enactment ofH.R. 3762 

but that the increase would be limited initially, because 

insurers would have already set their premiums for the 

current year, and many people would have already made 

their enrollment decisions for the year. Subsequently, in 

the first full plan year following enactment, by CBO and 

JCT's estimates, about 18 million people would become 

uninsured. That increase in the uninsured population 

would consist of about 10 million fewer people with 

coverage obtained in the non group market, roughly 

S million fewer people with coverage under Medicaid, 

and.about 3 million fewer people with employmentbased coverage. 

Most of those reductions in coverage would stern from 

repealing the penalties associated with the individual 

mandate. However, CBO and JCT also expect that insurers in some areas would leave the nongroup market in the 

first new plan year following enactment. They would be 

leaving in anticipation of further reductions in enrollment and higher average health care costs among 

enrollees who remained after the subsidies for insurance 

purchased through the marketplaces were eliminated. As 

a consequence, roughly 10 percent of the population 

would be living in an area that had no insurer participating in the nongroup market. 

Effects on Premiums, According to CBO and JCT's 

analysis, premiums in the nongroup market would be 

roughly 20 percent to 25 percent higher than under current law once insurers incorporated the effects of 

H.R. 3762's changes into their premium pricing in the 
135 


JANUARY 2017 HOW REPEALING JlORTIOKS OF THE ACA WOVID AFFECT HEALTH ISSCRA.~CE COVERAGE A. 'ill PREMiliMS 

first new plan year after enactment. The majority of that 

increase would stem from repealing the penalties associated with the individual mandate. Doing so would both 

reduce the number of people purchasing health insurance 

and change the mix of people with insurance-tending to 

cause smaller reductions in coverage among older and less 

healthy people with high health care costs and larger 

reductions among younger and healthier people with low 

health care costs. Thus, average health care costs among 

the people retaining coverage would be higher, and insurers would have to raise premiums in the nongroup market to cover those higher costs. Lower participation by 

insurers in the nongroup market would place further 

upward pressure on premiums because the market would 

be less competitive, 

Estimated Changes After the Elimination of the 

Medicaid Expansion and Subsidies 

The bill's effects on insurance coverage and premiums 

would be greater once the repeal of the Medicaid expansion and the subsidies for insurance purchased through 

the marketplaces took effect, roughly two years after 

enactment. 

Effects on Insurance Coverage. By CBO and JCT's estimates, enacting H.R. 3762 would increase the number 

of people without health insurance coverage by about 

27 million in the year following the elimination of the 

Medicaid expansion and marketplace subsidies and by 

32 million in 2026, relative to the number of uninsured 

people expected under current law. (The number of people without health insurance would be smaller if, in addi~ 

tion to the changes in H.R. 3762, the insurance market 

reforms mentioned above were also repealed. In that case, 

the increase in the number of uninsured people would be 

about 21 million in the year following the elimination of 

the Medicaid expansion and marketplace subsidies; that 

figure would rise to about 23 million in 2026.) 

The estimated increase of 32 million people without coverage in 2026 is the net result of roughly 23 million fewer 

with coverage in the nongroup market and 19 million 

fewer with coverage under Medicaid, partially offset by 

an increase of about 11 million people covered by 

employment-based insurance. By CBO and JCT's estimates, 59 million people under age 65 would be uninsured in 2026 (compared with 28 million under current 

law), representing 21 percent of people under age 65. By 

2026, fewer than 2 million people would be enrolled in 

the non group market, CBO and JCT estimate. 

According to the agencies' analysis, eliminating the 

mandate penalties and the subsidies while retaining the 

market reforms would destabilize the nongroup market, 

and the effect would worsen over time. The ACA's 

changes to the rules governing the nongroup health 

insurance market work in conjunction with the mandates 

and the subsidies to increase participation in the market 

and encourage enrollment among people of different ages 

and health statuses. But eliminating the penalty for not 

having health insurance would reduce enrollment and 

raise premiums in the nongroup market. Eliminating 

subsidies for insurance purchased through the marketplaces would have the same effects because it would result 

in a large price increase for many people. Not only would 

enrollment decline, but the people who would be most 

likely to remain enrolled would tend to be less healthy 

(and therefore more willing to pay higher premiums). 

Thus, average health care costs among the people retaining coverage would be higher, and insurers would have to 

raise premiums in the nongroup market to cover those 

higher costs. CBO and JCT expect that enrollment 

would continue to drop and premiums would continue 

to increase in each subsequent year. 

Leaving the ACA's market reforms in place would limit 

insurers' ability to use strategies that were common before 

the ACA was enacted. For example, insurers would not be 

able to vary premiums to reflect an individual's health 

care costs or offer health insurance plans that exclude 

coverage of preexisting conditions, plans that do not 

cover certain types of benefits (such as maternity care), or 

plans with very high deductibles or very low actuarial 

value (plans paying a very low share of costs for covered 

services). 

Effects on Participation by Insurers. In CBO and JCf's 

estimation, the factors exerting upward pressure on pre~ 

miums and downward pressure on enrollment in the 

nongroup market would lead to substantially reduced 

participation by insurers and enrollees in many areas. 

Prior experience in states that implemented similar 

nongroup market reforms whhout a mandate penalty or 

subsidies has demonstrated the potential for market 

destabilization. Several states that enacted such market 

reforms later repealed or substantially modified those 

3 
136 


4 HOW REPEALING PORTIONS OF THE ACA WOUlD AFFECT HEALTH INSUR.A.'~;CE COVERAGE AND PREMil!MS jM1JARY2017 

reforms in response to increased premiums and insurers' 

departure from the market. 

After weighing the evidence from prior state-level reforms 

and input from experts and market participants, CBO 

and JCT estimate that about half of the nation's population lives in areas that would have no insurer participating in the nongroup market in the first year after the 

repeal of the marketplace subsidies took effect, and that 

share would continue to increase, extending to about 

three-quarters of the population by 2026. That contraction of the market would most directly affect people 

without access to employment-based coverage or public 

health insurance. 

Effects on Premiums. In total, as a result of reduced 

enrollment, higher average health care costs among 

remaining enrollees, and lower participation by insurers, 

CBO and JCT project that premiums in the nongroup 

market would be about 50 percent higher in the first year 

after the marketplace subsidies were eliminated-relative 

to projections under current law-and would about double by 2026. 

Comparison With CBO andJCT's 2015 

Cost Estimate This analysis differs in a number of respects from the one 

CBO and JCT did in December 2015. In particular, the 

projected increase in the number of uninsured people is 

now greater largely because, at that rime, the agencies had 

not estimated the changes in coverage from leaving the 

ACA's insurance market reforms in place while repealing 

the mandate penalties and subsidies. Moreover, the current estimates of how H.R. 3762 would affect coverage 

are measured relative to CBO's March 2016 baseline, 

rather than the March 2015 baseline, which was the basis 

for the earlier estimates. Those baselines differ in part 

because CBO and JCT have reduced their projections of 

the number of people with health insurance coverage 

through the marketplaces and increased their projections 

of the number of people with coverage through Medicaid 

under current law.2 

Future Legislation 

If the Congress considers legislation similar to H.R. 3762 

in the coming weeks, the estimated effects could differ 

from those described here. In particular, the response of 

individuals, insurers, and states would depend critically 

on the particular specifications contained in such 

legislation. 

This document was requested by the Senate Minority 

Leader, the Ranking Member of the Senate Committee 

on Finance, and the Ranking Member of the Senate 

Committee on Health, Education, Labor, and 

Pensions. Kate Fritzsche and Sarah Masi prepared it 

with guidance from Jessica Ban thin, Chad Chirico, and 

Holly Harvey and with contributions from 

Allison Percy and the staff of the Joint Committee 

on Taxation. An electronic version is available on 

CEO's website (www.cbo.gov/publication/52371). 

Keith Hall 

Director 

2. See Congressional Budget Office, Federal Subsidies for Health 

[nsttrance Coverage for People Under Age 65:2016 to 2026 

(March 2016), www.cbo.gov/publication/51385. 
137 


• /<illiny the needjor trusted inj(wmution on nationull~ealtl• issues ... 

July 2016 I Issue Brief 

High-Risk Pools For Uninsurable Individuals 

Karen Pollitz 

In the debate over the future of the Affordable Care Act (ACA), proposals have emerged that would repeal or 

weaken rules prohibiting health insurance discrimination based on health status, instead offering high-risk 

pools as a source of coverage for people who would be uninsurable due to pre-existing conditions. 

In Congress, ~was introduced by members of the House Republican Study Committee to repeal the 

ACA and replace it with other changes, including state high-risk pools. This bill would authorize $50 million 

for seed grants to help states establish high-risk pools, and $2.5 billion annually for 10 years to help states fund 

high-risk pools. Recently, House Republicans released their proposal to replace the ACA, entitled A Better 

WID'- This plan would significantly modify ACA insurance market rules to provide a one-time open enrollment 

opportunity; thereafter, only individuals who maintain continuous coverage would be guaranteed access to 

insurance without regard to their health status. This plan also would provide $25 billion over 10 years in state 

grants to help fund high-risk pools. Pools would be required to cap premiums (at unspecified levels) and would 

be prohibited from imposing waiting lists. 

For more than 35 years, many states operated high-risk pool programs to offer non-group health coverage to 

uninsurable residents. The federal government also operated a temporary high-risk pool program established 

under the ACA to provide coverage to people with pre-existing conditions in advance of when broader 

insurance market changes took effect in 2014. This issue brief reviews the history of tllese programs to provide 

context for some of the potential benefits and challenges of a high-risk pool. 

Distribution and Persistence of Population Health Spending 

In the U.S. and other developed nations, population health care spending is highly concentrated: in any given 

year, the healthiest so% of the population accounts for less than 3% of total health care expenditures, while the 

sickest 10% account for nearly two-thirds of population health spending. (Figure 1) Private health insurance 

pools risks so that premiums paid by most enrollees, who have low claims costs, help pay claims for the small 

share of enrollees with high costs. 

Who is included in the high-cost and low-cost groups changes from year to year. Most people are healthy most 

of the time, but illness and injury can and do onset unexpectedly for millions of people. Some high-cost 

conditions, such as hemophilia or HIV, persist and require treatment for extended periods, even a lifetime. 

Other high-cost conditions may improve or resolve, allowing patients to return to low annual health care 

spending. In any given year, among the so% least expensive people in a year, 73% will remain in tllat group for 

a second year; similarly, of people who are among the most expensive 10% of the population in one year, only 

45% would still be in that group the following year.' 
138 


Flaurel 

Concentration of Health Care Spending In U.S. Population, 

2011 

Prior to implementation of the ACA, insurers selling individual insurance commonly practiced medical 

underwriting. excluding people with pre-existing conditions or charging them higher premiums. Medical 

underwriting effectively excludes a large proportion of total health care spending from the insurance pool. This 

can permit less expensive policies for healthier individuals, but requires some other mechanism, such as highrisk pools, to help finance costs attributable to the sickest individuals if they are to be covered. Enrollee 

premiums can finance a portion of the cost of such programs, but by definition, significant additional funding 

will also be required because the cost of each person covered will be substantial. For example, based on the 

distribution illustrated in Figure 1, per person costs in the top 10th percentile are more than 100 times, on 

average, that of people in the bottom soth percentile. 

State High-Risk Pools 

Prior to implementation of the ACA, 35 states offered high-risk pools as a source of non-group health insurance 

for eligible residents. (Figure 2) The first pools were implemented by Minnesota and Connecticut in 1976; 

North Carolina implemented a high-risk pool in 2009. Pools offered eligibility to people in one or more of the 

following categories: 

Medically eligible -Originally, high-risk pools were created to offer coverage to state residents with pre-existing 

conditions that made them uninsurable in the medically underwritten non-group health insurance market. 

Medically eligible individuals had to demonstrate their application for individual health insurance had been 

denied or restricted, or -in about two-thirds of state pools with presumptively eligible medical conditions lists 

that they had been diagnosed with an eligible condition.' 

HIPAA eligible - Following enactment of the Health Insurance Portability and Accountability Act of 1996 

(HIPAA)- a federal Jaw requiring non-group coverage to be available on a guaranteed issue basis with no preexisting condition exclusions to certain individuals who had lost group health plan coverage- most state highHigh-Risk Pools For Uninsurable Individuals 
139 


risk pools extended eligibility to HIPAA-eligible individuals. One state, Alabama, opened its pool only to 

HIP AA-eligible individuals. 

HCTC eligible- The Trade Act of 2002 established a federal health coverage tax credit (HCTC) to subsidize 

HIP AA-like coverage for ce11ain eligible individuals with trade-related job Joss. Roughly two-third of state 

pools extended eligibility to H eTC-eligible individuals. 

Medicare eligible- Finally, nearly two-thirds of state high-risk pools offered coverage to Medicare-eligible 

residents who needed supplemental coverage. (Appendix Table 1) 

Figure?; 

Traditional State High-Risk Pools, Pre-ACA 

STATE HIGH-RISK POOL ENROLLMENT, PROGRAM FEATURES, AND COSTS 

Before HIPAA was enacted in 1996, there were 25 state high-risk pools with combined enrollment of 91,054.3 

By the end of 2011, combined enrollment in 35 state high-risk pools reached 226,615, or about 2 percent of the 

number of non-group health insurance market participants in those states that year.• (Appendix Table 2) 

The potentially medically eligible population in high-risk pool states was likely much larger. For example, a 

study by the General Accounting Office (GAO) found between 20% and 60% of non-elderly adults have preexisting conditions that could result in a health insurer restricting coverage. The range of estimates depended 

on the list of pre-existing conditions included; the most prevalent conditions included hypertension, mental 

health disorders, diabetes, pulmonary disease and cancer. In a Kaiser Family Foundation national SJllY!lY, 50% 

of respondents said they or a member of their household had a pre-existing condition. Another~ 

reported that in 2010, 19% of applicants for non-group health insurance coverage nationwide were denied.' A 

Kaiser Family Foundation study of medical underwriting practices in the individual health insurance market 

High·Risk Pools For Uninsurable Individuals 
140 


found applicants with medical conditions as serious as HIV or as mild as seasonal hay fever could have 

coverage denied or restricted or premiums surcharged when applying for medically underwritten policies. 

Although no two traditional state-high risk pools were identical, nearly all adopted certain common features 

that tended to limit enrollment of eligible individuals.' These included: 

Premiums above standard non-group market rates- All state high-risk pools set premiums at a multiple 

of standard (i.e., typical or average) rates for medically underwritten coverage in the non-group market, 

usually 150%-200%. Fifteen pools provided low-income premium subsidies that varied in 

comprehensiveness. The Oregon pool, for example, discounted premiums 95% for enrollees with income 

up to 185% of the poverty level, while the New Hampshire pool provided a 20% premium discount for 

enrollees with income below 200% FPL. Other pools required people to pay the full premium, regardless of 

income. 

• Pre-existing condition exclusions - Nearly all state high-risk pools excluded coverage of pre-existing 

conditions for medically eligible enrollees, usually for 6-12 months. This made coverage less attractive for 

people who needed coverage specifically for their pre-€xisting conditions. 

Lifetime and annual limits -Thirty-three pools imposed lifetime dollar limits on covered services, most 

ranging from $1 million to $2 million. In addition, six pools imposed annual dollar limits on all covered 

services while 13 others imposed annual dollar limits on specific benefits such as prescription drugs, mental 

health treatment, or rehabilitation. 

• High deductibles- Most pools offered a choice of plan options with different deductibles; in 25 programs, 

the plan option with the highest enrollment had a deductible of $1,ooo or higher. (Appendix Table 3) 

A small number of states capped or closed enrollment to limit program costs, though enrollment caps were not 

allowed for HIPAA-eligible individuals. Limiting enrollment, directly or indirectly, was a key strategy to limit 

the cost of high-risk pools to states. By design, all state high-risk pools experienced net losses -that is, 

expenses greater than premium revenue. In 2011, net losses for 35 state high-risk pools combined were over 

$1.2 billion, or $5,510 per enrollee, on average. (Appendix Table 4) Most states financed net losses through 

an assessment on private non-group health insurance premiums; however, nearly all state high-risk pool 

assessments were offset by tax credits so that, in effect, general state revenue funding applied. A few states 

used other revenue sources -tobacco taxes and hospital assessments -to fund high-risk pool losses. In 

addition, in 2003-2010 federal grants were available intermittently, subject to appropriations, to help fund 

qualified state-high risk pools that met certain criteria. For the first two fiscal years (2003-2004) $8o million 

per year was appropriated; $75 million in grants was next awarded in 2006, followed by $49 million in 2008, 

$73·5 million in 2009, and $55 million in each of 2010 and 2011. In some years, a portion of federal grant 

funds was reserved for states that adopted supplemental consumer benefits such as low-income premium 

subsidies. Federal grants comprised between 2% and 12% of program expenses in states that received them.' 

Federal Pre-existing Condition Insurance Program (PCIP) 

The ACA established a temporary, national high-risk pool pt"Ogram, implemented in 2010, to offer coverage for 

uninsured individuals with pre-existing conditions until2014, when private non-group policies would be 

available under new market rules prohibiting insurance discrimination based on health status. The Jaw 

High-Risk Pools For Un1nsurab!e Individuals 
141 


required PCIP enrollees to pay premiums and appropriated $5 billion to fund expected net losses during the 

program's duration. Twenty-seven states opted to administer PCIP for their residents; the federal government 

operated PCIP for 23 states and D.C. 

PCIP ENROLLMENT, PROGRAM FEATURES, AND COSTS 

Program features under PCIP varied from state high-risk pools in several significant respects. Uuder the law, 

PCIP premiums were set at 100% of the standard risk rate for non-group health insurance in each state, 

meaning rates varied by age but were otherwise equivalent to what a typical person without a pre-existing 

condition would pay. Low income premium subsidies were not offered. PC!P did not impose annual or lifetime 

dollar limits on covered benefits. Annual out-of-pocket-cost sharing was capped at the level set for tax-favored 

high-deductible health plans ($6,050 in 2012) and a minimum actuarial value of 65% was established for 

program coverage (meaning patients were expected to pay, on average, 35% of their health expenses). In 42 

states, the lowest deductible option offered in 2012 was at least $1,000.8 

PCIP did not impose pre-existing condition exclusions. However, to prevent "crowd out" from existing state 

pools and other private insurance, PCIP eligibility was limited to individuals who had been uninsured for at 

least 6 months immediately prior to enrolling. 

PCIP was operational in all so states by the fall of 2010. By late 2012, just over 1oo,ooo individuals were 

enrolled and program expenses had consumed nearly half of the $5 billion appropriation. For the fmal 12-

month period for which PCIP expense data were reported, net losses for the program were over $2 billion. 

(Tablet) 

May 31,2011 24,712 $0.180 billion 

Sep. 30, 2011 37,624 $0.386 billion $207 million 

Dec.31, 2011 48,879 $0.618 billion $232 million 

Mar. 31,2012 61,619 $0.963 billion $334 million 

June 30, 2012 77,877 $1.401 billion $439 million 

Sep. 30, 2012 90,347 $1.861 billion $460 million 

Dec. 31,2012 103,160 $2.406 billion $545 million 

Mar. 31,2013 114,959 $2.978 billion $571 million 

June 30, 2013 104,966 $3.602 billion $625 million 

Sep. 30, 2013 89,438 $3.956 billion $354 million 

Source: PCIP quarterly data reoorts, 2011-2013. 

Hlgh·Risk Pools For Uninsurable lndlvlduals 
142 


In 2012, average per enrollee claims costs for PCIP were $32,108, or more than 2.5 times higher than average 

per enrollee claims costs ($12,471) under traditional state high-risk pools, all of which continued to operate 

that year.' Compared to traditional state high-risk pool enrollees, PCIP enrollees tended to have more 

immediate and intensive health care needs, including higher hospital admissions, likely due to the six-month 

prior uninsurance requirement and lack of pre-existing condition exclusions. 10 By contrast, many traditional 

state pool enrollees were HIP AA-eligible, meaning they had to have been continuously covered and were less 

likely to have put off needed treatment prior to joining the pool. Pre-existing condition exclusions would have 

limited traditional pool coverage of initial treatment costs of (or enrollment by) other non-HIPAA eligible 

individuals.n 

In addition, PCIP premiums were based on standard rates for underwritten non -group coverage, while under 

traditional state pools, premiums were set at 150%-200% of standard market rates. As a result, enrollees under 

traditional state pools paid a greater share of their claims costs compared to PCIP enrollees. This meant that 

the loss ratio -the ratio of claims costs to premiums -would naturally be higher in PCIP compared to the 

traditional state pools. In 2011, claims under traditional state high-risk pools averaged 181% of pool premiums; 

that year, PCIP claims averaged 417% of premiums. By late 2013, the PCIP loss ratio had reaclled 6oo%." 

In the face of growing expenses, PCIP adopted a series of cllanges to limit program costs. In 2012 federallyadministered programs switclled to a less expensive provider network and negotiated additional discounts with 

targeted hospitals that treated large numbers of PCIP enrollees. State-run programs were required to achieve 

similar cost savings or transition to federal administration; 17 state programs transitioned in mid-2013. The 

federal PCIP program also consolidated plan options for 2013, eliminating those offering the lowest patient 

cost sharing. Even with these changes, program expenses were still projected to exceed appropriated funds 

before the end of 2013. In March 2013, new PCIP enrollment was suspended to ensure sufficient funds to pay 

claims for people already enrolled." PCIP enrollment peaked at nearly 115,000 in Marcil 2013, then declined 

below 90,000 six months later. 

Discussion 

Nearly four decades of experience with high-risk pools suggests they have the potential to provide health 

coverage to a substantial number of people with pre-existing conditions. State high-risk pools that existed prior 

to passage of the ACA covered over 200,000 people at their peak, and the temporary PCIP pool created as part 

of the ACA covered over 100,000 individuals. 

These high-risk pools likely covered just a fraction of the number of people with pre-existing conditions who 

lacked insurance, due in part to design features that limited enrollment. State pools typically excluded coverage 

of services associated with pre-existing conditions for a period of time and charged premiums snbstantially in 

excess of what a typical person would pay in the non-group market. PCIP had fewer barriers to enrollmentcllarging standard premiums with no pre-existing condition exclusions -but it did restrict signups to people 

who had been uninsured for a least six months. 

Even with these limitations, the government subsidies required to cover losses in these high-risk pools were 

substantial -over $1 billion per year in the state pools and about $2 billion in the final year of PCIP. A highrisk pool that had minimal barriers to enrollment could cost substantially more. 

H!gh·Risk Pools For Uninsurable Individuals 
143 


Appendix Tables 

Alabama X 

Alaska X X X X 

Arkansas X X X 

California X X X 

Colorado X X X X 

Connecticut X X X X 

Florida X X 

Idaho X X X 

Illinois X X X X 

Indiana X X X X 

Iowa X X X X 

Kansas X X X 

Kentucky X X X 

Louisiana X X X 

Maryland X X X 

Minnesota X X X X 

Mississippi X X 

Missouri X X X 

Montana X X X X 

Nebraska X X X X 

Neva.da X X X 

New Hampshire X X X X 

New Mexico X X X 

North Carolina X X X X 

North Dakota X X X 

Oklahoma X X X 

Oregon X X X X 

South Carolina X X 

South Dakota X X 

Tennessee X X X X 

Texas X X 

Utah X X X 

washington X X X 

West Virginia X X X 

Wisconsin X X X 

Wyoming X X X X 

Total 34 34 24 19 

Source: NASCHIP, Comprehensive Health Insurance for High-Risk Individuals: A State-by-State Analysis, 2011/2012 

High-Risk Pools For Uninsurable Individuals 
144 


Alabama 2,133 216,884 0.1% 

Alaska 525 20,940 2.5% 

Arkansas 2,801 116,501 2.4% 

California 6,334 2,203,043 0.2% 

Colorado 13,859 396,950 3.5% 

Connecticut 1,603 158,581 1% 

Florida 208 914,604 0.02% 

Idaho 1,658 123,742 1.3% 

Illinois 19,998 589,454 3.4% 

Indiana 7,502 190,011 3.9% 

Iowa 3,268 185,988 1.8% 

Kansas 1,528 149,443 1% 

Kentucky 4,798 170,835 2.8% 

Louisiana 1,728 161,923 1% 

Maryland 20,646 271,473 7.6% 

Minnesota 26,859 264,370 10.2% 

Mississippi 3,328 135,913 2.4% 

Missouri 4,009 345,408 1.2% 

Montana 2,878 82,021 3.5% 

Nebraska 4,021 139,251 2.9% 

New Hampshire 2,586 68,940 3.8% 

New Mexico 8,442 84,667 9.9% 

North Carolina 8,160 408,557 2% 

North Dakota 1,446 61,539 2.3% 

Oklahoma 2,422 154,818 1.6% 

Oregon 12,152 240,724 5% 

South Carolina 1,799 189,469 1% 

South Dakota 645 61,672 1% 

Tennessee 3,265 320,607 1% 

Texas 24,792 955,857 2.6% 

Utah 3,946 158,000 2.5% 

Washington 3,862 357,130 1.1% 

West Virginla 1 '152 26,466 4.4% 

Wisconsin 21,317 313,149 6.8% 

Wyoming 945 28,191 3.4% 

Total 226,615 10,266,121 2.2% 

Sources: NASCHIP, Comprehensive Health Insurance for Htgh·Risk Individuals: A State-by-State Analysis, 2011/2012; 

U.S. Census Bureau, 2011 Current Population Survey. 

High~Risk Pools For Uninsurable Individuals 
145 


Alaska 150% 6 months $5,000 none 

Arkansas 150% 6 months !1,000 $1 million $4,000' X 

California 125-137.5% 3 months $500 $750,000 S75,000 

Colorado 150% 6 months $1,000 $1 million $3,000' X 

Connecticut 150% 12 months $1,500 Sl.S million none 

Florida 250% n/a2 $1,000 $5 million none 

Idaho 150% 12 months $5,000 Sl million multiple' 

Illinois 150% 6 months $500 $2 million none 

Indiana 200% 3 months $500 none $50,000" 

Iowa 150% 6 months $2,500 $3 million none 

Kansas 150% 3 months $5,000 $2 million $100,000 

Kentucky 175% 6 months $1,500 none none 

Louisiana 200% 6 months $5,000 $625,000 $125,000 

Maryland 200% 6 months $500 $2 million none X 

Minnesota 125% 6 months $2,000 $5 million none X 

Mississippi 175% 6·1 2 months 3 $3,000 $1 million $100,000" 

Missouri 200% 12 months $5,000 Sl million none X 

Montana 200% 12 months $5,000 $2 ml!!lon multlple12 X 

Nebraska 135% 6 months $2,000 Sl million none 

New Hampshire 150% 9 months $1,000 $2.5 million multiplen X 

New Mexico 150% 6 months $500 none none X 

North Carolina 200% 12 months $5,000 $1 million $100,00014 

North Dakota 135% 6·9 months~ !500 $1 million $6,000'5 

Oklahoma 150% 12 months $2,000 $1 million $4,0001$ 

Oregon 125% 6 months $500 $2 million none X 

South Carolina 200% 6 months $1,500 $1 million none 

South Dakota 150% 6 months $1,000 $2 million multiple 11 

Tennessee 200% 6·9 monthss $1,000 $1 million $200,000" X 

Texas 200% 12 months $2,500 $2 million multiple''~ 

Utah 200% 6 months $500 $1.5 million $300,000 X 

Washington 150% 6 months $500 $2 mlllion none X 

West Virginia 150% 6 months $2,000 $1 million $200,000 

Wisconsin 200% 6 months $2,500 $1 million none X 

Wyoming 200% 12 months $1,000 $750,000 none X 

Source: NASCHIP, Comprehensive Health Insurance for Htgh·Risk Individuals: A State·by·'State Analysis, 2011/2012 

Notes: Pre-existing condition exclusions: 'Alabama pooll.)pen only to H!PM·el!glble individuals, no pre-ex imposed. 1F!or!da pool dosed to new enrollment ln 1991, pre·ex not applicable. 1Mississ!pp! pool imposed separate 6-month pre-ex exclusion period for pharmacy benefits, 9 months fo'r pregnancy related benefits, 12 

months for physician and hospltal services for all other conditions. •North Dakota Imposed separate 9-month pre-ex exclusion for pregnancy related benefits, 1ln lieu of pre-ex exclusion, Tennessee pool reduced benefits 50% for most outpatient services for pre-existing conditions, Imposed 12· month waiting period for maternitv·related services, Annual maximums: 6Al: $1 0,000 for pharmacy benefit; 'AR: $4,000 for mental health/substance abuse benefit; •co: $3,000 for OME benefit 

~10: $2,000 for rehab benefit, $5,000 for hospice benefit: $10,000 for DME benefit; 10 IN: $50,000 for mental health/substance abuse, Plan 

3 only; 11MS: $100,000 for pharmacy benefit; 11MT; $5,000 applies to DME, $4,000 applies to rehab benefit; 13NH: $10,000 applies to 

pharmacy, SS,OOO applies to DME, $3,000 applles to mental health/substance abuse, various day limits apply to skilled nursing, rehab, home health; ~<NC: S 100,000 applies to Injectable drugs; various day limits apply to skilled nursing, rehab; "NO: $6,000 applies to DME 

benefit; 110K: $4,000 applies to mental health and chemical dependency combined; 1150: S2,000 applies to substance abuse, $900 applies 

to mental health treatments for non-biologically based conditions, $8,000 applies to DME benefit; "TN: annual !!mit Increased by $100,000 

for organ transplant; "TX: $2,000 applies to rehab, SS,OOO applies to home health, $10,000 applies to hosplce, various day limits apply to 

skilled nursing care and menta! health care, 

High-Risk Pools For Uninsurable Individuals 
146 


$20,255 

Arkansas $2,999 

California $3,579 

Colorado $67.3 $127.2 $4,322 

Connecticut $19.4 $29.0 $5,993 

Florida $1 .3 $3.6 $2.3 $10,894 

Idaho $6.1 $11.4 $5.3 $3,197 

Illinois $118.9 $224.0 $105.1 $5,255 

Indiana $64.2 $134.2 $70 $9,335 

Iowa $20.2 $42.1 $21.9 $6,690 

Kansas $13.2 $27.9 $14.7 $9,626 

Kentucky $34.6 $67.9 $33.2 $6,926 

Louisiana $9.0 $20.8 $11.8 $6,808 

Maryland $97.9 $203.8 $106 $5,133 

Minnesota $133.3 $294.8 $161.5 $6,008 

Mississippi $18.0 $36.3 $18.3 $5,501 

Missouri $33.9 $49.2 $15.4 $3,852 

Montana $17.6 $29.5 $11.9 $4,128 

Nebraska $32.0 $59.2 $27.2 $6,774 

NewHampshire $13.3 $21.3 $8 $3,102 

New Mexico $27.1 $123.0 $95.9 $11,358 

North Carolina $38.3 $48.3 $10 $1 ,225 

North Dakota $8.5 $13.6 $5.1 $3,499 

Oklahoma $11.9 $36.5 $24.6 $10,165 

Oregon $87.3 $170 $82.6 $6,799 

South Carolina $25.3 $27.7 $2.4 $1,329 

South Dakota $4.6 $8.0 $3.4 $5,313 

Tennessee $31.7 $43.4 $11.7 $3,586 

Texas $207.4 $322.7 $115.3 $4,649 

Utah $23.0 $38.3 $15.4 $3,897 

Washington $31.0 $95.8 $64.8 $16,753 

West Virginia $5.3 $7.1 $1.8 $1,562 

Wisconsin $104.2 $186.2 $82 $3,847 

Wyoming $5.5 $8.9 $3.4 $3,611 

Total $1,395.7 $2,644.5 $1,248.7 $5,510 

Source: NASCHIP, Comprehensive Health Insurance for High~Risk Individuals: A State-by-State Analysis, 2011/2012 

High·Risk Pools For Uninsurable Individuals 10 
147 


Endnotes 

1 S Cohen and W Yu, "The Concentration and Persistence in the Level of Health Expenditures over Time: Estimates for the US 

Population, 2008-2009. AHRQ Statistical Brief #354, January 2012. 

2 In the Maryland pool, for example, the list of eligible conditions included behavioral health conditions (bipolar disorder 1 chemical 

dependency, dementia, ps}'thotic disorders); blood disorders (aplastic anemia, hemochromatosis, hemophilia, sickle cell disease)i cardiovascular conditions (angina pectoris, cardiomyopathy, congestive heart failure, coronary artery disease, coronary insufficiency, 

coronary occlusion); endocrine disorders (Addison's disease, cystic fibrosis, diabetes, porphyria, Wilson's disease); gastrointestinal 

disorders (ascites, Banti's disease, cirrhosis of the liver, Chron's disease, esophageal varices, hepatitis B and C, ulcerative colitis}; infectious diseases (HIV I AIDS); musculoskeletal/connective disorders (ankylosing spondylitis, lupus, rheumatoid arthritis, 

scleroderma); pulmonary disorders (chronic obstructive pulmonary disease, emphysema); neoplasm (cancer treated or diagnosed 

within 5 years, Hodgkin's disease, leukemia, multiple myeloma, non~ Hodgkin's lymphoma, Wilm's tumor); neurologic conditions (Alzheimer's disease, ALS, Friedreich's Ataxia, GuiUain-Barre syndrome, Huntington's disease, hydrocephalus, multiple sclerosis, muscular dystrophy, myasthenia gravis, myotonia, palsy, paraplegia, Parkinson's disease, quadriplegia, stroke, Tay-Sachs disease); also 

major organ transplant and pregnancy. 

3 Communicating for Agriculture, Comprehensive Health Insurance for High-Risk Individuals, 1996. 

4 All but eight traditional state high-risk pools have since suspended new enrollment. 

s The total number of applications included those made in states, such as New York, which required non-group coverage to be offered 

on a guaranteed issue basis. 

6 K Schwartz, G Claxton, K Martin, and C Schmidt, "Spending to Survive: Cancer Patients Confront Holes in the Health Insurance 

System," Kaiser Family Foundation, 2009. Available at https:/fkajserfamilyfoundation files.wordpress.com/2013/0t/:zSst.pdf 

7 NASCHIP, Comprehensive Health Insurance for High-Rislt Individuals: A State-by~State Analysis, aon/2012. 

8 J Hall and J Moore, The Affordable Care Act's Pre-Existing Condition Insurance Plan; EnrolJment, Costs, and Lessons for Reform. 

September 2012, available at http· lfwww .commonwealthfund.org/publicationsJissue~briefs/2012/seo/preexisting-conditioninsurance-nian 

"PCIP Annual Report, 2012 available at https·//www.cms.goy/CCIIO/Resources/Fjles/Down!oads/pcip-report pdf, and PCIP Annual 

Report, 2013 available at httos:!/www.cms.gov/CCllO/Resources/Files/Downloadsjpcip annual report 01312013.pdf. 

IG For example, in Colorado, enrollees in the state PCIP experienced 562 hospital admissions per 1,000 and used 5,174 inpatient days 

per 1,ooo, while enrollees in Colorado's traditional high~risk pool experienced 137 hospital admissions per 1,000 and used 735 inpatient 

days per 1,000. See PCIP Annual Report, 2012. 

11 PCIP Annual Report, 2013. 

12 PCIP Annual Report, 2012 and 2013. 

13 PCIP Annual Report1 2013. The report notes that various cost containment measures had been adopted prior to enrollment 

suspension, including switching to a more competitively priced provider networks, negotiating special discounts with hospitals treating a disproportionate share of PCIP enrollees, and requiring use of cost effective preferred pharmacies for specialty drugs, See also PCIP Data Report1 March 2013, available at https: /!www.cms.gov/CCIIO/Resources/Forms-Reports~and~Other-Resources/Downloads/pcipexpenditures~3-31-2013.pdf 

The Henry J. Kaiser Fam\ly Foundation Headquarters: 2400 S1md Hill Road, Menlo Park, CA 94025 ! Phone 650--854~9400 

Waahington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 I Phone 202~347w5270 

www.kff.org ! Ema!l Alerts~ kff.org/emaii I facebook.com/KaiserFnmilyFounds:tlon ! twitter.eom{Kals&FIImFound 

Filling the need for trusted iriformotion on national health issues, the Kai${!J' Family Foundation Is a nonprofit organization based fn Menlo Park, Coliforni<l. 
148 


APIAHF 

ASIAN & PACIFIC ISLANDER 

AMERICAN HEALTH FORUM 

WRITIEN STATEMENT FOR THE RECORD 

FOR THE HEARING ENTITLED "PATIENT RELIEF FROM COLLAPSING HEALTH EXCHANGES." 

UNITED STATES HOUSE OF REPRESENTATIVES 

COMMITIEE ON ENERGY AND COMMERCE 

SUBCOMMITIEE ON HEALTH 

FEBRUARY 2, 2017 

BY THE 

ASIAN & PACIFIC ISLANDER AMERICAN HEALTH FORUM 

The Asian & Pacific Islander American Health Forum (APIAHF) submits this written testimony for 

the record for the February 1, 2017 hearing before the House Subcommittee on Health entitled 

"Patient Relief from Collapsing Health Exchanges." 

As the nation's oldest and largest health policy and public health organization working with 

Asian American, Native Hawaiian and Pacific Islander (AA and NHPI) communities, APIAHF 

provides a voice in the nation's capital for AA and NHPI communities. APIAHF works toward 

health equity and health justice for all by influencing policy, mobilizing communities, and 

strengthening programs and organizations to improve the health of the over 20 million AAs and 

nearly 1 million NHPis in the United States. 

This hearing seeks to address concerns about the effect the Affordable Care Act (ACA) has had 

on the individual health insurance market. The record of evidence demonstrates that the ACA 

has successfully done what it was designed to do- reduce the number of uninsured persons in 

the U.S. To date, 20 million Americans have coverage they can afford and rely upon!, including 

nearly 2 million AAs and NHPis who are eligible for coverage under the ACA. 2 

APIAHF has worked to protect and implement the ACA since its passage. Since 2012, APIAHF 

and partners have worked to outreach, educate and enroll nearly 1 million consumers through 

Action for Health Justice, a national collaborative of more than 70 AA and NHPI national and 

1 Department of Health and Human Services, 20 million people have gained health insurance coverage because of 

the Affordable Care Act, new estimates show, March 3, 2016, available at: 

httos://www.hhs.gov/about/news/2016/03/03/20-million-people-have-gained-health-insurance-coveragebecause-affordable-care-act-new-estimates. 

2 Rose Chu, et al., The Affordable Care Act and Asian Americans and Pacific Islanders, HHS ASPE Research Brief, 

Aprill, 2012, available at: https://aspe.hhs.gov/sites/default/files/pdf/37346/rb.pdf. 
149 


local community-based organizations and health centers. These community-based partner 

organizations are located in over 20 states and hear the real effects of AAs and NHPis gaining 

coverage through the ACA. 

The ACA Has Expanded Access to Essential Care for AAs and NHPis 

The ACA's coverage expansions reduced the overall rate of uninsured AAs from 15.7 to 7.8 

percent and the percentage of NHPis without insurance fell from 17.4 to 9.9 percent.3 Health 

coverage is critical forMs and NHPis who experience a number of barriers to accessing 

affordable health insurance and care. The AA and NHPI community speaks over 100 different 

languages and traces their heritage to more than 50 different countries. As of 2016, 11% of AAs 

and 23% of NHPI families live below the poverty line.• Language barriers, lack of cultural 

competency, poverty, and immigration status all affect the ability of AAs and NHPis to access 

coverage and care. 

Eight in 10 AAs and NHPis qualify for financial assistance under the ACA.5 Prior to the ACA, high 

costs caused many AAs and NHPis to either forgo care entirely or sell everything they had to 

afford care. People like Trieu, a young adult from Pennsylvania, had to forgo care and hoped he 

did not get sick until he got coverage thanks to the ACA's financial help. 

The ACA's financial assistance saved the life of Jirapon in Georgia. Jirapon is a single mom with 

three children who works as a cook. Thanks to a local community based organization, she was 

able to enroll in health care for the first time. She qualified for subsidies as well as Medicaid for 

her youngest child. After getting covered, Jirapon went for a general screening and was 

diagnosed with breast cancer. She was able to access affordable surgery, reconstruction, and 

long-term care because of the ACA. 

Falani and his wife, Teuloi, from Utah went uninsured for 15 years prior to the ACA, even 

though Falani was battling stomach cancer and diabetes. Without coverage, he resorted to 

home remedies and emergency care when things got really bad. The ACA changed their lives 

when they realized they could afford a plan for $45 a month and finally get much needed 

dialysis. 

3 American Community Survey Table 52701. (2015 and 2010). United States Census. 

4 Samantha Artiga, et al., Key Facts on Health and Health Care by Race and Ethnlcity, Section 1: Demographics, 

Kaiser Family Foundation, June 7, 2016, available at: http:l/kff.org/report-section/key-facts-on-health-and-healthcare-by-race-and-eth n icity-section-1-demographics/. 5 Minh Wendt, et al., Eligible Uninsured Asian Americans, Native Hawaiians, and Pacific Islanders: 8 in 10 Could 

Receive Health Insurance Marketplace Tax Credits, Medicaid, ar CHIP, HSS ASPE Research Brief, March 18, 2014, 

available at: https://aspe.hhs.gov/sites/default/files/pdf/180311/rb UninsuredAANHPI.pdf. 
150 


The ACA's consumer protections and financial assistance have given 4.3 million Asian Americans 

access to free routine preventive care. 6 This is especially important for diagnosing and treating 

chronic conditions amongst AAs and NHPis. The risk of diabetes for AAs is 18% higher than for 

Whites? Additionally, AAs and NHPis are the only racial group for whom cancer is the leading 

cause of death.8 Early routine care is essential for treating these chronic conditions. Lup, a 

senior-citizen in Louisiana, got coverage for the first time because of the ACA. She and her 

husband can now rely on preventive care to stay healthy and she no longer has to live with the 

constant anxiety that a huge medical emergency would ruin them. 

The Health Insurance Market is Strong Under the ACA 

Under the ACA, 10.2 million Americans are eligible to enroll in qualified health plans.9 

Marketplace enrollment has grown every year since the ACA was enacted, resulting in a larger 

and more diverse risk pool. Despite concerns about increasing premiums, a report by Standard 

& Poor found that the individual market is headed toward stabilization at the end of 2016, with 

a study projecting more improvement in 2017. 10 This suggests that the premium increases in 

some states are the result of insurers correcting course as they adjust to a more diverse risk 

pool compared to pre-ACA underwriting. Nationally, the ACA has lowered overall health 

expenditures and slowed the growing cost of health care. 11 

Proposed Replacements for the ACA Would Not Provide Access to Comprehensive Care 

The ACA provides consumer protections, the financial means to afford coverage, and mandates 

to ensure protection for the market. APIAHF opposes repealing the ACA without a 

replacement. Any replacement plan must, at minimum, do not harm and maintain 

comprehensive, affordable coverage for the 20 million Americans currently enrolled and those 

eligible for coverage under the ACA and maintain consumer protections and civil rights.'2 

'Increased Coverage of Preventive Services with Zero Cost Sharing Under the Affordable Core Act, HHS ASPE 

Research Brief, June 27, 2014, available at: https://aspe.hhs.gov/pdf-report/increased-coverage-preventiveservices-zero-cost-sharing-under-affordable-care-act. 

7 Centers for Disease Control, National Diabetes Fact Sheet, 2011, available at: 

https://www.cdc.gov/diabetes/pubs/pdf/ndfs 2011.pdf. 8 Barry A. Miller, et al., Cancer incidence and mortality patterns among specific Asian and Pacific Islander 

populations in the U.S., November 2007, available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2268721/. 

'Department of Health and Human Services, The Affordable Care Act is Working, 2015, available at: 

https://www.hhs.gov/healthcare/facts-and-features/fact-sheets/aca-is-working/index.html?language-es. 

10 Deep Banerjee, The ACA Individual Market: 2016 Will Be Better Than 2015, But Achieving Target Profitability Will 

Take Langer, S&P Global Ratings, December 22, 2016, available at: https://morningconsult.com/wpcontent/uploads/2016/12/12-22-16-The-ACA-Individuai-Market-2016-Wiii-Be-Better-Than-2015-But-AchievingTarget-Profitability-Wiii-Take-Longer.pdf. 

11 White House Council of Economic Advisors, The Economic Record of the Obama Administration: Reforming the 

Health Care System, Pg. 80, December 2016, available at: 

https://obamawhitehouse.archives.gov/sites/default/files/page/files/20161213 cea record healh care reform.p 

Qt. 

12 Department of Health and Human Services, The Affordable Care Act is Working, 2015, available at: 

https://www.hhs.gov/healthcare/facts-and-features/fact-sheets/aca-is-working/index.html?language=es. 
151 


The replacements offered in the four proposed bills are not comprehensive coverage and not a 

replacement for the ACA. Special enrollment periods (SEP) are not being abused, but rather 

underutilized and are a necessary component for individuals facing changes in life 

circumstances. Only five percent of SEP eligible consumers enrolled in 2015. 13 Adding an 

additional burden to accessing coverage would hinder eligible people from enrolling.14 

Three-month grace periods are important for low and moderate income families whose 

finances fluctuate regularly. A study from 2016 showed that these families had a twenty-five 

percent income drop for 2.7 months of the year and an income increase for another 2.7 months 

of the year. 15 These families would lose health coverage under the shortened grace period 

simply because they struggle on a monthly basis. 

Additionally, when lower income families' finances drop, they could be forced off of coverage 

by a reduced grace period. They would then also fall prey to the proposed continuous coverage 

limitation if they have a preexisting condition. In addition, protecting consumers from 

preexisting condition exclusions is not sufficient to guarantee access to coverage without 

financial assistance. This is why the ACA's consumer protections and guaranteed issue 

provisions are coupled with financial help for the majority of persons eligible for coverage. 

In summary, the ACA has substantially improved access to both coverage and care for 20 

million Americans, including millions of AAs and NHPis. These coverage gains benefit the entire 

nation, providing life-saving care and financial security for those who would otherwise have no 

or limited coverage. APIAHF opposes repealing the ACA without a replacement plan that allows 

all enrolled and eligible people to maintain their coverage with financial help and maintains 

consumer and civil rights protections. 

13 Stan Dorn, Helping Special Enrollment Periods Work under the Affordable Care Act, Urban Institute, June 2016, 

available at: http://www.urban.org/sites/default/files/publication/81806/2000834-Helping-Speciai-EnrollmentPeriods-Work-Under-the-Affordable-Care-Act.pdf. 

141d. 

15 Julia B. Isaacs, et al., Stabilizing Children's Lives when Family Income Fluctuates from Month to Month, Urban 

Institute, December 8, 2016, available at: http://www.urban.org/urban-wire/stabilizing-childrens-lives-whenfamily-income-fluctuates-month-month. 
152 


Statementforthe Record 

House Committee on Energy and Commerce 

Subcommittee on Health 

"Patient Relief from Collapsing Health Markets" 

February 2, 2017 

The American Heart Association appreciates the opportunity to submit this testimony for the House 

Committee on Energy and Commerce, Subcommittee on Health related to the Pre-existing Conditions 

Protection and Continuous Coverage Incentive Act of 2017. We strongly support maintaining protections 

for the millions of Americans with pre-existing conditions, including cardiovascular (CVD) conditions; and 

we are concerned that any requirement of continuous coverage will not maintain these protections. 

Our concerns are detailed below. 

The American Heart Association is the nation's oldest and largest voluntary organization dedicated to 

building healthier lives free from heart disease and stroke- the two leading causes of death in the 

world. Our non-profit and non-partisan organization includes more than 30 million volunteers and 

supporters. The American Heart Association and our American Stroke Association division fund 

innovative research to accelerate advances in preventing heart disease and stroke. We also work to 

advance strong public health policies, and provide critical tools and information to health care providers, 

patients and families to prevent and treat these deadly diseases. 

As measured by prevalence, death, disability, and costs, CVD is the most burdensome disease in the 

United States. An estimated 92.1 million US adults have at least one type of CVD. By 2030, 43.9% of the 

US adult population is projected to have some form of CVD, including hypertension, coronary heart 

disease, stroke, and congestive heart failure. Protections for people with pre-existing conditions are 

vitally important to patients with CVD. An analysis of some of the largest for-profit health insurance 

companies in the country found that between 2007 and 2009, one out of every seven applicants was 

denied coverage based on a health condition. Lists of so-called "declinable conditions" included many 

cardiovascular conditions such as congestive heart failure, coronary artery/heart disease, bypass surgery 

and stroke. Applicants were also denied if they were taking drugs on issuers' lists of "declinable 
153 


medications." Without the protections put in place by the Affordable Care Act, over a quarter of 

nonelderly adults would again be subject to denials, exclusions, and exorbitant rates. 

We support the goal of the Pre-existing Conditions Protection ond Continuous Coverage Incentive Act of 

2017to protect health insurance access for people with preexisting conditions. However, we are 

concerned about the potential for unintended consequences if provisions requiring continuous coverage 

as a condition of retaining those protections are not crafted to recognize and allow for certain 

extenuating circumstances, including those we described in more detail in subsequent paragraphs. 

While continuous coverage is optimal for individuals and for the risk pool, the reality is that patients can 

face gaps in coverage for many reasons, including the inability to keep up with premiums, the loss of a 

job, or a change in family circumstances. For patients with chronic conditions these challenges can be 

compounded by job instability linked to the demands of managing their health. We hear regularly from 

patients and family members about the burden of dealing with CVD and stroke. The burden is so high 

that it may require the patient or family member, often the parent of a child facing CVD or stroke, to 

miss time from a job or even lose the job entirely. These extenuating circumstances are realparticularlyfor low-income individuals. 

An AHA survey of CVD patients from January 2010 demonstrates the challenges that many with heart 

disease or stroke face that make continuous coverage a challenge for many. Key findings included: 

• Approximately 16% of non-elderly adults surveyed did not currently have health insurance. And 

even among those who do have insurance, 24% of CVD patients (and 36% of stroke patients) said 

they've gone without health insurance at some time since their diagnosis. 

• Of those CVD patients without insurance coverage, the high cost of the insurance premium was 

cited as the major reason why (48%), followed by losing insurance coverage because of job loss 

(37%), their employer doesn't offer coverage or the employee doesn't qualify, the insurance 

company wouldn't cover their condition, or the insurance company refused coverage due to a preexisting medical condition. 

• Patients identified lack of money or insurance coverage as the leading barrier to taking action to 

improve their health (25% total CVD patients, 32% stroke). Nearly one-third of totaiCVD patients 

(30% total and 39% of stroke patients) said they didn't have access to affordable preventive 

screenings for their illness prior to their diagnosis. 

2 
154 


Ofthose who said they had difficulty paying medical expenses, 50% said it was because they 

couldn't afford their co-pays, deductibles or other cost-sharing, 41% said it was because their 

insurance plan didn't cover it, and 17% said it was because they had to pay higher costs because 

their provider was out-of-network. 

• Of those who had difficulty paying medical expenses, nearly half (48%} said they had difficulty 

paying bills, 39% said they used up all or most of their savings, 30% said they had incurred 

thousands of dollars of medical debt, 25% said they had been unable to pay for basic necessities 

like food, housing, or heat, and 9% had declared bankruptcy. 

A study released in 2016 by the American Heart Association revealed that more than six million adults at 

risk for CVD and 1.3 million who suffered from heart disease, hypertension or stroke gained health 

insurance between 2013 and 2014. That figure is likely much higher today. We know that merely having 

coverage does not guarantee access to quality or affordable care- and we are once again surveying our 

patients to see what their experience has been to date with the Affordable Care Act and what 

improvements still need to be made to our health care system to serve the needs of individuals with 

preexisting conditions like cardiovascular disease. 

We appreciate that the committee is still gathering input and information as they work to construct the 

specifics of this provision and the second reserved title on continuous coverage, and welcome this 

opportunity to provide comment on subsequent proposals. As you move forward, the American Heart 

Association/American Stroke Association urges the subcommittee to consider the following: 

Nongroup health plans should not be able to deny coverage to applicants because of a preexisting health condition. 

Health plans providing nongroup coverage should not be able to charge people with pre-existing 

health conditions higher premiums based on their health. 

Nongroup and group health plans (both insured and self-funded} should not be able to exclude 

coverage for benefits for a defined period of time for new enrollees if the benefit relates to a 

pre-existing health condition (called pre-existing condition exclusions (PECE}}. 

• Insured people with pre-existing health conditions should not face barriers when they want or 

need to change health plans. 

3 
155 


The millions of people with CVD that we serve are among the many Americans with pre-existing 

conditions. Ensuring meaningful health insurance coverage for these individuals is critical to our 

mission. We look forward to working with the members of this subcommittee to identify strong policy 

solutions for individuals with preexisting conditions in need of affordable health insurance coverage. 

4 
156 


~UNITY 

~ CATALYST 

The Honorable Greg Walden 

Chairman 

Committee on Energy and Commerce 

U.S. House of Representatives 

Washington, D.C. 20515 

February 2, 2017 

ONE FEDERAL STREET, BOSTON. MA 02110 

MAIN: 617.338.6035 

FAX. 617.451.5838 

The Honorable Frank Pallone 

Ranking Member 

WVIIW communitycatalyst.org 

Committee on Energy and Commerce 

U.S. House of Representatives 

Washington, D.C. 20515 

Dear Chairman Walden and Congressman Pallone: 

We are writing to express our strong opposition to any changes under consideration in 

insurance rules that would loosen the current 3:1 age-rating band ratio under current Jaw. 

This limit is a crucial consumer protection that ensures that older adults- specifically 

those ages 50-64 who are not yet eligible for Medicare- have access to affordable coverage. 

Consideration of moving to a 5:1 ratio will push premiums up, further exacerbating the 

affordability of insurance for older adults and result in many becoming uninsured. 

Community Catalyst is a national non-profit advocacy organization dedicated to quality 

affordable health care for all. Since 1997, Community Catalyst has been working to build 

the consumer and community leadership required to transform the American health 

system. With the belief that this transformation will happen when consumers are fully 

engaged and have an organized voice, Community Catalyst works in partnership with 

national, state and local consumer organizations, policymakers, and foundations, providing 

leadership and support to change the health care system so it serves everyone- especially 

vulnerable members of society. 

A study by RAND Corporation' concluded that switching to a 5:1 band would reduce 

premiums for young adults by much less than it would boost premiums for older enrollees. 

For a 64-year-old, the annual premium for a typical silver plan would grow from about 

$8,500 to $10,600. A 24-year-old enrollee would see premiums fall from $2,800 to $2,100. 

The higher premiums for older, low-income enrollees would cost the federal government 

an additional $9.3 billion a year in federal premium subsidies. Moreover, RAND estimates 

about 400,000 older adults who don't qualify for subsidies would drop coverage. 

Surely the intent of the Committee is not to increase uninsurance rates nor raise costs to 

the federal government. The changes made in 2010 to share risk and stop medical 

underwriting for those with pre-existing conditions have gone a long way to making 

insurance accessible and affordable to millions previously left out. If the Committee agrees 

1 http·//www commonwea!thfund.org/publications /blog /2015 /sept/charging-o!der-adults-hjgherpremiums-could-cost-taXj;layers 
157 


~UNITY 

~ CATALYST 

ONE FEDERAL STREET, BOSTON, MA 02110 

MAIN' 617.338.6035 

FAX: 617.451.5838 

www communitycatalyst org 

that a goal is to eliminate discrimination based on health status, then any loosening of the 

current rules would undermine that goal and would significantly harm the health and 

economic security2 for millions of older adults, especially those with multiple health 

conditions. 

The ACA's federal age-rating protection should be maintained and strengthened, not 

weakened or eliminated. We appreciate the opportunity to submit our comments for the 

record. 

Sincerely, 

Rob Restuccia, Executive Director 

Cc: Members of the Committee on Energy and Commerce 

2 According to a March 2013 study by the Urban Institute, looser rate bands would significantly increase out~ 

of· pocket rates paid by the oldest purchasers, who are substantially less likely than young adults to be eligible 

for subsidies. Blumberg, Land Buettgens, M, "Why the ACA Limits on Age· Rating will not Cause "Rate-Shock": 

Distributional Implications of Limited Age Bands in Non-Group Health Insurance", March 2013 

http· //www urban oq:/sites/defanlt/files/alfresco/publjcatjon-pdfs/41275?-Wby-the-ACA-s~Limits-on-A(:eRating-Wjli-Not-Cause-qyot-Rate-Shock-quot-Djstributiona!~rmpljcatjons-of-l..imited-Age-Bands-inNongroup-Health-!nsurance PDF 

2 
158 


national 

~""' partnership 

for women & families Because actions speak louder than words, 

'-../ 

February 2, 2017 

The Honorable Greg Walden 

Chairman, Committee on Energy and 

Commerce 

2125 Rayburn House Office Building 

Washington, DC 20515 

The Honorable Frank Pallone, Jr. 

Ranking Member, Committee on Energy 

and Commerce 

2322A Rayburn House Office Building 

Washington, DC 20515 

Dear Chairman Walden and Ranking Member Walden: 

The National Partnership for Women & Families (National Partnership) represents women 

across the country who rely on the Affordable Care Act (ACA) for access to essential health 

care services and who are counting on continued successful implementation of the law. The 

ACA is working and has already helped millions of women gain access to both health 

coverage and care. We are deeply troubled by Congressional efforts to repeal this 

groundbreaking and essential law. Any vote to repeal the law- or significant portions of it 

-puts the health, wellbeing and economic security of women in dire jeopardy. This is 

especially true in the absence of any meaningful proposal that ensures continued access to 

the ACA's women's health protections and coverage gains. 

Repealing the ACA risks going back to a time when women struggled to find affordable 

health coverage in the individual market, were routinely charged more than men for the 

same policies, and often found that health coverage did not cover their essential health care 

needs. This effort, combined with Congressional efforts to defund and close Planned 

Parenthood health centers, demonstrates a full-fledged attack on women's lives and health. 

For millions of women, repealing the ACA means stripping away their health insurance 

and leaving them without affordable coverage options. Since the enactment of the ACA, 9.5 

million previously uninsured women have gained affordable, comprehensive health 

coverage.' For 2016, 6.8 million women and girls chose health coverage through the health 

insurance marketplace.' If the law is repealed, millions of women and families will lose 

their tax credits and cost-sharing reductions. For many, this will force them to go without 

health insurance and many will not be able to afford essential care. 

Even women and families who could continue to afford health insurance could find 

themselves without the important protections they have under the A CA. The ACA ended 

outrageous, predatory practices that allowed insurers to refuse to cover women who had 

breast cancer or cesarean sections, received medical treatment due to domestic violence or 

who have chronic conditions like high blood pressure or diabetes. Now, under the law, 

women can no longer be denied coverage just because they are sick or have a pre-existing 

condition- nor can they be charged more because of their health status. The ACA also 

1875 connecticut avenue, nw N suite 650 N washington, de 20009 N phone: 202.986.2600 N fax: 202.986.2539 

email: info@nationalpartnership.org N web: www.nationalpartnership.org 
159 


prohibits plans in the individual and small group markets from charging women higher 

premiums simply because of their gender (a common practice before the ACA called "gender 

rating"). 

To date, proposals for replacing the ACA have fallen short of ensuring that women and 

families would be guaranteed these same protections if the ACA was repealed. For example, 

the "Preexisting Conditions Protection and Continuous Coverage Incentive Act of 2017" 

offers a hollow promise that individuals will retain the same level of protection against 

discrimination on the basis of health status or gender that they currently enjoy. While this 

bill provides that any legislation to repeal the ACA must include a bar on exclusions for 

pre-existing conditions, it noticeably does not prohibit medical underwriting for health 

status or gender. Thus, while coverage may be available to people with pre-existing 

conditions, that coverage will likely only be offered at high premium rates- making health 

coverage unaffordable or inaccessible to those who need it most. The bill would also result 

in a return to the days when women were consistently charged more for health insurance 

than men simply because of their gender. 

In addition to ensuring the availability of affordable coverage, the ACA also sets nationwide 

standards for benefits that women and families can expect their health insurance to offer. 

For example, women purchasing insurance in the individual or small group markets are 

guaranteed access to critical essential health benefits including maternity and newborn 

care. The ACA also requires most health insurance plans to cover vital preventive 

services, including well-woman visits, birth control, and interpersonal and domestic 

violence screening and counseling, without copayments, deductibles or other out-of-pocket 

costs. These are just some of the many protections that have helped improve the health and 

lives of women across the country. 

Repealing the ACA would leave women and families without the quality, affordable health 

care they need. It not only endangers advances in women's health care access, but also puts 

women's economic security at risk. We urge Congress to deeply consider the effects repeal 

would have on individuals and families across the country, and to end all efforts to repeal 

this groundbreaking and successful law. 

Sincerely, 

Debra L. Ness, President 

1 US Department of Health and Human Serv'h::es. (:1 March 2016). Health Insurance Coverage and the Affordable Care Act 2010-2016 Retrieved 24 January 2017, from 

https//aspehhs.gov/sites/default/files/pdf/187551/ACA2010-2016pdf 

2 U 5 Department of Health and Human Services. (14 June 2016) The Afford(Jb/e Care kt: Promoting Better Health for Women. Retrieved 31 January 2017, from 

httpsJ/aspehhs.gov/site~/default!file$/pdf/205066/ACAWomenHeal!hlssueBrief.pdf 
160 


~~NATIONAL ~ ,.~ w 0 M E N I s 

LAW CENTER EXPANDING THE POSSIBILITIES 

Testimony Submitted for the Record 

Gretchen Borchelt 

Vice President for Reproductive Rights and Health 

National Women's Law Center 

Hearing on "Patient Relief from Collapsing Health Markets" 

U.S. House of Representatives Energy and Commerce Committee 

Subcommittee on Health 

February 2, 2017 

With the law on your side, great things are possible. 

II Dupont Circle NW • Suite 800 • Washington, DC 20036 • 202.588.5180• 202.588.5185 Fax. WNW.nwlc.org 
161 


The National Women's Law Center ("Center") has worked for more than 40 years to advance 

and protect equality and opportunity for women and girls in every aspect of their lives, including 

health care and economic security. The Center submits this testimony in strong opposition to the 

"Preexisting Conditions Protection and Continuous Coverage Incentive Act." 

The "Preexisting Conditions Protection and Continuous Coverage Incentive Act" is a false 

promise of protection. The end result would be to return women to the days of discrimination in 

the health care market. 

As the Center demonstrated in our 2008 report, Nowhere to Turn: How the Individual Health 

Insurance Market Fails Women, prior to the Affordable Care Act, insurance companies used 

health status and health history, including pre-existing conditions, in order to determine whether 

an individual received coverage and if so, to determine what premium to charge the individual 

applicant or what limits to put on that coverage. 

Women often fared worst because of conditions unique to them, which insurers deemed "preexisting conditions." For example, women have greater health needs than men and are more 

likely than men to suffer from a chronic condition requiring ongoing treatment, like asthma or 

arthritis. These conditions could lead to rejection of coverage or higher premiums. In addition, if 

during the medical underwriting process the insurer discovered that an applicant underwent a 

past Cesarean delivery, the company might have charged her a higher premium, imposed an 

exclusionary period during which it refused to cover another Cesarean delivery or pregnancy, or 

even rejected her for coverage altogether unless she had been sterilized or was no longer of 

childbearing age. Insurers in DC and nine states were allowed to deny coverage to domestic 

violence survivors. In addition, news reports at the time documented the practice of insurance 

companies obtaining prescription drug histories as a basis to reject applicants for health 

coverage. Women were more likely than men to be potentially affected by this practice- at any 

age they are more likely than men to take prescription medications on a regular basis. 1 

In other words, before the Affordable Care Act, just being a woman amounted to being treated 

like a pre-existing condition. Because of"pre-existing conditions," women seeking coverage in 

the individual market faced limits that made coverage meaningless, such high premiums that 

they could not afford coverage, or outright rejection from coverage. 

The Affordable Care Act changed these practices. Right now, under the health care law, insurers 

can no longer charge more or deny coverage to an individual because of a pre-existing condition. 

Insurers cannot limit benefits for that coverage either. Once individuals have coverage, insurers 

cannot refuse to cover treatment for a pre-existing condition. Approximately 65 million women 

with pre-existing conditions can no longer be denied or charged more for their health coverage 

thanks to the Affordable Care Act.2 

The "Preexisting Conditions Protection and Continuous Coverage Incentive Act" fails to protect 

individuals seeking coverage in these ways, leaving them once again vulnerable to the same 

unfair practices that existed prior to the Affordable Care Act. Although the bill prohibits preexisting condition exclusions, it does not address the other problems associated with health status 

underwriting. Specifically, it does not prohibit issuers from charging an individual more for 

2 
162 


health insurance coverage based on a pre-existing condition. This means that although health 

insurance coverage may be theoretically available to a woman with a pre-existing condition, the 

insurance company could price the premium in such a way that she is effectively denied 

coverage. Nor does this bill include provisions requiring that insurers cover treatment related to 

the pre-existing condition. So even if a woman could get coverage, she could be denied 

coverage for treatments she needs related to the underlying condition. There is no reason to think 

insurers would not revert to these prior tactics, and in fact, there are incentives for insurers to do 

so, given that the other parts of the Affordable Care Act that discouraged such practices are 

absent. 

Furthermore, the "Preexisting Conditions Protection and Continuous Coverage Incentive Act" 

includes an incomplete "placeholder" for a "continuous coverage incentive." This indicates that 

the pre-existing condition exclusion is tied to an individual having health insurance and having 

been insured without a gap for a specified period of time. There are numerous scenarios under 

which a woman could lose continuous coverage, like losing a job, going back to school, or 

choosing to pay for groceries one month instead of paying a premium bill. If that were to happen, 

she would lose the pre-existing condition protection and once again face insurance coverage 

denials. 

Because the "Preexisting Conditions Protection and Continuous Coverage Incentive Act" would 

return women to being considered a pre-existing condition, we urge you to reject it. No woman 

should again be denied insurance coverage or charged more because she has had a prior 

pregnancy or Cesarean delivery, because she received fertility treatment, had breast or cervical 

cancer, is a survivor of domestic violence, or because she had medical treatment following a 

sexual assault. The Affordable Care Act made sure that these practices were no longer allowed. 

Despite claims to the contrary, the "Preexisting Conditions Protection and Continuous Coverage 

Incentive Act" does not, and would allow insurance companies to return to these harmful and 

discriminatory practices. 

1 NATIONAL WOMEN'S LAW CENTER, NOWHERE TO TURN: HOW THE INDIVIDUAL HEALTH INSURANCE MARKET 

FAILS WOMEN 8 (2008), available at https://nwlc.orglwp-contentluploads/2015/08/NWLCReport-NowhereToTurn81309w.pdf. 

2 DEPARTMENT OF HEAL Til AND HUMAN SERVICES, The ACA Is Working for Women (July 21, 2016), available at 

http://www.hhs.gov/healthcare/facts-andfeatures/fact-sheets/aca-working-womenlindex.html. 

3 
163 


I STATE OF WISCONSIN I 

Fact Sheet on 

Mandated Benefits in 

Health Insurance Policies 

H OFFICE OF THE COMMISSIONER OF INSURANCE 

Health insurance policies sold ln Wisconsin often 

include "mandated benefits." These are benefits that 

an insurer must include in certain types of health 

insurance policies. Some mandated benefits apply 

only to group policies. Some apply both to policies 

sold to individuals and to groups. Most apply only 

to policies issued or renewed after a certaln date. 

Except for health maintenance organizations (HMOs) 

organized as cooperatives under ch. 185, Wis. Stat., 

HMOs are required to provide the same benefits as 

traditional insurers. Cooperative HMOs are subject to 

the mandates regarding chiropractors, optometrists, 

genetic testing, nurse practitioners, newborns, adopted 

children, HIV drugs, dentists, temporomandibular 

(TMJ) disorders, breast reconstruction, and hospital 

and ambulatory surgery center charges, anesthetics 

for dental care, coverage of certain health care costs 

in cancer clinical trials, and coverage of student on 

medical leave. 

This brochure gives a brief description of current 

mandated benefits. 

Professional Health Care Services 

Board Certified Behavior Analyst-Behavior 

analysts are added to the list of providers that 

may provide physician~prescribed services for the 

treatment of autism spectrum disorders required 

to be covered by disability insurance policies and 

self-insured governmental and school district 

health plaf!s. Paraprofessionals working under a 

behavior analyst's supervision are also covered. 

The Department of Regulation and Licensing 

{ORL) provides licensure and regulation ofbehav~ 

ior analysts engaging in the practice of behavior 

analysis. 

Chiropractors-All health insurance policies 

must cover services provided by a chiropractor if 

the policy would provide coverage for the same 

services if performed by a physician or osteopath. 

Policies may not require the insured to be referred 

to a chiropractor by a physician to receive benefits. 

Insurers may apply the same deductible and 

copayment provisions to chiropractic care. that 

Pl-019 (R 0612012) ~ 

apply to all other benefits. In addition, insurers 

may apply cost containment or quality assurance 

measures to chiropractic care if it applies those 

provisions to nonchiropractic benefits. For 

example, an HMO can limit chiropractic care for 

its enrollees to those chiropractors who are either 

employed by or under contract to the HMO. [s. 

632.87(3), Wis. Stat] 

Dentists-All health insurance policies are 

required to provide coverage for diagnosis or 

treatment of a condition or complaint performed 

by a licensed dentist if the policy covers diagnosis 

and treatment ofthe condition if performed by any 

other health care provider. [s. 632.87(4), Wis. Stat] 

Nonphysician Providers-Unless the policy 

provides otherwise, insurers may not refuse to 

pay for services by certain non physician providers 

if the service is covered by the policy and the 

professional is licensed to provide the service. 

Insurers may refuse to pay for services given by 

certain providers if the policy clearly states that 

this is the case. For example, insurers could refuse 

to pay for services provided by a social worker in 

private practice even though a social worker is 

licensed to provide services covered under the 

contract. 

This applies both to group and to individual policies. 

[s. 632.87(1), Wis. Stat] 

Nurse Practitioners-Health insurance policies 

that provide coverage for Papanicolaou (PAP) 

tests, pelvic examinations, and associated 

laboratory work if performed by a physician must 

also provide coverage for these services when 

performed by a nurse practitioner acting within 

the scope of his or her license. 

This applies to all insured policies, all plans offered 

by the Group Insurance Board, and all self-funded 

plans offered by school distrtcts or municipalities. 

[s. 632.87(1) and (5), Wis. Stat] 
164 


Optometrists-Insurers may not exclude 

coverage for s~rvices provided by an optometrist 

if the contract covers the same service when 

it is provided by another health care provider. 

Insurers may exclude all vision care services and 

procedures from coverage. This applies to both 

individual and group policies. [s. 632.87(2) and 

(3), Wis. Stat.] 

Covered Persons 

Adopted Children-All health insurance policies 

that provide coverage for dependent children 

must cover adopted children and children placed 

for adoption on the same terms and conditions 

as natural children. Policies may not exclude or 

limit coverage of a disease or physical condition 

of the child because the disease or condition 

existed before coverage under the policy began. 

This applies to all policies, including plans offered 

by the state to its employees, cities, counties, 

school districts, cooperative sickness care plans, 

and prepaid plans. [s. 632.896, Wis. Stat.] 

Dependents-Insurers that offer individual or 

group health insurance policies (including vision 

and dental plans) and self-insured health plans 

of the state or of a county, city, village, town, or 

school district that provide dependent coverage 

of children are required to provide coverage if 

requested to an adult child of the applicant or 

insured as a dependent of the applicant or insured 

if the child is under the age of 26. 

Coverage must also be provided to an adult child 

regardless of age if the child was under 27 years 

of age when he or she was called to federal active 

duty in the National Guard or in a reserve component of the U.S. armed forces while the child 

was attending, on a full-time basis, an institution 

of higher education and the child returns to school 

as a full-1ime student within 12 months of fulfilling 

his or her active duty obligation. 

An insurer or self~insured health plan of the state 

or of a county, city, village, town, or school district 

may not define "dependent" for purposes of eligibility other than in terms of the relationship between 

a child and an applicant or insured nor vary the 

terms of coverage on the basis of age except for 

children 26 years of age or older. 

The state requirements above take effect for 

policies issued or renewed and governmental or 

school district self~insured health plans that are 

established, extended, modified or renewed, on 

or after January 1, 2012. [Section 632.885, Wis. 

Stat.] 

Grandfathered health plans may exclude adult 

children who are eligible to enroll in an employersponsored health plan other than the group health 

plan of their parent. However, beginning with plan 

or policy years on or after January 1, 2014, children 

up to age 26 can stay on their parent's employer 

plan even if they have another offer of coverage 

through an employer. 

Grandchildren-Health policies that provide 

coverage for any child of the insured shall provide 

the same coverage for all children ofthat child until 

that child reaches the age of 18. [s. 632.895(5m), 

Wis. Stat.] 

Handicapped Children-Hospital or medical 

expense policies that cover dependent children 

may end coverage when the child reaches maturity. 

However, coverage of a dependent child cannot 

end while the child continues to be both: 

Incapable of self-sustaining employment 

because of a mental retardation or physical 

handicap; and 

Chiefly dependent upon the person insured 

under the policy for support and maintenance. 

This applies both to group and individual 

policies. Insurers can require notice of continued 

dependence after a child reaches the maximum 

age under the policy. [s. 632.88, Wis. Stat.] 

Newborn Infants-All health insurance policies 

must provide coverage from the moment of birth 

for a newborn child of the insured. The newborn 

shall receive the same coverage that the policy 

provides for any children covered or eligible for 

coverage under the policy. The only exception is 

that waiting periods do not apply. If a pregnant 

person or a person whose spouse is pregnant 

applies for a policy providing hospital or medical 

expense benefits, insurers may not issue a policy 

that excludes or limits benefits for the expected 

child. Insurers must issue the policy without 

exclusions or limitations or decline or postpone the 

application. Coverage for newborn children must 

include congenital defects and birth abnormalities 

as an injury or sickness under the policy. 

lfthe payment of a specific premium or subscription 

fee is required to provide coverage for a child, 

policies may require that notification of a child's 

birth and payment of the required premiums or 

fees be furnished to the insurer within 60 days 

after the date of birth. Insurers may refuse to 

continue coverage beyond the 60-day period if 

such notification is not received, unless within one 

year after the birth of the child the insured makes 
165 


all past due payments with interest at the rate of 

5-112% per annum. 

lfthe payment of a specific premium or subscription 

fee is not required to provide coverage for a child, 

the policy or contract may request notification of 

the birth of a child but may not deny or refuse 

to continue coverage if such notification is not 

furnished. Benefits may exclude costs associated 

with a normal delivery. [s. 632.895(5). Wis. Stat.] 

Student on Medical Leave-Every disability 

insurance policy and every self-insured health 

plan of the state or of a county, city, town, village, 

or school district that provides coverage for a person as a dependent of the insured because 

the person is a full-time student shall continue to 

provide dependent coverage for the person if, due 

to a medically necessary leave of absence, he or 

she ceases to be a full-time student. 

A student is required to submit documentation and 

certification from the person's attending physician 

stating the medical necessity of the leave of 

absence. 

This applies to insurance policies issued or 

renewed on or after July 1, 2008, and self-insured 

health plans ofthe state or of a county, city, village, 

town, or school district, established, extended, 

modified, or renewed on or after July 1, 2008. 

However, if an insurance policy covers employees 

under a collective bargaining agreement containing 

provisions inconsistent with this provision, it first 

applies to a policy issued or renewed on the 

earlier of: (a) the date the collective bargaining 

agreement expires; or (b) the date the collective 

bargaining agreement is extended, modified, or 

renewed. If a self-insured plan covers employees 

under a collective bargaining agreement containing 

provisions inconsistent with this provision, it first 

applies to a plan established, extended, modified, 

or renewed on the earlier of: (a) the date the 

collective bargaining agreement expires; or (b) 

the date the collective bargaining agreement is 

extended, modified, or renewed. 

[ss. 40.51 (8), 40.51 (8m), 66.0137 (4), 111.91 

(2)(nm), 120.13 (2) (g), 185.981 (4t), 185.983 (1) 

(intro.), 609.76, and 632.895 (15), Wis. Stat.] 

Mandatory Benefits 

Autism Spectrum Disorder-All disability insurance policies and self~insured health plans ofthe 

state or of a county, city, town, village, or school 

district are required to provide coverage for the 

treatment of autism spectrum disorders which 

includes autism disorder, Asperger's syndrome, 

3 

and pervasive developmental disorder not otherwise specified. This provision does not apply to a 

disability policy that covers only certain specified 

diseases, a health care plan offered by a limited 

service health organization or by a preferred 

provider plan that is not a defined network plan, 

a long-term care insurance policy, or a Medicare 

replacement or a Medicare supplement policy. 

Coverage must be provided for the treatment 

of autism spectrum disorders if the treatment 

is prescribed by a physician and provided by 

qualified providers. Coverage required includes 

at least $50,000 for intensive~level services per 

insured per year with a minimum of30 to 35 hours 

of care per week for a minimum duration of 4 

years and at least $25,000 for nonintensive-level 

services per insured per year. For calendar year 

2012, insurers must provide coverage of at least 

$51,700 for intensive-level seiVices and $25,850 

for nonintensive-level services. The adjusted 

coverage amounts are effective for newly issued 

policies or on the first date of a modified, extended 

or renewed policy or certificate after January 1 , 

2012. 

Coverage may be subject to deductibles, coinsurance, or copayments that generally apply to 

other conditions covered by the policy or plan. 

The coverage may not be subject to limitations or 

exclusions, including limitations on the number of 

treatment visits. 

The above provisions take effect for health insurance policies that are issued or renewed and 

governmental or school district self~insured health 

plans that are established, extended, modified, or 

renewed on or after November 1, 2009. [s. 632.895 

(12m), Wis. Stat.] 

Breast Reconstruction-Health insurance 

policies that provide coverage for a mastectomy 

are required to provide coverage of breast 

reconstruction of the affected tissue incident to a 

mastectomy. 

This applies to both group and individual policies, 

including HMOs, PPPs, and LSHOs, and every 

self-funded county, municipality and school district 

health plan. [ss. 609.77 and 632.895 (13), Wis. 

Stat.] 

Coverage of Certain Health Care Costs in 

Cancer Clinical Trials-Health care policies, 

plans, and contracts are prohibited from excluding 

coverage for certain health care services, items, 

or drugs administered to an insured in a cancer 

clinical trial in certain situations that would be 

covered under the policy, plan, or contract if the 
166 


insured were not enrolled in a cancer clinical trial. 

The coverage is subject to all terms, conditions 

and restrictions that apply to other coverage 

under the policy, including the treatment 

and services performed by participating and 

nonparticipating providers. This includes policy 

requirements that the cancer clinical trial se!Vices 

be performed by a participating provider. 

This applies to all health insurance policies and 

self-insured health plans ofthe state or of a county, 

city, village, town, or school district. However, if 

an insurance policy covers employees under 

a collective bargaining agreement containing 

provisions inconsistent with these changes, the 

changes first apply to a policy issued or renewed 

on the earlier of: (a) the date the collective 

bargaining agreement expires; or (b) the date 

the collective bargaining agreement is extended, 

modified, or renewed. If a self-insured plan 

covers employees under a collective bargaining 

agreement containing provisions inconsistent with 

the changes, the changes first apply to a plan 

established, extended, modified, or renewed on 

the earlier of: (a) the date the collective bargaining 

agreement expires; or (b) the date the collective 

bargaining agreement is extended, modified, or 

renewed. 

[ss.40.51 (8), 66.0137 (4), 120.13 (2)(g), 185.981 

(4t), 185.983 (1) (intro.), 632.855 (2) (intro.) 

632.855 (3), and 632.855 (3) (bm), 632.87 (1), 

and 632.87 (6), \Ms. Stat.] 

Cochlear Implants-Coverage is required for 

hearing aids, cochlear implants, and related 

treatment for infants and children. This applies 

to group and individual disability policies and 

to self-insured health plans of the state or of a 

county, city, town, village, or school district newly 

issued or renewed on or after January 1, 2010. 

The following coverage Is provided: 

The cost of hearing aids and cochlear im~ 

plants that are prescribed by a physician or 

by a licensed audiologist for a child covered 

under the policy or plan who is under 18 

years of age and who is certified as deaf or 

hearing impaired by a physician or a licensed 

audiologist 

The cost oftreatment related to hearing aids 

and cochlear implants, including procedures 

for the implantation of cochlear devices, for 

a child as described above. 

The cost of hearing aids is not required to 

exceed the cost of one hearing aid per ear 

per child more than once every three years. 

4 

Coverage may be subject to any cost-sharing 

provisions, limitations, or exclusions, other than 

a preexisting condition exclusion, that apply 

generally under the disability insurance policy 

or self-insured health plan. 

These provisions do not apply to a disability policy 

that covers only certain specified diseases, a 

disability policy or self-insured health care plan 

that provides only limited-scope dental or vision 

benefits, a health care plan offered by a limited 

service health organization or by a preferred 

provider plan that is not a defined network plan, 

a long-term care insurance policy, a Medicare 

replacement or a Medicare supplement policy, 

or a short-term individual health benefit plan. 

This applies to all insured policies and all selffunded plans offered by school districts or municipalities. 

Contraceptive Coverage-All disability insurance policies and self-insured health plans of 

the state or of a county, city, town, village, or 

school district that provide coverage for outpatient 

health care se!Vices, preventive treatments and 

services, or prescription drugs and devices are 

required to also provide coverage for contraceptives prescribed by a heallh care provider, and 

outpatient consultations, examinations, procedures, and medical services that are necessary 

to prescribe, administer, maintain, or remove 

a contraceptive if covered for any other drug 

benefits under the policy or plan. Coverage may 

only be subject to the exclusions, limitations, or 

cost-sharing provisions that apply generally to 

the coverage of outpatient health care services, 

preventive treatment and services, or prescription 

drugs and devices that are provided under the 

policy or self-insured health plan. 

These provisions do not apply to a disability policy 

that covers only certain specified diseases, a 

disability policy or self-insured health care plan 

that provides only limited-scope dental or vision 

benefits, a health care plan offered by a limited 

service health organization or by a preferred 

provider plan that is not a defined network plan, 

a long-term care insurance policy, or a Medicare 

replacement or a Medicare supplement policy. [s. 

632.895 (17), \MS. Stat] 

Colorectal Cancer Screening-All disability 

insurance policies and self-insured health plans 

of the state or of a county, city, town, village, or 

school district that cover any diagnostic or surgi* 

cal procedures are required to cover colorectal 

cancer examinations and laboratory tests for any 

insured or enrollee who is 50 years of age or older 
167 


or any insured or enrollee who is under 50 years 

of age and at high risk for colorectal cancer. 

Coverage may be subject to any cost-sharing 

provisions, limitations, or exclusions that apply 

generally under the disability insurance policy or 

self-insured health plan. 

These provisions do not apply to a disability policy 

that covers only certain specified diseases other 

than cancer, a disability policy or self-insured 

health care plan that provides only limited-scope 

dental or vision benefits, or a health care plan 

offered by a limited service health organization or 

by a preferred provider plan that is not a defined 

network plan. 

The Commissioner of Insurance, in consultation 

with the Secretary of the Department of Health 

Services and after considering nationally validated guidelines, including guidelines issued by 

theAmerican Cancer Society for color ectal cancer 

screening, is required to promulgate rules that: 

Specify guidelines for colorectal cancer 

screening that must be covered under the 

law. 

Specify the factors for determining whether 

an individual is at high risk for colorectal 

cancer. 

Periodically update the guidelines and factors, described above. 

This applies to all insured policies, and all selffunded plans offered by school districts or municipalities. [s. 632.895 (16m), Wis. Stat.] 

Hospital and Ambulatory Surgery Center 

Charges and Anesthetics for Dental CareHealth insurance policies are required to cover 

hospital or ambulatory surgery center charges 

incurred and anesthetics provided in conjunction 

with dental care if any of the following applies: 

1. The individual is a child under the age of 5. 

2. The individual has a chronic disability that 

meets all the conditions ins. 230.04 (9r) (a) 

2. a., b., and c., Wis. Stat 

3. The individual has a medical condition 

that requires hospitalization or genera! 

anesthesia for dental care, 

This applies to both group and individual policies, 

including HMOs, PPPs, and LSHOs, and every 

seff-funded county, municipality and school district 

health plan. [ss. 609.79 and 632.895 (12), Wis. 

Stat.] This requirement does not apply to dentalonly plans. 

5 

Diabetes-Policies that cover expenses for the 

treatment of diabetes shall provide coverage 

for insulin Infusion pumps, other equipment 

and supplies, including insulin, and diabetic 

self-management education programs. Insurers 

may apply the same deductible and coinsurance 

provisions that apply to other covered expenses. 

Coverage may be limited to the purchase of one 

pump per year, and the insured may be required 

to use the pump 30 days before purchase. 

All health insurance policies that provide coverage 

of expenses incurred for the treatment of diabetes 

shall also provide coverage for expenses incurred 

for prescription medication used in the treatment 

of diabetes. Insurers may apply the same exclusions, limitations, deductibles and coinsurance 

provisions that apply to other covered expenses. 

[s. 632.895(6), Wis. Stat.] 

Genetic Testing-Insurers, other than insurers 

writing life or income continuation coverage, are 

prohibited from: 

Requiring an individual or a member of 

the individual's family to obtain a genetic 

test using DNA from the person's blood to 

determine the presence of a genetic disease 

or disorder. 

Requiring an individual to reveal if he or she 

or a member ofthe family has had a genetic 

test and revealing the results of that test. 

Requiring orrequesting a heaHh care provider 

to reveal either that an individual or family 

member had a genetic test or the results of 

a genetic test. 

Conditioning coverage on whether a person 

or member of a person's family has had a 

genetic test. 

Basing premium rates or other aspects of 

insurance coverage on whether a person or 

a person's family member has had a genetic 

test and revealing the results of the test. 

Insurers that write life or income continuation 

coverage who obtain genetic test information 

about an individual or family member are 

prohibited from: 

Using the information in writing any type 

of insurance other than life or income 

continuation. 

Setting rates or coverage conditions that are 

not reasonably related to the risk involved. 

[s. 631.89, Wis. Stat.] 

Drugs for Treatment of HIV Infection-All 

health insurance policies that provide coverage 

of prescription medicine shall provide coverage 

for each drug that satisfies all of the following: 
168 


Is prescribed by the insured's physician lor 

the treatment of HIV infection or an illness or 

medical condition arising from or related to 

HIV infection. 

Is approved by the Federal Food and Drug 

Administration lor the treatment of HIV 

infection or an illness or medical condition 

arising from or related to HIV infection, 

including each investigational new drug that 

is approved under 21 CFR 312.34 to 312.36 

for the treatment of HlV infection or an illness 

or medical condition arising from or related to 

HIV infection and that is in or has completed 

a phase 3 clinical investigation performed in 

accordance with 21 CFR 312.20 to 312.33. 

If the drug is an investigational new drug 

described in subd. 2, is prescribed and administered in accordance with the treatment 

protocol approved for the investigational new 

drug under 21 CFR 312.34 to 312.36. 

Coverage of these drugs may be subject to any 

copayments and deductibles that the health 

insurance policy applies generally to other 

prescription medication covered by the policy. 

These requirements do not apply to a policy that 

covers only certain specified diseases, is issued 

by a limited service health organization, or is a 

Medicare supplement or Medicare replacement 

policy. 

[s. 632.895(9), Wis. Stat.] 

Home Health Care-Both group and individual 

health policies that provide benefits lor inpatient 

hospital care must provide coverage for the usual 

and customary lees lor at least 40 home health 

care visits per year. Home health care may include 

intermittent home nursing care, home health 

aide services, various types of therapy, medical 

supplies, medication prescribed under the home 

care plan, and nutrition counseling. If two or more 

insurers jointly provide health insurance coverage 

to an insured under two or more policies, home 

health care coverage is required under only one 

of the policies. 

Coverage may be limited to cases where 

hospitalization or skilled nursing confinement 

would be necessary if home care were not provided 

and the necessary care cannot be provided by 

the patient's family without undue hardship. Only 

state~licensed or Medicare~certified home health 

agencies or certified rehabilitation agencies must 

be covered. 

ln addition to the 40 visits, insurers must offer 

buyers of Medicare supplement policies coverage 

for up to 365 visits a year, including those visits 

paid by Medicare. [s. 632.895(2), Wis. Stat.] 

6 

Child Immunizations-All health insurance 

policies and every sell-insured health plan of the 

state or of a county, city, town, village, or school 

district that provides coverage for a dependent of 

an insured, must provide coverage of appropriate 

and necessary immunizations from birth to the age 

of 6 years lor a dependent who is a child of the 

insured. The coverage may not be subject to any 

deductibles, copayments or coinsurance under 

the policy or plan, except that a managed care 

plan is prohibited from applying such cost-sharing 

only with respect to services provided by network 

providers. 

The mandate does not apply to health insurance 

policies that provide coverage of only certain 

specified diseases, policies that cover only 

hospital and surgical charges, policies offered by a 

limited service health organization, long~term care 

policies, and Medicare supplement or Medicare 

replacement policies. [s. 632.895 (14), Wis. Stat.] 

Kidney Disease-Policies that cover hospital 

expenses must provide at least $30,000 of 

coverage per year for inpatient and outpatient 

treatment of kidney disease, including dialysis, 

transplantation, and donor-related services. The 

coverage is not required to duplicate Medicare 

benefits and may be subject to the same limitations 

that apply to other covered health cond~ions. [s. 

632.895(4), Wis. Stat.] 

Lead Screening-All health insurance policies 

and all self-insured plans offered by a city, village, 

or school district are required to provide coverage 

lor blood lead tests lor children under 6 years of 

age, according to screening protocols established 

by the Department of Health Services. 

This requirement does not apply to a policy that 

covers only certain specified diseases, policies 

offered by a limited service health organization, 

long-term care insurance policies, Medicare 

supplement policies, or Medicare replacement 

policies. 

[ss. 609.85 and 632.895 (10), Wis. Stat.] 

Mammography-All health insurance policies 

except specified disease, Medicare supplement, 

or long-term care policies, must provide women 

between the ages ol45 and 49 two examinations 

by low-dose mammography. Insurers may refuse to 

provide coverage for an examination by low-dose 

mammography for a woman aged 45 to 49 if she 

has had such an examination within the previous 

two years. Insurers may apply any mammogram 

obtained during that age period, even if obtained 

prior to coverage under the policy, toward the two 

mandated examinations. Women who are age 50 

to 65 must be covered for annual mammograms. 
169 


Coverage is required regardless of whether the 

woman shows any symptoms. Policies may not 

apply exclusions or limitations that do not apply 

to other radiological examinations covered under 

the policy. The mammography examinations 

shall be performed at the direction of a licensed 

physician or nurse practitioner unless all of the 

following apply: 

The woman does not have an assigned or 

regular physician or nurse practitioner when 

the examination is performed. 

The woman designates a physician to receive 

the results. 

Any previously obtained mammography 

examination was obtained at the direction 

of a licensed physician or nurse practitioner. 

[s. 632.895(8). Wis. Stat.] 

Maternity Coverage-If a group health policy 

provides maternity coverage for anyone covered 

under the policy, it must provide coverage for 

all persons covered under the policy. Insurers 

may not apply exclusions and limitations to the 

mandated maternity coverage that do not apply 

to other maternity coverage provided under the 

policy. [s. 632.895(7). Wis. Stat.] 

Mental Health Parity-Wisconsin's current 

mandate is amended to remove the minimum 

coverage amounts for the treatment of menta! 

and nervous disorders and substance use 

disorders. Group health benefit plans and selfinsured health plans of the state or of a county. 

city, town, village, or school district that provides 

coverage for inpatient hospital treatment or 

outpatient treatment must provide coverage of 

inpatient hospital services, outpatient services, 

and transitional treatment arrangements for the 

treatment of nervous and mental disorders and 

substance use disorders. 

Individual health plans are not required to cover mental health or substance use disorder services; 

however, if coverage is provided, it must be at a 

parity level. 

Treatment limitations for mental health and 

substance use disorder services shall be no more 

restrictive than the most common or frequent type 

of treatment limitations applied to substantially 

all other coverage under the plan. 

These provisions do not apply to a heaHh care 

plan offered by a limited service health organization or by a preferred provider plan that is not a 

defined network plan or to a hospital indemnity, 

income continuation, accident only, long-term 

care, or Medicare supplement policy. 

7 

An exemption is provided for small employers 

who provide health coverage for their employees 

through a group heaHh benefit plan ifthe employer 

has fewer than 10 eligible employees on the first 

day of the plan year. Employers who qualify for 

and elect the small employer exemption under s. 

632.89 (31), Wis. Stat.. must first notifytheinsurer 

who in turn will inform the employer to notify all 

enrollees under the plan within 30 days that they 

have elected an exemption. 

A cost exemption also applies for employer plans 

where the increase exceeds 2% in the first plan 

year or 1% in any plan year thereafter. Specifically, 

an insurer offering a group health benefit plan 

shall have a qualified actuary determine whether 

the employer is eligible for a cost exemption 

based on the actual group claims experience 

in accordance with s. 632.89 (3c), Wis. Stat. 

Additionally. insurers may require employers to 

provide at least 90 days' advance notice to the 

insurer from the employer's renewal date for 

obtaining the determination. 

Despite exemptions from the state nervous and 

mental disorders and substance use disorders 

coverage requirement, state law requires 

compliance with the minimum mandated 

coverage requirements and limitations contained 

ins. 632.89 (2). 2007 Wis. Stat., for treatment of 

services for nervous and mental disorders and 

substance use disorders. 

Coverage may be subject to any exclusions and 

limitations; deductibles; co-payments; coinsurance; annual and lifetime payment limitations; 

out-of-pocket limits; out-of-network charges; day, 

visit, or appointment limits; limitations regarding 

referrals to nonphysician providers and treatment 

programs; and duration or frequency of coverage 

limits if no more restrictive than the most common 

or frequent type of treatment limitations applied 

to substantially all other coverage under the 

plan. Any overall deductible amount or annual 

or lifetime limit or out-of-pocket limit for the plan 

shall include expenses incurred for the treatment 

of nervous and mental disorders and substance 

use disorders. 

Health plans that provide coverage for the 

treatment of mental health and substance use 

disorders are required to make available the 

criteria for determining medical necessity under 

the plan with respect to that coverage. The criteria 

must be made available to any current or potential 

insured, participant, beneficiary, or contracting 

provider. Also, health plans that provide coverage 

for mental health and substance use disorders 

and deny coverage for services for treatment 
170 


shall, upon request, make the reason for the 

denial available to the insured, participant, or 

beneficiary. 

Mandated coverage for mental health and 

substance use disorders does not apply to 

treatment for autism spectrum disorders. 

Federal law may provide additional coverage 

under provisions included in the Patient Protection 

and Affordable Care Act (PPACA) and Mental 

Health Parity and Addiction Equity Act (MHPAEA) 

of2008. 

The above provisions apply to health benefit plans 

that are issued or renewed and governmental 

self-insured health plans that are established, 

extended, modified, or renewed on December 

1, 2010. [s. 632.89, Wis. Stat.] 

Skilled Nursing Care-Policies that cover 

hospital expenses must cover at least 30 days 

of skilled nursing care to patients who enter a 

licensed skilled nursing facility within 24 hours 

after discharge from a hospital. Coverage may 

be limited to care that is medically necessary as 

certified by the attending physician every seven 

days and that is for the same condition treated 

in the hospital. Skilled nursing care is narrowly 

defined. Many people in nursing homes are not 

receiving skilled care. [s. 632.895(3), Wis. Stat.] 

TMJ Disorders-All group and individual health 

insurance policies that provide coverage of any 

diagnostic or surgical procedure involving a bone, 

joint, muscle, or tissue are required to provide 

coverage for diagnostic procedures and medically 

necessary surgical or nonsurgical treatment 

(including prescribed intraoral splint therapy 

devices) far the correction of temporomandibular 

(TMJ) disorders. 

This applies to both group and individual policies, 

except dental·only and Medicare supplement 

policies, including HMOs, PPPs, and LSHOs, and 

every selfwfunded county, municipality, or school 

district health plan. [ss. 609.78 and632.895(11), 

Wis. Stat.] 

Health insurance policies may cap coverage of 

nonsurgical diagnosis and treatment of TMJ at 

$1,250 per year. Plans are permitted to impose 

a prior authorization requirement on surgical or 

nonsurgical TMJ services, but not diagnosis. 

If you have a specific complaint about your insurance, refer it first to the insurance company or agent 

involved. If you do not receive satisfactory answers, 

contact the Office of the Commissioner of Insurance 

(OCI). 

For information on how to file insurance complaints 

call: 

(608) 266-0103 (In Madison) 

or 

1-800-236-8517 (Statewide) 

Mailing Address 

Office of the Commissioner of Insurance 

P.O. Box 7873 

Madison, WI 53707-7873 

Electronic Mail 

ocicomp!aints@wisconsin.gov 

Please indicate your name, phone number, 

and e~mail address. 

OCI's Web Page 

oci.wi.gov 

Deaf, hearing, or speech impaired callers may 

reach OCI through WI TRS 

A copy of OCI's complaint form is available on OCI's 

Web site. You can print it, complete it, and return it 

to the above mailing address. 

Copies of OCI publications are available on-line on 

OCI's Web site. 

Disclaimer 

This guide is not a legal analysis of your rights under 

any insurance policy or government program. Your 

insurance policy, program rules, Wisconsin law, federal 

law, and court decisions establish your rights. You 

may want to consult an attorney for legal guidance 

about your specific rights. 

OCI does not represent that the information is com~ 

plete, accurate or timely in all instances. All information 

is subject to change on a regular basis, without notice. 

Printed copies of publications are updated annually 

unless otheiWise stated. In an effort to provide more 

current information, publications available on OCI's 

Web site are updated more frequently to reflect any 

necessary changes. Visit OCI's Web site at oci.wi.gov. 
171 


Opening Statement of Representative Bill Flores 

Energy and Commerce Committee Health Subcommittee Hearing 

"Patient Relief from Collapsing Health Exchanges" 

February 2, 2017 

Chairman Burgess and Ranking Member Green, thank you for having me here this 

morning and thank you to our three witnesses here today. 

Each of us on this dais has heard from hardworking constituent families who are 

facing fewer choices and staggering price hikes in insurance markets with ever 

dwindling coverage options. 

A provision to extend grace periods for nonpayment in the Affordable Care Act 

has exacerbated this by creating a scenario where some patients with exchange 

plans are only paying 9 months of premiums, yet receiving 12 months of coverage. 

These premium payment defaults are producing an imbalance in the risk pool, and 

in tum, raising premiums for hardworking American families that were promised 

lower health care costs. 

The Health Coverage State Flexibility Act, before us today, corrects this simply by 

better aligning the grace period for nonpayment of premiums with grace periods 

provided for under state laws prior to the adoption of the ACA. 

I look forward to working with this committee on these four commonsense bills 

that will help stabilize premiums and help patients get covered and stay covered. 

Again, I thank the Chairman and Ranking Member and I yield back. 
172 


Statement for the Record to: 

COMMITTEE ON ENERGY AND COMMERCE 

SUBCOMMITTEE ON HEALTH 

U.S. HOUSE OF REPRESENTATIVES 

Hearing on Patient Relief from Collapsing Health Markets 

Submitted by: 

Blue Cross and Blue Shield Association 

February 1, 2016 

& Ciii1 BlueCross 

T ~ BlueShield 

Association 

1310 G Street, N.W. 

Washington, D.C. 20005 

202.626.4800 

www.BCBS.com 

1 
173 


The Blue Cross and Blue Shield Association (BCBSA) appreciates the opportunity to comment 

on legislative proposals under consideration by the House Energy and Commerce 

Subcommittee on Health. 

BCBSA is a national federation of 36 independent, community-based and locally operated Blue 

Cross and Blue Shield companies ("Plans") that collectively provide healthcare coverage for 

more than 107 million members - one-in-three Americans. BCBS Plans offer coverage in 

every zip code across the United States and provide coverage in the vast majority of the 

Exchange Marketplaces today. BCBS Plans have an 85 year history providing coverage across 

all markets in their local communities. 

BCBSA commends Chairmen Burgess and Walden for considering changes to improve the 

individual health insurance market with these stabilizing bills that will encourage people to get 

the ongoing health care they need to stay healthy and manage their chronic illnesses. 

BCBSA strongly supports the three bills recently introduced to address existing policies that 

allow some people to buy health insurance only when they need care, threatening the 

sustainability of the market. We believe these bills would help balance the overall risk pool and 

stabilize the market by: 

• Ensuring individuals are eligible for a Special Enrollment Period before enrolling 

• Aligning grace periods for non-payment of premium with state requirements 

• Modifying age variation in premium rates to 5:1 or a rate set by a state 

A system where people can get health insurance regardless of preexisting conditions can only 

be viable if people maintain continuous coverage and there are appropriate incentives for all 

Americans to participate. Experience from the past two and a half years shows that the newly 

enrolled individuals are older than originally projected; have higher rates of certain conditions 

(e.g., hypertension, diabetes, depression, coronary artery disease, HIVand Hepatitis C); use 

more medical services; and have much higher costs. 1 In addition, medical costs continue to 

increase with significant growth in prescription drug costs. 

BCBSA supports these legislative proposals that would help ensure that the individual market is 

stable, affordable and encourages people to get the ongoing care they need: 

1. Eligibility for Special Enrollment Periods (SEPs) should be determined up front before 

coverage is effective. 

Special enrollment periods (SEPs) play a key role in promoting continuity of coverage during 

important life transitions, such as job changes, relocations, marriage, and births. However, 

CMS allows SEPs for more events than either Medicare Advantage or employer coverage. 

It is important that CMS verifies that consumers are eligible for SEPs in order to avoid "just 

in time" insurance which undermines the stability of the market. We support Congressman 

Blackburn's re-introduction of H.R. 706 that will ensure a strong verification process. 

Individuals who gain coverage through SEPs are a substantial and growing percentage of 

the Exchange population, and they incur significantly higher medical claims than others. 

CMS data show only 40% of those ever covered in the federal exchange in 2015 had 

1 BCBSA Health of America Report, "Newly Enrolled Members in the Individual Health Insurance Market after 

Health Care Reform: The Experience from 2014 and 2015". 

2 
174 


coverage for 12 months, and that about 25 percent 2015 enrollment came in through SEPs.2 

Moreover, these enrollees typically incur higher costs than those individuals who enroll 

during the open enrollment period. In fact, the actuarial firm Oliver Wyman found those 

individuals enrolling in coverage through SEPs amassed 24% more in health care costs 

over their first three months of coverage in 2014 than those coming in during the open 

enrollment period. Oliver Wyman found strong evidence that the relative cost of the 

enrollees signing up for coverage during SEPs was even higher in 2015. 3 

2. Grace periods for non-payment of premiums should be shortened to 30 days as 

required by almost all states. 

We commend Congressman Flores for re-introducing H.R. 710, which will incentivize 

individuals to stay covered. The ACA required a 3-month grace period for certain individuals 

to continue receiving coverage without paying their health insurance premiums. The ACA 

requirement far exceeds state grace periods which are typically 30 days, allowing some 

individuals to stop paying premiums in October but continue to get medical services through 

December, causing premiums to go up for everyone. 

A recent national consumer survey shows that more individuals are using the grace period 

than before. It found that 18% of consumers stopped paying their premium in 2015 and 

then reenrolled again in 2016. Further, half of these consumers returned to the same plan 

they stopped payment for in 2015. Of the consumers that stopped paying premiums last 

year, 45% said they had stopped payments in 2014.' 

3. Allow states to determine the age rating factors to ensure appropriate incentives to 

enroll younger, healthier people. 

The ACA limited the amount premiums for adults can vary based on age to a 3 to 1 band. 

This has made premiums for younger people much more expensive than their actual 

medical costs and resulted in fewer people age 25-44 obtaining health insurance. In fact, 

the uninsured rate is much higher than was originally projected for those ages 25-44. We 

applaud Congressman Bucshon for re-introducing legislation, H.R. 708, which will allow 

states more flexibility while encouraging younger and healthier individuals to enroll. 

CONCLUSION 

Keeping premiums affordable for everyone is crucial to increasing participation and coverage 

among healthier individuals who help balance the overall risk pool and stabilize the market. The 

current risk pool is out of balance -with a disproportionate number of people who need 

significant healthcare services- making health insurance more expensive for everyone. The 

bipartisan legislation under consideration by the Committee provides a needed course 

correction to ensure greater market stability and more affordable coverage. BCBSA 

encourages immediate passage of these bills. 

https://academyhealth.confex.com/academyhealth/2016arm/mediafile/Presentation/Session4923/Keri%20Apostl 

~ 3 Oliver Wyman, "Special Enrollment Periods and the Non-Group, ACA-Compliant Market". 4 

http://healthcare.mckinsey.com/sites/default/files/McK%202016%200EP%20Consumer%20Survey%201nfographic 

vF.pdf 

3 
175 


Written Testimony 

Of 

The American Congress of Obstetricians and Gynecologists 

Before the 

House Energy and Commerce Subcommittee on Health 

Regarding 

Patient Relief from Collapsing Health Markets 

February 2, 2017 

Chairman Burgess, Ranking Member Green, and distinguished members of the Subcommittee on Health, 

thank you for giving the American Congress of Obstetricians and Gynecologists (ACOG), representing 

more than 58,000 physicians and partners in women's health, the opportunity to submit written 

testimony in response to your February 2, 2017 hearing titled "Patient Relief from Collapsing Health 

Markets." We look forward to working closely with you to preserve landmark women's health gains, and 

to improve the ACA for patients and providers. We hope you will view ACOG as a resource and trusted 

partner as you continue to examine our nation's health care system. 

As the nation's leading organization of women's health providers, ACOG is keenly aware of many of the 

benefits, and shortfalls, ofthe Patient Protection and Affordable Care Act (ACA). ACOG has a strong 

history of supporting access to coverage and care for all women. While ACOG engaged extensively with 

Congress during the development of the ACA, we reluctantly opposed the final bill because of the 

inclusion, and exclusion, of several provisions that we believed undermined health reform's great 

promise. 

However, ACOG does not support full repeal of the ACA. We stand strongly behind the landmark 

women's health gains achieved through the ACA, and urge the Congress not to turn back the clock on 

women's health. 

ACOG's health reform principles (attached) serve as our guide to measuring the adequacy of all ACA 

reform proposals. Any reforms must preserve: 

Guaranteed maternity coverage for all women in all plans. This essential health benefit righted a 

wrong in our healthcare system, helping pregnant women access prenatal care and leading to 

healthier pregnancies and healthier babies. Every $1 spent on prenatal care saves $3.38, 

primarily in cost of low birthweight and preterm infants. Preterm birth costs our nation $26 

billion annually- more than $50,000 for every infant born prematurely. 

• Coverage with no cost sharing for women's preventive health services. More than 55 million 

women gained access to evidence-based preventive services under the ACA, including 

mammograms, immunizations, and contraception. This provision saved women $1.4 billion on 

out-of-pocket costs for contraception in one year, and has helped drive down the rate of 

unintended pregnancies. 

Direct access to ob-gyn care. Ob-gyns deliver primary and preventive care to women, and are 

often the only doctor a woman sees on a regular basis. This patient-centered protection 

guarantees our patients the ability to see their preferred physician. 

• No pre-existing condition exclusions. Before the ACA, insurers dodged coverage in too many 

ways, including by refusing coverage of roughly 65 million women with pre-existing conditions, 

including prior C-section or having been the victim of domestic violence, can no longer be 

denied coverage. This important patient-centered protection must be maintained. 
176 


No gender rating. Before the ACA, insurers charged women approximately $1 billion more 

annually and a 25-year old woman could pay 81% more than a man for identical coverage. let's 

continue to make insurers play fair. 

No insurance coverage annual or lifetime limits or rescissions. Before the ACA, 39.5 million 

women were subject to coverage limits, leaving our patients with serious health issues 

vulnerable to losing coverage mid-treatment. This patient-centered protection is critical to our 

ability to care for our sickest patients. 

No excessive waiting periods (defined as longer than 90 days). Before the ACA, insurance 

companies could impose excessive waiting periods, such as 9-months or two years, before 

beneficiaries could use their coverage, including maternity coverage. That practice was the 

exact opposite of patient-centered, allowing insurers to collect monthly premiums and deny 

coverage for needed care. 

ACOG supports thoughtful improvements to current law. We hope to work closely with the 

Subcommittee to reduce administrative burdens on patients and physicians, address unaffordably high 

deductible plans, correct the narrowing of networks, reform the medical liability system, and abolish the 

Independent Payment Advisory Board (IPAB). 

Thank you for your consideration of these key provisions, which are imperative to the health of our 

patients. We look forward to continuing to engage with you and provide guidance as you further 

evaluate our nation's health care system and consider potential reforms. 
177 


ACOG 

THE AMERICAN CONGRESS 

Of OBSTETRICIANS 

AND GYNECOLOGISTS 

ACOG Health Reform Principles 

Good Economics. Good Women's Health. 

Affordable access to care improves health and reduces health system and employer costs. 

January 2017 

ACOG is a strong supporter of the landmark women's health gains made in the Affordable Care Act. Any attempt to 

reform our nation's health care system must not compromise or reduce these health insurance guarantees and 

protections. Alternative proposals must: 

Maintain critical benefits 

Guarantee maternity coverage for all women in all plans. This coverage, leading to healthier outcomes and lower 

costs, was routinely excluded from private insurance plans prior to the ACA. 

./ An estimated 8.7 million American women gained maternity services under the ACA. Previously, only 12% of 

individual market plans covered these services.1 

./ Every $1 spent on prenatal care saves $3.38, primarily in reduced spending for low birthweight and preterm 

infants.h 

Ensure full coverage and no cost-sharing for women's preventive health services under all plans, including the full 

range of FDA-approved contraceptives . 

./ More than 55 million women gained access to preventive services, including mammograms, flu shots, and 

contraception without a copay or a deductible . 

./ Women saved $1.4 billion on out-of~pocket costs for contraception in one year. Iii 

./ Currently, 49% of US pregnancies are unintended; unintended pregnancies resulted in approximately $12.5 

billion in government expenditures in 2008. 1

v 

Continue Medicaid coverage for tobacco cessation services to pregnant women, leading to better care and lower 

costs . 

./ Smoking during pregnancy is associated with intrauterine growth restriction, preterm birth, low birthweight, 

perinatal mortality, and ectopic pregnancy . 

./ Up to 34% of sudden infant death syndrome (SIDS) cases can be attributed to prenatal maternal smoking.' 

Maintain the Medicaid state plan option to expand coverage of family planning services for low-income women . 

./ Medicaid accounted for 75% of 2010 expenditures on publidy~funded family planning. vi 

./ In 2010, every $1 invested in publicly-funded family planning services saved $7.09 in Medicaid expenditures 

that would have otherwise been needed to pay the medical costs of maternity and infant care.vii 

Preserve market protections Prohibit pre-existing condition exclusions, gender rating, coverage rescissions, and annual and lifetime benefit caps . 

./ Roughly 65 million women with pre~existing conditions, such as a prior C-section or a history of domestic 

violence, must not be denied coverage . 

./ Prior to the ACA, gender rating cost women approximately $1 billion annually.v•u 

./ Insurers must guarantee renewability and availability of coverage. 

Ensure direct access to ob-gyn care . 

./ Ob~gyns deliver primary and preventive care services to women. An ob~gyn is often the only doctor a 

woman sees on a regular basis. Reforms must not impose a barrier to this care. 

Allow individuals through age 26 to maintain coverage on their parents' health insurance. 

Continue prohibition on excessive waiting periods . 

./ Prior to the ACA, insurance companies could impose waiting periods ranging from 9 months to 2 years 

before maternity coverage could be used. ix 

THE AMERICAN CONGRESS OF OBSTETRICIANS AND GYNECOLOGISTS • WOMEN'S HEAlTH CARE PHYSICIANS 

40912TH STREET SW, WASHINGTON DC 20024-2188 

Phone: 202/638-5577 Internet: http://www.acog.org 
178 


Ensure premium subsidies are available to help small employers and low~income individuals purchase private health 

insurance . 

./ In 2011, nearly 40% of uninsured women had incomes between 139%-399% of the federal poverty level, 

making them eligible for subsidies.x Alternative proposals must ensure continued affordability. 

Strengthen the health care safety net 

Continue Medicaid expansion, ensuring a public safety net for no-income and low-income non-pregnant women, 

and encourage all states to expand their Medicaid programs to cover this population. Thanks to Medicaid 

expansion: 

./ Between 2010 and 2015, the uninsured rate among women ages 18-64 decreased from 19.3% to 10.8%, 

nearly half. • 

./ Hospital uncompensated care costs dropped by $10.4 billion in 2015.'" 

Preserve the changes to the Medicaid and CHIP application process and allow states to continue to give real-time 

determinations for non-disabled adults and children, to ensure that women, including pregnant women, can enroll 

in health insurance and begin accessing care in a timely manner. 

Continue identification and development of Medicaid quality measures with multi-stakeholder input . 

./ Continued development and testing of quality measures, including those concerning maternity care, will 

further efforts to enhance the quality of health care delivered through Medicaid and lead to better 

outcomes. 

Maintain permanent authorization of the Indian Health Care Improvement Act . 

./ The cornerstone legal authority for the provision of health care to American Indians and Alaska Natives, the 

Act modernized and improved health care provided to American Indian/ Alaska Native populations, who 

generally experience lower health status and disproportionate disease burden. 

Protect public health 

Provide break time and a place at work for breastfeeding women to express milk . 

./ One study estimates that $3.6 billion would be saved annually in the cost of treating some childhood 

illnesses if breastfeeding rates were increased . 

./ Children who were breastfed as infants have fewer childhood illnesses and fewer visits to the pediatrician's 

office, which leads to decreased parental absenteeism from work and lower health system costs.xiii 

Continue the Patient~Centered Outcomes Research Institute (PCORI) to advance the evidence on health outcomes 

through research . 

./ The work of PCORI improves the quality of care and speeds implementation of evidence-based practices, 

positively impacting the rising rates of health care costs . 

./ PCORI's work in women's health ranges from maternity patient reported outcomes, uterine fibroid 

management, reduction of preterm birth, contraceptive counseling, and maternal mental health. 

Continue the Prevention and Public Health Fund . 

./ The Prevention Fund helps states keep communities healthy and safe via immunization programs, 

epidemiology and laboratory capacity grants, breast and cervical cancer screenings, smoking cessation 

programs, etc . 

./ Every $1 invested in evidence~based prevention programs saves $5.60. xlv 

Continue the Center for Medicare and Medicaid Innovation (CMMI) to support the advancement of innovative 

payment and delivery system models . 

./ The Strong Start for Mothers and Newborns initiative seeks to reduce preterm birth and other adverse birth 

outcomes . 

./ The Medicare Access and CHIP Reauthorization Act (MACRA) law that repealed the flawed Sustained Growth 

Rate (SGR) relies on CMMI to test innovative payment models. 
179 


1 Garrett, D. National Women's law Center, Turning to Fairness: Insurance Discrimination Against Women Today and the Affordable 

Care Act (Mar. 2012), available at http://www.nwlc.org/sites/defau!t/files/pdfs/nwlc 2012 turningtofairness report.pdf. 

H Henderson JW. The Cost Effectiveness of Prenatal Care. Health Care Financing Review. 1994;15{4):21~32, available at 

https://www.ncbi.nlm.nih.gov/pmc/artides/PMC4193436/. 

,; Becker, N. V,, & Polsky, 0. {July 2015). Women Saw large Decrease in Out-of-Pocket Spending for Contraceptives After ACA 

Mandate Removed Cost Sharing. Health Affairs, 34{7), pp. 1204-1211, available at 

http: II content. health affairs .org/ content/34/7/1204. abstract. 

N Access to contraception. Committee Opinion No. 615. American College of Obstetricians and Gynecologists. Obstet Gynecol 

2015;125:250-5. 

v Smoking cessation during pregnancy. Committee Opinion No. 471. American College of Obstetricians and Gynecologists. Obstet 

Gynecol2010;116:1241-4. 

vi Sonfield A and Gold RB, Public Funding for Family Planning, Sterilization and Abortion Services, FY 1980-2010, New York: 

Guttmacher Institute, 2012, available at https://www.guttmacher.org/report/public-funding-family-p!anning-sterillzation-andabortion-services-fy-1980-2010. 

vi• Frost JJ et a!., Return on investment: a fuller assessment of the benefits and cost savings of the US publicly funded family planning 

program, Milbank Quarterly, 92(4):696-749, 2014, available at http:/lonlinelibrary.wiley.com/doi/10.1111/1468~ 

0009.12080/abstract. 

vll1 Garrett, D. Ibid. 

ix Karen Pollitz eta!., Kaiser Family Foundation, Maternity Care and Consumer~Driven Health Plans {June 2007). 

x Health Reform: Implications for Women's Access to Coverage and Care. Issue Brief #7987-03. Kaiser Family Foundation. August 

2013, available at https://kaiserfamilyfoundation.files.wordpress.com/2012/03/7987-03-health-reform-implications-for-women saccess-to-coverage-and-care.pdf. 

xl Simmons, A et. a!. The Affordable Care Act: Promoting Setter Health for Women. Office of the Assistant Secretary for Planning and 

Evaluation Issue Brief. Department of Health and Human Services. June 14, 2016, available at 

https://aspe.hhs.gov/sites/default/files/pdf/205066/ACAWomenHealth!ssueBrief.pdf. 

x" The Economic Record of the Obama Administration: Reforming the Health Care System. Council of Economic Advisers. Executive 

Office of the President. December 2016, available at 

https://www.whitehouse.gov/sites/defau!t/files/page/files/20161213 cea record hea!h care reform.pdf 

xiii Sreastfeeding in underserved women: increasing initiation and continuation of breastfeeding. Committee Opinion No. 570. 

American College of Obstetricians and Gynecologists. Obstet Gynecol2013;122:423-8. 

xiv Prevention for a Healthier America: Investments in Disease Prevention Yield Significant Savings, Stronger Communities. Issue 

Report. Trust for America's Health {February 2009), available at 

http://healthyamericans.org/reoorts/prevention08/Prevention08.pdf. 
180 


~Alliance ~ for Retired 

Americans® 

January 2, 2017 

The Honorable Michael Burgess 

Chainnan 

House Energy & Commerce 

Subcommittee on Health 

2125 Rayburn House Office Building 

Washington, DC 20515 

The Honorable Gene Greene 

Ranking Member 

House Energy & Commerce 

Subcommittee on Health 

2322A Rayburn House Office Building 

Washington, DC 20515 

Dear Chairman Burgess and Ranking Member Greene: 

President 

Robert Roach, Jr. 

Secretary-Treasurer 

Joseph Peters, Jr. 

On behalf of the more than 4.4 million Alliance for Retired Americans, I appreciate the 

opportunity to provide comments to the hearing entitled, "Patient Relief from Collapsing Health 

Markets." Although the focus of the hearing is on reducing the cost of health care for Americans, 

Representative Bucshon's proposal to modify the health variations in health insurance premium 

rates only helps younger adults and would actually increase premiums for older Americans. 

Prior to passage of the Affordable Care Act (ACA), the premium for a single 64 year old 

compared to a 19 year old typically varied by 5-to-1 and, in some markets, as high 11-to-1. This 

made insurance unaffordable for many early retirees who were not yet Medicare eligible and had 

to purchase insurance in the individual market. Instituting a 5-to-l age rating would not only 

destroy the basic principles of the ACA, but it reverts back to previous law and to a broken 

system. 

The Commonwealth Fund found that while the rate of insured would increase among young 

people if the age rating was changed to 5-to-l, 400,000 older adults would lose coverage. The 

shift in age rating would also increase costs to the federal government. Because the ACA caps 

premium contributions for low- and moderate-income marketplace enrollees as a percent of 

income, many individuals affected by the change in age rating would face higher premiums, 

reach the cap and the federal government would be required to pick up the cost difference. 

We are also concerned about legislation relating to pre-existing conditions. While Representative 

Walden's bill promises to protect patients with pre-existing condition, it is our understanding that 

this would only be the case if the individual had continuous coverage. Should an individual lose 

coverage at any time, insurers would be allowed to charge much higher premiums. 

815 16" Street, NW, 4" Floor 0 Washington. DC 20006-4103 0 (202) 637-5399 0 (202) 637-5398 fax 

www.retiredarnericans.org 
181 


I am pleased to add my voice to the chorus of individuals and organizations that oppose efforts to 

expand age rating bands and oppose the modified and narrower protections against pre-existing 

conditions. Thank you to taking my concerns into consideration and helping to spare older 

Americans from increased and unaffordable premiums. 

Executive Director 

Alliance for Retired Americans 

815 16'' Street, NW, 4" Floor 0 Washington, DC 20006-4103 0 (202) 637-5399 0 (202) 637-5398 fax 

www.retiredamericans.org 
182 


February 2, 2017 

HE\lTHC\RF 

! .EADERSII!P 

The Honorable Michael Burgess, M.D. 

Chairman 

Subcommittee on Health 

Committee on Energy and Commerce 

United States House of Representatives 

Dear Chairman Burgess: 

Thank you for your efforts to make healthcare accessible and affordable for all 

Americans. As the Subcommittee on Health prepares to hold a hearing on improving 

the health insurance markets, the Healthcare Leadership Council (HLC) welcomes the 

opportunity to share our thoughts on this important issue. 

HLC is a coalition of chief executives from all disciplines within American healthcare. It 

is the exclusive forum for the nation's healthcare leaders to jointly develop policies, 

plans, and programs to achieve their vision of a 21st century health system that makes 

affordable, high quality care accessible to all Americans. Members of HLC-hospitals, 

academic health centers, health plans, pharmaceutical companies, medical device 

manufacturers, biotech firms, health product distributors, pharmacies, post-acute care 

providers, and information technology companies-are committed to advancing a 

consumer-centered healthcare system that values innovation, accessibility, and 

affordability. 

HLC believes that the post-Affordable Care Act (ACA) insurance structure must bolster 

the stability of the marketplace, encourage greater competition, and give all Americans 

enhanced choice and flexibility in their coverage. Like the Subcommittee, HLC is 

concerned that loopholes such as the large number of Special Enrollment Periods 

(SEPs) and the three-month premium payment grace period mean that the individual 

mandate does not serve its purpose of ensuring that that all consumers have 

continuous coverage and that the coverage is affordable. To address these issues, the 

number of SEPs should be reduced to align with the large employer insurance market 

and pre-enrollment verification should be required. In addition, the length of the grace 

period should align with state law and consumers should be required to pay their 

outstanding premiums before re-enrolling in coverage. 

If the post-ACA insurance structure does not include an individual mandate, then there 

needs to be a continuous coverage requirement and/or other critical safeguards against 

adverse selection. For individuals who have not had continuous coverage, insurers 

should be able to charge them higher premiums, limit their benefit options, or defer 

them to a federally funded high risk system in order to keep costs affordable for 

everyone. 

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183 


A permanent high risk pool for the continuously covered should also be in place and 

should receive broad-based and stable funding. In addition, risk adjustment 

mechanisms to account for higher cost enrollees should be improved. 

Consumers should be provided with advanceable, refundable tax credits to help them 

purchase coverage. To attract consumers, flexible plan designs should be encouraged. 

Decision support tools-including out of pocket cost calculators, smart plan-finder tools, 

searchable provider networks and drug formularies, and clear cost information for 

common services-would help consumers to understand their options and choose 

among the plans. 

Thank you for your efforts to improve the health insurance markets. HLC looks forward 

to continuing to work with you to make health insurance accessible and affordable for all 

Americans. Should you have any questions, please contact Debbie Witchey at 202-

449-3435. 

President 

cc: The Honorable Gene Green, Ranking Member 

Subcommittee on Health 

2 
184 


--A, 

AHIP 

Statement on 

"Patient Relief from Collapsing Health Markets" 

Submitted to the 

House Energy and Commerce Committee 

Subcommittee on Health 

February 2, 2017 

America's Health Insurance Plans (AHIP) is the national association whose members provide 

coverage for health care and related services. Through these offerings, we improve and protect 

the health and financial security of consumers, families, businesses, communities and the nation. 

We are committed to market-based solutions and public-private partnerships that improve 

affordability, value, access and well-being for consumers. 

We appreciate this opportunity to comment on a series of bills the committee is examining as 

part of its effort to develop health reforms for replacing the Affordable Care Act (ACA). As the 

committee examines these issues, it is clear that certain parts of the ACA have not worked as 

well as intended, especially for individuals who purchase coverage on their own. In fact, the 

individual market-which has grown significantly in recent years and currently provides 

coverage to 18 million Americans 1

-has faced challenges for many years, including prior to the 

implementation ofthe health reform law. 

For consumers who purchase coverage in the individual market, the more immediate 

challenges-which have been well-documented-include significant increases in average 

premiums in 2017 (driven by underlying growth in medical and prescription drug costs, the 

sunset of the transitional reinsurance program and other factors), fewer health plan choices, 

lower-than-expected exchange enrollment and risk pool challenges in some states. 

1 ASPE Data Point-About 2.5 Million People Who Buy Coverage Off-Marketplace May Be Eligible for ACA 

Subsidies. October 4, 2016. https://aspe.hhs.gov/sitesldefaultlfileslpdf/208306/0ftMarketplaceSubsidyeligible.pdf 

1 
185 


While these challenges are real, it is also true that the ACA has expanded coverage to 20 million 

Americans and the percentage of Americans without health insurance has dropped to historical 

lows-down from 16.0% in 2010 to 8.6% in 2016.2 These gains have been achieved through the 

Medicaid expansion as well as through the ACA exchange marketplace (which has been 

accomplished through a combination of insurance market reforms, financial assistance via 

premium subsidies, and the individual mandate). 

Draft Bills Under Consideration in Today's Hearing 

We appreciate that today's hearing will focus on several draft bills that offer promising strategies 

for addressing some of the challenges in the individual market. We look forward to working 

with the committee on these and other proposals. 

"Plan Verification and Fairness Act" 

We support this legislative proposal to implement a pre-enrollment verification process, using 

available electronic data sources, for special enrollment periods (SEPs). While the Centers for 

Medicare & Medicaid Services (CMS) has taken steps to address the misuse ofSEPs, preenrollment verification represents the most effective approach to ensure the appropriate use of 

SEPs in promoting both affordability for consumers and stability in the new Exchanges. 

While most consumers play by the rules, many have misused SEPs-and that raises costs for 

everyone. Too many Americans have incentives to game the system by applying for coverage 

only when they need care. We must eliminate opportunities for fraud if we are to make care 

more affordable for everyone. 

In February 2016, A HIP and the Blue Cross Blue Shield Association released a joint policy 

analysis3 that raised concerns about the misuse and abuse of SEPs by some individuals and 

discussed the importance of verifying eligibility for SEPs. Our joint policy analysis stated: "We 

continue to support ensuring consumers have access to affordable coverage. Special enrollment 

periods are important to ensure continuity of coverage given changing life situations for 

consumers and must be implemented through verification processes that do not allow 'just in 

time' insurance which will undermine the stability of the marketplaces. Verification should 

focus on ensuring program integrity up front because it is a more consumer friendly approach 

2 Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 

january-March 2016. https:/ / www.cdc.gov / nchs/ data/ nhis/ earlyrelease/ insur201609.pdf 3 AH!P-BCBSA, Appropriate Use of Special Enrollment Periods Is Key to Exchange Stability, Affordability for 

Consumers, February 2016 

2 
186 


that avoids issues on the back end that consumers, providers, issuers and exchanges must 

reconcile." 

"Health Coverage State Flexibility Act" 

We support this legislative proposal to align the current grace period for recipients of advanced 

premium tax credits (APTC) with existing state law and regulation. This bill would take another 

important step toward eliminating opportunities for fraud and making health care more 

affordable. 

Under current law, Exchange enrollees who receive APTC are provided a three-month grace 

period before coverage is discontinued if they are delinquent on their premium payment, and 

health plans are required to pay health care claims during the first month of the grace period. We 

believe current law should be amended to make the grace period requirements consistent with 

existing state rules, most of which currently allow for a 30-day grace period. This legislation 

could help promote continuous coverage and consumer affordability by improving risk pool 

stability. 

"State Age Rating Flexibility Act" 

We support this legislative proposal to grant states the flexibility to adopt wider age rating bands 

to promote more affordable coverage and expand participation among younger, healthier 

individuals. 

The ACA established 3: I age rating bands that led to higher premiums for certain younger 

consumers, particularly those who purchased individual market coverage prior to the ACA 

and/or are not currently eligible for subsidies. Providing flexibility for states to adopt wider age 

bands--combined with other steps, such as modifying the formula for the existing premium 

assistance tax credits to factor in age bands--could encourage younger and healthier people to 

enroll in coverage. This, in tum, could improve affordability for consumers by promoting 

greater stability of the risk pool. 

"Preexisting Conditions Protection and Continuous Coverage Incentive Act" 

We appreciate that this legislative proposal aims to address the needs of individuals with preexisting conditions and we look forward to seeing the incentives that will be included in a later 

version of this bill. 

Our members have strongly supported an approach to health reform that brings everyone into the 

system. Broad coverage can ensure the availability of affordable options. Health insurance only 

3 
187 


works when everyone is covered: those who utilize insurance to obtain quality care as well as 

those who are healthy but have insurance to protect themselves in case they get sick. Both types 

of consumers must be insured for coverage to remain affordable. To address this priority and 

achieve a more stable and workable marketplace, it is important for Congress to approve robust 

policies that encourage people to maintain continuous coverage. 

Conclusion 

AHIP and the health plans we represent look forward to working with the committee, members 

of Congress on a bipartisan basis, and the administration as it works to improve health care for 

all Americans. We can achieve this by working together in a good faith and bipartisan manner to 

fix critical problems while preserving the expanded coverage and enhanced affordability of 

coverage for millions of patients and families. Thank you again for the opportunity to work with 

you on these important issues. 

4 
188 

[Dr. Holtz-Eakin did not answer submitted questions for the 

record by the time of printing.] 


GREG WALDEN. OREGON 

CHAIRMAN 

Dr. Doug Holtz-Eakin 

President 

ONE HUNDRED FIFTEENTH CONGRESS 

FRANK PALLONE. JR., NEW JERSEY 

RANKING MEMBER 

feongress ot tbe mniteb ~tate5 

J$ou!it of l\rpre!ientatibr!i 

COMMITIEE ON ENERGY AND COMMERCE 

2125 RAYBURN HousE OFFICE BuiLDING 

WASHINGTON, DC 20515-6115 !202)225-1:927 

(202!225-3641 

February 17, 2016 

American Action Forum 

1747 Pennsylvania Avenue, N.W. 

Fifth Floor 

Washington DC, 20006 

Dear Dr. Holtz-Eakin: 

Thank you for appearing before the Subcommittee on Health on February 2, 2017, to testity at the 

hearing entitled "Patient Relief from Collapsing Health Markets." 

Pursuant to the Rules of the Committee on Energy and Commerce, the hearing record remains 

open for ten business days to permit Members to submit additional questions for the record, which are 

attached. The format of your responses to these questions should be as follows: (I) the name of the 

Member whose question you are addressing, (2} the complete text of the question you are addressing in 

bold, and (3) your answer to that question in plain text. 

To facilitate the printing of the hearing record, please respond to these questions with a 

transmittal letter by the close of business on March 3, 2017. Your responses should be mailed to Jay 

Gulshen, Legislative Clerk, Committee on Euergy and Commerce, 2125 Rayburn House Office Building, 

Washington, DC 20515 and e-mailed in Word format to jay.gulshen@mail.house.gov. 

Thank you again for your time and effort preparing and delivering testimony before the 

Subcommittee. 

cc: The Honorable Gene Green, Ranking Member, Subcommittee on Health 

Attachment 
189 


Attachment- Additional Questions for the Record 

The Honorable Gus Bilirakis 

Mr. Holtz.. Eakin, the Center for Health and Economy analyzed the Better Way agenda, can you 

provide details on what they found that the plan broadly accomplishes? What is the impact on 

premiums? ls there a change to provider access? What would be the impact on the federal 

budget? Are you able to share the findings on the premium impact Better Way would have on 

both single and family coverages at each of the coverage levels -catastrophic through platinum 

-offered by Obamacare? 
190 


GREG WALDEN. OREGON 

CHAIRMAN 

ONE HUNDRED FIFTEENTH CONGRESS 

FRANK PALLONE, JA., NEW JERSEY 

RANKING MEMBER 

~ongrt~~ of tbt 'ltntttb ~tate~ 

~ouse of l\epresentatibes 

COMMITTEE ON ENERGY AND COMMERCE 

2125 RA vsuRN House OFFICE BuiLDING 

WASHINGTON, DC 20515-6115 

Dr. J. Leonard Lichtenfeld 

Deputy Chief Medical Officer 

American Cancer Society 

250 Williams Street, N.W. 

Atlanta, GA 30303 

Dear Dr. Lichtenfeld: 

Major!ly !202)225-2927 

Minority {202)225---3641 

February 17, 2016 

Thank you for appearing before the Subcommittee on Health on February 2, 2017, to testifY at the 

hearing entitled "Patient Relief from Collapsing Health Markets." 

Pursuant to the Rules of the Committee on Energy and Commerce, the hearing record remains 

open for ten business days to permit Members to submit additional questions for the record, which are 

attached. The format of your responses to these questions should be as follows: (I) the name of the 

Member whose question you are addressing, (2) the complete text of the question you are addressing in 

bold, and (3) your answer to that question in plain text. 

To facilitate the printing of the hearing record, please respond to these questions with a 

transmittal letter by the close of business on March 3, 2017. Your responses should be mailed to Jay 

Gulshen, Legislative Clerk, Committee on Energy and Commerce, 2125 Rayburn House Office Building, 

Washington, DC 20515 and e-mailed in Word format to jay.gulshen@mail.house.gov. 

Thank you again for your time and effort preparing and delivering testimony before the 

Subcommittee. 

cc: The Honorable Gene Green, Ranking Member, Subcommittee on Health 

Attachment 
191 


Attachment - Additional Questions for the Record 

The Honorable Frank Pallone, Jr. 

1. One important consumer protection that the ACA put in place were the Essential Health 

Benefits. Before the ACA, many Americans bought insurance only to find out that it did 

not cover necessary care, such as prescription drugs or hospitalization. Under the ACA, 

all Qualified Health Plans must cover a basic set of services, known as Essential Health 

Benefits. Rep. Walden's discussion draft assumes repeal of the entire ACA, including the 

Essential Health Benefits. We know that for example, before the ACA, 62 percent of 

plans lacked maternity coverage and 18 percent lacked coverage for mental health 

services. Without additional legislation, insurance companies would presumably have to 

cover anyone who applied, but the coverage could be lacking basic benefits. 

Q: Dr. Lichtenfeld, can you talk about the kinds of medical care services patients need 

when they are in cancer treatment? 

Cancer patients in active treatment need a full range of medical services including 

but not limited to: hospitalization, specialty cancer care, physician services, 

prescription drugs, rehabilitative care, and mental health services. 

It':; important to note that the need for care doesn't end once the cancer is treated. 

Cancer survivors also need access to a wide range of services for years following 

their cancer treatment. 

Streamlined "basic" policies that do not include explicitly defined comprehensive 

benefits put cancer patients and survivors at risk of inadequate treatment, and could 

jeopardize access to necessary preventive care, treatment and follow-up care. 

Q: If the ACA benefit standards were to be repealed, how would cancer patients be 

affected if insurance policies no longer covered prescription drugs? Or if they only 

covered generic drugs? 

As I mentioned previously, cancer patients in active treatment, as well as cancer 

survivors, need access to a full range of medical services. 

Pharmaceutical therapies are an integral part of cancer treatment today. Further, 

millions of cancer survivors rely on drug therapies to prevent recurrence of their 

cancer. Without access to drug therapies cancer treatments would be severely 

limited and the lives of cancer patients and survivors put at risk. 

We support access to lower cost generic versions of cancer drugs. But currently 

many of the newer and innovative therapies are biologics that do not yet have 

biosimilars. But even biosimilars- while less costly- will be expensive. Without 
192 


adequate insurance coverage these drugs would still be unaffordable for many 

cancer patients. 

Newer cancer treatments such as immunotherapy are expensive and becoming 

standards of care for several types of cancer including but not limited to lung cancer 

and melanoma, for example. These treatments are also expensive and well out of 

the reach of patients without insurance coverage. 

Q: What if policies limited coverage to 3 doctor visits per year? 

Arbitrary coverage limits make no sense- particularly in cancer care. 

Every cancer and every cancer patient is unique and their treatment regimen should 

be dictated by what patients need in order to beat their cancer- not by a one size 

fits all limit on coverage. 

The typical cancer patient needs many more than 3 doctor visits per year. 

Q: What if policies had annual deductibles of $10,000 or $20,000 per person? 

Access to affordable health care is critical to cancer care. Unreasonably high 

deductibles are a serious barrier to care. Most people cannot afford to pay $20,000 

out of pocket before their health insurance coverage begins. 

For someone with cancer a high deductible that prevents them from getting the care 

they need could be a matter of life and death. 

Further, some cancers -like colorectal, breast, and cervical- can be prevented or 

caught very early with access to screening and early detection. Yet unaffordable 

deductibles could cause people to go without life-saving screening services. And if 

cancer is detected through screening there must be adequate coverage for prompt 

treatment to provide the best opportunities for success. 

2. The Affordable Care Act allows for certain Special Enrollment Periods (SEPs) for those 

who are eligible to purchase health insurance outside of the designated open 

enrollment period. The individual market has always been transitional as people move 

into and out of sources of coverage, such as job-based plans and Medicaid. Thus life 

changes triggering an SEP often occur outside of open enrollment leading some people 

to "churn" into and out of marketplace plans during the year. 

We have heard from insurers that SEPs allow patients to game the system and that 

patients are using SEPs when they are not eligible. We care about program integrity, and 

we care about having a stable risk pool, and so did the prior administration. This is why 

CMS took steps to tighten up SEPs by reducing the number of SEPs and requiring that 

consumers provide proof that they are eligible. CMS has also instituted a requirement 

for the "permanent move" SEP; under which those applying have to prove they had 

minimum essential coverage before their move. 

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193 


H.R. 706 would require that HHS verify eligibility before coverage can start. I'm 

concerned that this will cause a delay in coverage. CMS is starting a pilot project to see if 

pre-enrollment verification can work without delays, but I'm skeptical. So is the 

nonpartisan Congressional Budget Office, who estimates that this policy would result in 

approximately 1 million patients experiencing a 1 to 2-month delay in coverage. 

Q: Dr. Lichtenfeld, can you explain the impact of a 1 to 2-month delay in coverage on a 

cancer patient? 

Someone who hears the words "you have cancer" wants and needs their treatment 

to begin as soon as possible. For many cancer patients delay is not an optionespecially when faced with an acute life-threatening condition. 

For later stage cancers, getting treatment underway quickly is especially important. 

A two-month delay in coverage not only puts a cancer patient through needless 

stress and anxiety, but it can actually impact the success of their treatment. 

3. Mr. Walden's draft includes a placeholder for a continuous coverage requirement. • 

However, since it's a placeholder, we don't know exactly what the policy will look like. 

Failing to pay your medical bills isn't always a choice. Sometimes people need the care 

and want to pay for the care but other circumstances prevent them from doing so. But 

this sort of policy has the potential to lock people out of the market. Financially 

vulnerable households in particular might face long-term consequences if insurance is 

temporarily unaffordable. Job loss often drives the loss of existing health insurance 

coverage. For families in tough situations, the loss of income combined with the loss of 

employer-sponsored coverage could cause them to be unable to re-enroll in an 

insurance plan or lead to a sizable increase in premiums. 

I'm worried that the continuous coverage punishment simply does not fit the crime. 

Q: Dr. Lichtenfeld, can you please talk about the effect of continuous coverage policies 

on the cancer community? 

The Kaiser Family Foundation estimates that 27 percent of adult Americans under 

the age of 65 have a pre-existing condition. 

Prior to January 1, 2014, health insurance issuers were permitted to refuse to cover 

an individual who had a pre-existing condition; could provide coverage but limit 

and/or refuse to cover care associated with the individual's pre-existing condition; 

or, could charge the individual a higher premium based on her pre-existing condition 

(thus making insurance unaffordable). A survey conducted before these exclusions 

were prohibited found that 36 percent of those who tried to purchase health 

2 
194 


insurance directly from an insurance company in the individual insurance market 

were turned down, were charged more, or had a specific health problem excluded 

from their coverage. 

Depending on how continuous coverage would be implemented it could actually 

restore the discriminatory practice of pre-existing condition exclusions insofar as 

individuals with pre-existing conditions could be charged higher premiums. 

Q: Can you explain why cancer patients might have a gap in coverage that is beyond 

their control? 

Research suggests that between 40 and 85 percent of cancer patients stop working 

while receiving cancer treatment, with absences from work ranging from 45 days to 

6 months depending on the treatment. 

Gaps in coverage also occur as a result of a divorce or death of a spouse when one 

spouse is no longer covered on the other's health plan. Moving from one state to 

another may also result in a gap in coverage. 

All of these examples- and many others- are common reasons why a person may 

have an unexpected gap in coverage. Penalties imposed on people in these 

situations may adversely impact access to care, interrupt life-saving treatment and 

make insurance unaffordable when they attempt to regain coverage. 

Q: Do you think that patients should be penalized with higher premiums for gaps in 

coverage beyond their control? 

A one-size-fits-all approach that imposes penalties for any interruption in coverage 

fails to recognize the many legitimate reasons that patients have coverage gaps. 

As I mentioned previously, many people may experience a gap in coverage when 

they lose their job and their employee coverage. Research suggests that between 40 

and 85 percent of cancer patients stop working while receiving cancer treatment, 

with absences from work ranging from 45 days to 6 months depending on the 

treatment. 

Gaps in coverage also occur as a result of a divorce or death of a spouse when one 

spouse is no longer covered on the other's health plan. Moving from one state to 

another may result in a gap in coverage. All of these examples- and many othersare common reasons why a person may have an unexpected gap in coverage. 

Penalties imposed on people in these situations may adversely impact access to 

care, interrupt life-saving treatment and make insurance unaffordable when they 

attempt to regain coverage. 

3 
195 


Dr. Lichtenfeld, we are also reviewing a bill today that would reduce the grace periods in 

the individual market to one month. This means that if someone misses their premium 

payment and doesn't make it up in a month, they will be removed from insurance and 

not be able to enroll again until the next open enrollment period. 

Q: Dr. Lichtenfeld, can you talk about the effect of this bill on the cancer community? 

The legislation under consideration by the Subcommittee would retain the threemonth grace period for plan years beginning before January 1, 2018, but would 

eliminate this patient protection for subsequent plan years. States would have the 

authority to set the appropriate grace period. If a state chooses not to do so, the 

default period would be one month. 

We are concerned that limiting the grace period would pose an undue burden on 

individuals who experience sudden or unexpected personal financial changes -such 

as coping with having to pay large deductibles and out-of-pocket costs associated 

with a serious disease like cancer. The out-of-pocket costs of a newly diagnosed 

cancer patient can be beyond the means of many Americans. 

When an individual is diagnosed and initially undergoes cancer treatment she usually 

incurs a significant portion in out-of-pocket costs between the deductible, and 

frequent copayments and coinsurance associated with services and/or medications. 

Nearly half of all American adults report being unable to cover an emergency 

expense costing $400 without having to borrow or sell something to do so. Yet many 

standard plans impose deductibles of $2,500 or more. 

Individuals often need additional time in order to try to obtain funds to cover these 

unexpected medical costs. Enacting legislation that would reduce the grace period 

would curtail the ability of individuals to retain their health insurance coverage at a 

time when they need it most (e.g., while they are undergoing treatment for a serious 

disease or illness). 

Moreover, we are deeply concerned that the legislation fails to provide a minimum 

protection- a state could conceivably limit the grace period to only a few days. 

While we would expect few states to take such draconian action, we nevertheless 

urge the Subcommittee to consider providing a federal floor of patient protections. 

Finally, we are concerned about how this provision will be impacted if the other 

legislative proposals discussed above were implemented. For example, if an 

individual failed to pay her health insurance premiums for more than 30 days and 

her coverage was terminated, she would be uninsured and thus potentially face 

medical underwriting if she lacked coverage for a period of time provided under the 

legislation. 

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196 


4. Several Republicans including President Trump and Speaker Ryan have stated that high 

risk pools will be put in place for people with preexisting conditions and significant 

medical expenses. Though we currently don't have any legislative language to show how 

they actually plan to implement or fund high risk pools, I'd still like to ask about the 

concept as I find it incredibly concerning. Past experience with high risk pools tell us that 

they are incredibly expensive and that individuals in high risk pools face high out of 

pocket costs and limited benefits. 

As we discussed at the hearing the draft bill by Mr. Walden would allow insurance 

companies to charge individuals with preexisting conditions more. I'm worried that this 

bill in combination with a high risk pool and the potential repeal of the ACA's essential 

health benefits would spell disaster for the sickest Americans. 

Q: Mr. Uchtenfeld, could you explain how high risk pools typically work? Have they 

worked well in the past? 

Between 1976 and 2010, 35 states implemented state high-risk pools that provided 

health insurance coverage to individuals unable to obtain health insurance in the 

individual market. 

High risk pools were often the only source of non-group coverage for an individual 

with a pre-existing condition like cancer because, prior to 2014, health plans in most 

states were permitted to deny health insurance coverage to an individual because of 

a pre-existing condition.1 

Eligibility for high risk pools varied by state, but generally in order to qualify an 

individual had to meet one or more of the following categories: 

~ Medically Eligible: In order to be medically eligible, an individual would have to 

demonstrate they had been turned down for private insurance due to a medical 

condition (e.g., a cancer diagnosis). 

~ HIPAA Eligible: In order to be HIPAA eligible an individual must have had group 

health insurance coverage within the past 63 days and that coverage must have 

lasted longer than 18 months. Individuals must also had exhausted any COBRA 

coverage (or similar coverage extension provided by the state). 

~ Health Coverage Tax Credit Eligible: In order to meet this eligibility category an 

individual must have experienced job loss as a result of foreign trade (e.g., 

eligible for Trade Adjustment Assistance) or were between the ages of 55 and 64 

and received benefits from the Pension and Guarantee Corporation. 

~ Medicare Eligible: A number of states also offered coverage to individuals 

eligible for Medicare as a supplemental source of coverage. 

A few states capped enrollment in their state high risk pools in order to limit the 

overall cost of the program. Eligible individuals were placed on a waiting list until 

the cap was removed or a spot opened up. People were often on waiting lists for 

years -leaving them without insurance coverage. 

5 
197 


Q: Do high risk pools ever have wait lists? 

Yes- some states had wait lists for individuals who wanted to enroll in the high risk 

pool plan. Individuals would have to wait until a spot opened up for them in the 

pool because the state did not have enough funding to cover everyone. 

Some states also imposed waiting periods before covering pre-existing conditions. 

For instance, an individual with a prior cancer diagnosis would have to wait a period 

of time after enrolling (usually 6-12 months) before the state high risk pool would 

cover the costs associated with cancer treatments. 

Q: Are the consumer protections in high risk pools as robust as those in the ACA? For 

example, are there annual or lifetime limits on care? 

In the past, not all state high risk pools had the same kind of protections afforded by 

the ACA. For instance, states employed a variety of measures to limit or curtail 

enrollment in high risk pools in order to keep costs down including: 

» Waiting Periods: Most states imposed waiting periods before covering 

preexisting conditions. For instance, an individual with a prior cancer diagnosis 

would have to wait a period of time after enrolling (usually 6-12 months) before 

the state high risk pool would cover the costs associated with cancer treatments. 

» Limitations on Coverage: A majority of states imposed limitations on coverage 

with either lifetime or annual limits. States that imposed annual limits did so by 

either imposing a cap on total covered benefits or capping particular benefit 

categories (e.g., prescription drugs, mental health, etc.). A majority of states 

imposed a lifetime dollar limit, which ranged from $1 million to $2 million. 

Q: How would the creation of high risk pools impact cancer patients? 

Cancer patients and survivors need insurance coverage that is affordable, readily 

accessible, and protects them from pre-existing condition exclusions, annual and 

lifetime caps on coverage and extraordinary out-of-pocket costs. 

Past experiences have shown us that high risk pools often did not meet the needs of 

cancer patients, due to high costs and lack of coverage for services cancer patients 

need. 

ACS CAN will analyze proposals with a required threshold that they provide the same 

coverage, or better than what is currently provided. 

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The Honorable Doris Matsui 

1. One of the bills we are considering today would allow insurers to charge older Americans 

more than five times as much- or more- as they charge younger consumers. Middle 

class seniors stand to lose the most. They could be charged over $2,000 dollars more 

per year. And what's worse is that this bill wouldn't do what Republicans promise. It 

doesn't encourage young people to get health insurance because the vast majority of 

them wouldn't see any savings generated from the age rating. 

Q: Dr. Uchtenfeld, how does this bill harm seniors, especially those that are 

fighting against cancer? 

Under current law, health insurance issuers in the individual market are prohibited 

from charging older adults more than three times the premium charged to younger 

adults for the same coverage (e.g., 3:1 age rating). The legislation under 

consideration by the Subcommittee would relax these requirements and permit 

health insurance issuers to charge older adults five times the amount charged to 

younger individuals (e.g., a 5:1 age rating). The legislation also would allow states to 

impose a different ratio- either a higher or a lower ratio. 

While cancer can be diagnosed at any age, the incidence of cancer increases with 

age. According to the American Cancer Society, 85 percent of all cancers in the 

United States are diagnosed in people 50 years of age and older. Thus, increasing the 

age rating bands would mean that older individuals (those more at risk of developing 

cancer) would face significantly higher health care premiums or be priced out of the 

market completely. 

This problem would be exacerbated in states that choose to go beyond the 5:1 age 

rating provided in the legislation. Prior to the enactment of the ACA's age rating 

band restrictions, older adults faced significant problems accessing health insurance 

coverage, in large part because of age rating restrictions 

(compounded by the ability of issuers to use health status when setting premiums). 

Research suggests that relaxing the age rating bands would result in a slight 

reduction in premiums changed to younger cohorts relative to the significant 

increase in premiums charged to older cohorts. One study estimated that increasing 

the age bands to 5:1 would result in premiums for a 64-year-old to increase from 

$8,500 to $10,600 per year (a $2,100 increase), while premiums for a 21-year-old 

would decrease from $2,800 to $2,100 (a reduction of only $700). In addition, the 

policy would actually result in higher federal expenditures of an estimated $9.3 

billion due to the advance premium tax credits. 

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Q: Does this bill help younger Americans who need access to affordable healthcare? 

Relaxing the age rating bands may result in a slight reduction in premiums charged 

to younger cohorts relative to the significant increase in premiums charged to older 

cohorts. 

It should be noted, however, that the bills under consideration today do not include 

any financial assistance for anyone to help afford premiums or cost-sharing, 

including younger Americans. If the ACA tax credits and Medicaid expansion is 

repealed, it is unclear to me how many younger Americans will be able to afford 

health insurance, even with changes to age bands. 

2. Dr. lichtenfeld, do cancer patients often spend a lot of time with their doctors and care 

teams getting treatments to help make them well? 

There are hundreds of different kinds of cancers and each of them requires a 

different treatment regimen. Cancer patients work with their physicians and care 

teams to create their treatment protocol and understand their treatment plan. This 

might include surgery, radiation, chemotherapy, immunotherapy or hormone 

therapy. 

During the course of these treatments- and well into survivorship- cancer patients 

will work closely with their doctors. This partnership is critical to the patient's 

treatment and long term quality of life. 

3. Do cancer treatments like chemotherapy have side effects that make it hard for patients 

to accomplish daily tasks? 

Many kinds of cancer treatments can cause serious side effects that make it difficult for 

cancer patients to actively engage in their normal routines, such as nerve pain and 

changes in heart function. 

It's one of the reasons why we are concerned about proposals that would exempt 

individuals from pre-existing condition exclusions only if they maintain continuous 

coverage. 

Research suggests that between 40 and 85 percent of cancer patients stop working 

while receiving cancer treatment, with absences from work ranging from 45 days to 6 

months depending on the treatment. 

Under proposals now being considered by the Committee, this kind of gap in coverage 

could possibly be subject to medical underwriting. 

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4. Do cancer patients get a "pass" on taking care of their finances ... putting food on the 

table ... or taking care of their families? Or do family and friends often have to step in 

and help with those duties? 

Depending on the severity of their treatment some cancer patients may find it difficult 

to maintain their normal activities of daily living and may require assistance from family 

and friends. 

Those cancer patients without a strong support network may find it difficult to maintain 

their usual routines- working, paying bills, maintaining their home, preparing meals, 

etc. Caregivers are an incredibly important part of one's cancer experience. 

5. Is it conceivable that with all that a cancer patient has to deal with ... or when a loved one 

is managing their affairs ... that one month's payment may get overlooked? 

As I mentioned previously, depending on the severity of a cancer patient's treatment 

and whether or not they have a strong support network that can step in and pick up 

some of the day to day responsibilities it is plausible that a cancer patient could miss 

making an insurance payment. Frequently, that support network itself becomes 

overwhelmed when tending to a patient's needs-especially during acute crises which 

are not uncommon in cancer care. 

6. If that cancer patient is then kicked off their plan for missing that one payment ... what 

happens to that patient? 

If a cancer patient loses his/her health insurance coverage it may directly impact their 

ability to successfully fight their cancer. 

losing access to insurance likely means losing access to their treatment which has a 

direct bearing on their chances of survival. 

7. What if the cancer patient didn't miss a payment when they were sick ... but maybe 

misses a payment a couple of years into remission? Now the patient has not mainhined 

continuous coverage. If allowed, as one of the policies we are discussing does, would 

insurance companies take the patient's previous cancer diagnosis into account when 

pricing their new plan? What would happen to that patient? 

Cancer survivors who are more likely to report being unable to work because of their 

health or having employment disability, including more missed work days or additional 

days spent in bed due to poor health. 

Depending on how a proposal is drafted health insurers could end up charging higher 

premiums to cancer survivors who experience a gap in coverage. 

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